Medical & Clinical Reviews

Description

Over the course of approximately 60 years, the field of pediatric urology has evolved as a convergence of pediatric surgery, urology, and plastic surgery to address congenital anomalies of the urinary tract and genitalia in children. Guidelines for training and certification are narrowing in High-Income Countries (HICs) at the same time as the fertility rate is declining and the prevalence of complex Genitourinary (GU) conditions is decreasing. In Low-And Middle-Income Countries (LMICs), health systems for large populations are currently in a state of stress. Here we briefly review the history of pediatric urology as a surgical subspecialty, identify unmet needs especially in LMICs and place the field in the context of a global surgical ecosystem. The proliferation of training programs in pediatric surgery and specialties in High-Income Countries (HICs) coupled with declining birth rates has led to a saturation of specialists and declining surgical case load. In LMICs, while the birth rate has also been declining, surgical specialization has not progressed. In the lowest income countries, especially in sub-Saharan Africa, training in pediatric surgical specialties and urology is rare. The broad workforce that supports surgical care, such as anesthesia,  pediatrics, radiology, laboratory, and nursing face similar challenges. Supply chains for specialized pediatric urological surgery are weak.

Frustrating Complexity of Health Systems Globally and Widening Gaps in Resources

There is an evolving maldistribution of pediatric surgical and pediatric urological workforce globally, with too few practitioners in LMICs and too many in HICs. The high cost of specialized equipment limits access to quality care, and the supply chain for consumables and medication is patchy. In LIC's, basic community-based infrastructure for health including reliable electricity is lacking. Recent experience with Covid and environmental disasters has highlighted that even in HICs surgical resilience can be challenged. This is an opportunity to consider the state of children's urological care globally and to build resilience by identifying and addressing strengths and gaps. Pediatric urology is a young specialty. Barely a working generation into existence, it is challenged by a frustrating complexity of health systems globally and widening gaps in resources. As surgeons and as patients, our opportunities for both providing and receiving care vary greatly around the world. In low-income countries, surgeons face poor access to training, to hospitals with good equipment and to staffing. Patients face the potential for catastrophic direct financial burden as well as indirect costs of travel and long-term care of family members. In some global regions, there is an over-abundance of surgeons relative to the pediatric population, and in others, a scarcity. In a few regions the pediatric population is growing, but in many others, declining. As the field of “global surgery” has become a bona fide academic discipline, new avenues are opening for identifying systems-related challenges in providing quality pediatric urological care. We can now begin to identify points of potential change to improve both quality and access to children's surgical care around the world. A framework for inquiry into the current state and future needs for global surgery in general and pediatric urology in particular considers surgery as an ecosystem within larger healthcare systems worldwide.

Pediatric Urology, As the Convergence of Urology and Pediatric Surgery

Optimal resources for children's surgical care can be considered within this framework .Pediatric urology, as the convergence of urology and pediatric surgery, interfaces with a broad spectrum of generalists and specialists within the surgical, medical and diagnostic disciplines as well as the frontline health workforce and public health. To get larger view of the current challenges and opportunities for pediatric urology we must look at the global burden of disease, the workforce, the hospitals, the community, infrastructure and all the consumables necessary for quality care. Systems are continually in flux, but awareness of the component factors will provide opportunity for positive change. Through the colonial era and emerging from it, urological care in poor countries was carried out by general surgeons or doctors without specific surgical training .But training is changing globally. New doctors learn not just through apprenticeship but through multimedia and professional and social networks. It is increasingly recognized that sustainable surgery requires the engagement of many different stakeholders including many outside of medicine. Some are in ministries of health or finance, patient advocate groups and multispecialty collaborative alliances. They are engaging the tools of public health and economics to make the case for investment in surgical care as an indivisible component of health .The ecosystems that support surgery, as we have seen with the Covid pandemic, also support the entire system of health.