Beyond the Abstract - Bridging the urological divide, by Robin Roberts, MD

BERKELEY, CA ( - Can we in the developing countries provide a standard of urological care equivalent to that of developed countries?

For those who live here and in particular for those who have nowhere else to go, we must strive to do so. “Bridging the Urological Divide” enumerates the barriers and the potential for collaborative research to offer solutions to minimize this health care disparity.

The challenges to reducing health care disparities in working in the developing countries are many, but they are not insurmountable. The portability of basic urology equipment such as endoscopes and supplies, and their relative cost compared to those for specialties such as cardiology and cardiovascular surgery, augers well for bridging the urological divide. The willingness of our colleagues in the developed countries to visit and share their experiences fortifies the “steel beams in the bridges.” I remember well Dr. Edward McGuire visiting me in the Bahamas and doing several fascial slings for stress incontinence with me; the poor man’s slings he called it. We harvested the 4 cm by 1 cm sling from the anterior rectus sheath. We had no Stamey needles so we used a straight hemostatic forceps to bring the sutures attached to the sling from the paraurethral zone thorough the retropubic space and tied the No. 1 nylon above the anterior rectus sheath. Synthetic slings are cost prohibitive. While the patients have the morbidity of some increased postoperative pain from the small suprapubic incision, surgeries are still outpatient-based and there is no fear of sling erosions.

I am grateful to Dr. Darwich Bejany who traveled to Nassau and guided me through doing nerve sparing prostatectomies. I would be remiss not to include my classmate from Jamaica, Dr. Trevor Tulloch who came diligently on a monthly basis to help me perfect the technique; and not to forget my Pediatric surgeon from Jamaica too, Dr. Colin Abel who would travel to Nassau to close my occasional bladder extrophies and assist in their subsequent reconstructions. For a solo surgeon providing care for more than 300,000 people in the Government Public sector services, the willingness of our colleagues to visit and share their skills and experiences is immeasurable; you are never alone. The use of the Internet, telemedicine and live video demonstrations makes it easier too.

While material and funding resources are vital, the appropriately trained surgeon, in my opinion, is the most valuable asset in the developing countries; it is the real steel required to bridge our health care disparities. The urologist must be a generalist and adept in treating the full spectrum of urological disease. Disease presentations are advanced and in most instances do not lend to minimal invasive surgery. Renal cell cancers less than 10 cm size are rare, urethral strictures are long and dense, most cases of urinary retention due to BPH have absolute indications for surgical intervention and 80% of prostate cancers are advanced staged on presentations. There is much merit in training our own for these advanced pathologies which are becoming increasingly less prominent in the training experience of residents in developed countries. The greatest contribution that the developed countries can make to bridge the divide is assisting us in advancing our training programs here at home where we are immersed in our local experience; we welcome fellowships, visiting professorships, workshops, supplies and equipment. My PERC services in the Bahamas were launched with a C-Arm donated from Mercy Hospital in South Florida when they upgraded their radiology suites.

The real challenge in reducing health care disparities however, is reducing the burden of advanced diseases. How do we get our people to present with early stage disease? Primary and secondary prevention must be the mainstay of our health care system. The urologist in developing countries must incorporate in his or her practice an arsenal of public health competencies. Primary care and secondary disease prevention must be central to delivering our urological services.

This is why the current PSA debate is such an unfortunate and confusing issue. The acceptance of a digital rectal examination and PSA testing took almost 10 years for our male culture to embrace and undertake the self-responsibility of an annual visit for their prostate health. The USCSTF recommendations to downgrade the PSA for screening and early detection are retrogressive. They have failed to acknowledge the tremendous significant decrease in morbidity and mortality with the stage migration from 80% to 20% advanced disease on initial presentation over the past 20 years. The need for decreasing morbidity has advanced better surgical procedures, radiation deliveries, and medical therapies. While we strive to bridge the urological divide, it’s incumbent on the developed countries to provide decisive leadership in disease management too. The major advances to reducing health care disparities will not be made in the delivery of tertiary care services, as is evidenced in the success of the PAP test for curbing cervical cancer.

Imagine the lives saved if we can identify the genes in our men of African descent, develop a diagnostic test for early detection and aggressiveness in our men at risk, and administer an the effective vaccine. Digital technology has bridged the world in communications - in nanoseconds we are anywhere in the world. Genes and vaccines - what a way to bridge the urological divide: imagine prostate cancer like polio, being eradicated in every corner of the world. The power of imagination and collaborative research! Awesome.

Written by:
Robin Roberts, MD as part of Beyond the Abstract on This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.

Bridging the urological divide - Abstract Prostate Cancer Section

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