10 Irwin DE, Kopp ZS, Agatep B, Milsom I, Abrams P. Worldwide prevalence estimates of lower urinary tract symptoms, overactive bladder, urinary incontinence and bladder outlet obstruction. BJU Int 2011; 108: 1132–8 11 Grimes CE, Henry JA, Maraka J, Mkandawire NC, Cotton M. Cost- effectiveness of surgery in low- and middle-income countries: a systematic review. World J Surg 2014; 38: 252–63 12 Gosselin RA, Thind A, Bellardinelli A. Cost/DALY Averted in a small hospital in Sierra Leone: what is the relative contribution of different services? World J Surg 2006; 30: 505–11 Correspondence: Nicholas J. Campain, Exeter Surgical Health Services Research Unit – Urology, Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter, Devon EX2 5DW, UK. e-mail: ncampain2@gmail.com Abbreviation: DALYS, disability-adjusted life years. Current challenges to urological training in sub-Saharan Africa Nicholas J. Campain, Ruaraidh P. MacDonagh † , Kien A. Mteta ‡ , John S. McGrath on behalf of BAUS Urolink Exeter Surgical Health Services Research Unit – Urology, Royal Devon and Exeter NHS Foundation Trust, Exeter, Devon , † Department of Urology, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Somerset, UK, and ‡ Bugando Medical Centre, Mwanza, Tanzania Introduction The global burden of urological disease is huge and there are inadequate resources in terms of healthcare providers and infrastructure to meet this need, particularly but not exclusively, in sub-Saharan Africa. In this article, we briefly outline the challenges with current training systems and the various models of overseas support. Challenges There are very few specialist urologists in sub-Saharan Africa and most urological care is provided by either general surgeons or clinical officers, who have received basic training over a 2- or 3-year course in order to deal with common clinical problems. Pathology frequently presents late and access to clinical investigations may be limited or non- existent. Gaining experience to decide when and how to perform surgery in this setting is complex, and operative decision making can be further compounded by cultural and patient factors such as the social acceptability of a urostomy or the ability of patients to access disposable resources, e.g. urethral catheters. Formal Urological Training Structure Currently, most countries in sub-Saharan Africa require trainees to complete a government ‘MMed’ programme in surgery before training as a specialist. Since 1999 the College of Surgeons of East, Central and Southern Africa (COSECSA) fellowship has existed, allowing trainees to complete member and fellowship examinations within urology. Specialist ‘MMed Urology’ programmes have also been developed, e.g. at the Kilimanjaro Christian Medical Centre (KCMC), Tanzania, where there are currently 17 residents in different stages of specialist urological training. The Pan African Urological Surgeons Association (PAUSA) also exists to promote initial and continual training and holds an annual scientific meeting. Challenges for Trainees (Educational Setting) Urological trainees in sub-Saharan Africa face unique challenges. The availability of basic urological equipment is fundamental to supplementing successful surgical training. Unfortunately, access to equipment remains problematic and trained urologists may not be able to fully utilise their operative abilities. Furthermore, operative outcomes and feedback are seldom attained as patients without complications rarely return from rural areas for follow-up. Operating independently without access to colleagues or mentors similarly makes the training environment sub- optimal. Challenges for Trainers (Educational Approach) Identifying who to train and what urological procedures to focus training efforts on is similarly difficult. Isolated surgeons in rural areas are unlikely to be able to limit themselves to just one surgical specialty. Maintaining service provision whilst attempting to teach others is particularly 316 © 2015 The Authors BJU International © 2015 BJU International Comments