Challenges facing the urologist in low- and middle-income countries



The challenges in providing urologic care across borders and in resource-constrained settings are poorly understood. We sought to better characterize the impediments to the delivery of urological care in low- and middle-income countries (LMICs) compared to high-income countries (HICs).


A 70 question online survey in RedCap™ was distributed to urologists who had practiced in countries outside of the United States and Europe categorized by World Bank income groups.


114 urologists from 27 countries completed the survey; 35 (39%) practiced in HICs while 54 (61%) practiced in LMICs. Forty-three percent of urologists received training outside their home country. Most commonly treated conditions were urolithiasis (30%), BPH (15%) and prostate cancer (13%) which did not vary by group. Only 19% of urologists in LMICs reported sufficient urologists in their country. Patients in LMICs were less likely to get urgent drainage for infected obstructing kidney stones or endoscopic treatment for a painful kidney stone or obstructing prostate. Urologists visiting LMICs were more likely to cite deficits in knowledge, inadequate operative facilities and limited access to disposables as the major challenges whereas local LMIC urologists were more likely to cite financial challenges, limited access to diagnostics and support staff as the barriers to care.


LMICs lack enough training opportunities and urologists to care for their population. There is disconnect between the needs identified by local and visiting urologists. International collaborations should target broader interventions in LMICs to address local priorities such as diagnostic studies, support staff and financial support.

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Author information




IM: Protocol/project development, manuscript writing. DB: Data analysis, Protocol/project development. MJ: Data collection, manuscript editing. HC: Protocol/project development. IS: Data collection, manuscript editing. All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by IM and DB. The first draft of the manuscript was written by IM and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Ian Metzler.

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The authors have no disclosures or conflict of interest related to the submitted material. Investigational Review Board designation for this study as exempt was obtained at University of California, San Francisco.

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Metzler, I., Bayne, D., Chang, H. et al. Challenges facing the urologist in low- and middle-income countries. World J Urol 38, 2987–2994 (2020).

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  • International
  • Global
  • Urology
  • Low-income countries
  • Disparities
  • Access
  • Socioeconomic
  • Barriers to care