The feasibility of endourological surgery in low‐resource settings

Abstract

One of the widest variations in contemporary surgical practice between high and low, or low-middle, income countries is the utilisation of endoscopy as a means of treating urological pathology. The endoscopic management of lower urinary tract problems such as benign prostatic hypertrophy, bladder cancer and urethral strictures was established in the UK in the late 1970s, whilst its adoption into everyday practice in sub-Saharan Africa (SSA) has been significantly retarded. It is still neither a major feature of urological training in those countries nor widely available to the patients that established consultants treat. Likewise, the explosion of less invasive technologies for treating upper tract stone disease in the 1980s, particularly the management of renal stone disease, has also lagged behind practice established in the UK over the last 40 years. This is not due to a lack of patients who could be treated endoscopically or restricted by the abilities of the surgeons in SSA. The restraint in assumption of these less-invasive management options is rather due to the physical availability of trained specialist surgeons, their access to basic infrastructure such as electricity and water, access to endoscopes and the peripheral equipment necessary to successfully deploy them, and the ability of patients to afford the disposable items required for less-invasive forms of management. Some endoscopic procedures are viable in resource-poor settings. However, they are largely dependent upon the supply of equipment from non-governmental organisations in highincome countries, frugal innovation to reduce individual procedure costs, adequately skilled mentors, and maintenance and supply chains to make them a durable option in patient management. Urolink and the Medi Tech Trust present their experience of how endoscopic surgery can be taught, and used sustainably, in a resource-poor healthcare environment.

Stone disease in low‐ and middle‐income countries: could augmented reality have a role in its management?

“…First, the relatively low prevalence of nephrolithiasis and the higher incidence of bladder stones in the large paediatric population, makes ESWL an uneconomic proposition for most low-resource settings [3]. Second, endoscopic stone surgery is not widely practiced due to difficulties in funding the capital, or maintenance, costs of relatively high-tech equipment, and the imaging modalities required to facilitate less invasive surgery [35]. So, open surgery for stone disease remains the norm, both in practice, and in the education of surgical trainees, in many LMICs.…”

“…It has long been known that there is significantly reduced morbidity, and lower complication rates, from endoscopic surgery than from open stone removal [36], or open nephrectomy [37], skills that many LMIC urologists have been shown to rapidly acquire with increasing exposure to the procedures [35]. Longitudinal mentoring has been shown to be the essential component for providing some sustainability in those skills [11,35,38,39], so that they can be further disseminated regionally to other surgeons for much wider patient benefit [37]. The coronavirus disease 2019 (COVID-19) pandemic resulted in a drastically reduced ability to travel so that on-site surgical missions or short-term surgical trips (STSTs) to LMICs could not take place.…”

“…With our combined experiences in teaching endoscopic stone surgery in our linked countries in SSA [35], we felt that it was perfectly reasonable to consider using AR as a longitudinal mentoring tool during our inability to travel during the COVID‐19 pandemic. The use of AR as a longitudinal mentoring aid, however, demanded consideration of the stability of the power supply in the LMIC, to ensure consistent illumination for endoscopes as well as providing consistent Wi‐Fi or 5G connectivity.…”

Urological surgeries in a West African Teaching Hospital

“…Whereas endoscopy for the management of urological diseases has been widely accepted in developed countries, in Nigeria, as in other SSA countries, open surgeries are commonly performed. [ 5 ] The use of this technology in Nigeria is evolving, with majority of the minimally invasive surgeries being carried out in private facilities. [ 6 7 8 ] This difference in use of endoscopy between high- and low-income countries revolves around physical availability of trained specialists, lack of basic facilities such as water, electricity to use these instruments and lack of funding of the hospitals.…”

“…[ 6 7 8 ] This difference in use of endoscopy between high- and low-income countries revolves around physical availability of trained specialists, lack of basic facilities such as water, electricity to use these instruments and lack of funding of the hospitals. [ 5 9 , 10 ]…”