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GLOBAL STATE OF UROLOGY Urology Down Under: The State of Urology in Australia

By: Helen O’Connell, MD, FRACS, MMed, MBBS, FAICD, Urological Society of Australia and New Zealand President, University of Melbourne, Australia; Damien Bolton, MD, PhD, BA, MBBS, FRCS, FRACS, Urological Society of Australia and New Zealand Vice President, University of Melbourne, Australia, Olivia Newton-John Cancer and Wellness Centre, Austin Health, Heidelberg, Australia | Posted on: 15 Mar 2024

The Urological Society of Australia and New Zealand was established in 1937, making it one of the oldest urological societies in the world.1,2 The society coordinates urological education and is the sole authority for accreditation of urologic training. Australia has a nationally funded health care system and well-established network of urological centers in urban and regional centers.

Within this universal health system aspects of urologic care have evolved that are unique to Australia. Among these have been efforts to reduce overdiagnosis of clinically insignificant prostate cancer.

Australia has among the world’s highest incidence of prostate cancer, with about 1 in 6 men diagnosed by the age of 85 years. Federal funding for prostate multiparametric MRI since 2018 has improved access to this investigation, particularly for men living regionally or in low socioeconomic areas.3 In order to reduce the frequency of prostate biopsy in those men with a low risk of clinically significant prostate cancer, government-funded multiparametric MRI is available to men where

  • Two PSA tests performed within an interval of 1 to 3 months are > 3.0 ng/mL, with a free/total PSA ratio < 25%, or
  • Two PSA tests performed within an interval of 1 to 3 months are > 2.0 ng/mL, with a free/total ratio < 25% (for men aged <70 years and a family history of first-degree relative with suspected BRCA1 or BRCA2 mutation), or
  • Two PSA tests performed within an interval of 1 to 3 months are > 5.5 ng/mL, with a free/total ratio < 25% (for men aged > 70 years).4

The use of transperineal prostate biopsy in preference to transrectal ultrasound–guided biopsy has also been supported by public health policy, with government reimbursements revised to financially incentivize and encourage the use of transperineal biopsy since 2020.5

Prostate-specific membrane antigen positron emission tomography/CT now is also funded for all patients with Grade Group 2 disease or higher for prostate cancer staging. The justification for the use of this technology as a more cost-effective means of cancer staging was largely based on data from a local study.6

  1. What do you see as the greatest opportunities in your specialty in the next 5 years? What are the emerging technologies in your country?
    1. Australia is an early adopter in prostate-specific membrane antigen theranostics. The phase 2 LuPSMA trial in 2018 showed the efficacy of 177Lu-PSMA-617 in patients with metastatic castration-resistant prostate cancer who had progressed on all available therapies, with 57% of patients seeing a 50% PSA reduction.7
    2. With an emphasis on prioritizing new technologies that supplement patient safety, federal health care regulatory bodies have approved systems such as the LithoVue Elite to permit monitoring of intrarenal pressure in real time in order to limit postoperative complications including systemic inflammatory response syndrome, sepsis, and renal damage.8
  2. How has the practice of urology changed since you began practicing?
    Widely subscribed national registries such as the Prostate Cancer Outcomes Registry and the Australasian Pelvic Floor Procedure Registry now play a crucial role in assessing quality of care within specific areas of urology. These registries serve as comprehensive repositories of real-world patient data, allowing for benchmarking and facilitating evidence-based decision-making for urologists across the region.
     The introduction of flexible surgical training has impacted greatly on the practice of Australian urology. While more than 30% of trainees have expressed interest in flexible training, less than 1% were traditionally in flexible training roles.9 As the proportion of female trainees in surgical training approaches a target of 40%, flexibility is now essential to prevent our trainees from leaving the profession. Flexible training appears to have increased diversity in the surgical workforce by increasing the appeal of surgical training to more candidates, and has enabled trainees to broaden their focus and pursue wider interests while training.
  3. Why is it important to stay connected to your urology colleagues in other parts of the world? What advice would you give to the next generation of urologists from your country?
    1. Particularly as a consequence of our geographical isolation, it is generally important to Australian urologists to stay connected to colleagues in other countries through international networks. This permits benchmarking of clinical and research standards against best practice in other regions.
    2. Greater emphasis on digital communication and education will permit ever closer engagement with colleagues from all regions of the world. The next generation of Australian urologists should grasp this opportunity, and should seek the chance to engage in fellowships, research, committees, and conference participation with larger international urologic organizations. Only via an understanding of the issues urologists and patients deal with globally can we hope to provide a truly inclusive and comprehensive practice of urology in our home country.
  1. Pirpiris A, Chung ASJ, Rashid P. From humble beginnings … the evolution of the FRACS (urology). ANZ J Surg. 2017;87(7-8):619-623.
  2. Lawson PS. Origins of the Urological Society of Australasia. ANZ J Surg. 1990;60(5):385-391.
  3. Kelly BD, Perera M, Bolton DM, Papa N. Social determinants of health: does socioeconomic status affect access to staging imaging for men with prostate cancer. Prostate Cancer Prostatic Dis. 2023;26(2):429-431.
  4. Wei G, Reeves F, Perera M, et al. The impact of health-policy-driven subsidisation of prostate magnetic resonance imaging on transperineal prostate biopsy practice and outcomes. BJUI Compass. 2022;3(4):304-309.
  5. Australian Government Department of Health. MBS Changes Factsheet: Transrectal Prostate Biopsy Factsheet. 2020.
  6. Hofman MS, Lawrentschuk N, Francis RJ, et al. Prostate-specific membrane antigen PET-CT in patients with high-risk prostate cancer before curative-intent surgery or radiotherapy (proPSMA): a prospective, randomised, multicentre study. Lancet. 2020;395(10231):1208-1216.
  7. Hofman MS, Violet J, Hicks RJ, et al. 177Lu-PSMA-617 radionuclide treatment in patients with metastatic castration-resistant prostate cancer (LuPSMA trial): a single-centre, single-arm, phase 2 study. Lancet Oncol. 2018;19(6):825-833.
  8. Tokas T, Herrmann TRW, Skolarikos A, Nagele U. Pressure matters: intrarenal pressures during normal and pathological conditions, and impact of increased values to renal physiology. World J Urol. 2019;37(1):125-131.
  9. Basto M. Making flexible surgical training accessible for everyone. Royal Australasian College of Surgeons (RACS) Surgical News. 2023. Accessed May 12, 2023.