Fading Frontiers: Pragmatic Paradigm of Urologic Practice in a changing Africa.

Reports

Gone are the days when the surgeon-barber was barely a skilled craftsman. Refined over time he has become the accountable professional fearful of malpractices that not only can ruin reputation but cause demise and bring to a halt lives and daily bread. Circumcision the premier urologic procedure of the Imhotep (father of African medicine) era (2200 years before Hippocrates)1 travelled from the African medical centers of Memphis, Alexandria and Timbuktu with other ancient medical practice to Greece and later Rome. Unfortunately its practice is still bedeviled with controversy and a much too high complication rate in sub-Saharan Africa.Migrating from the banks of the Nile when ancient Africans circumsized with the reed plant to today's Africa, thousands of years later, we are plagued with urethro-cutaneous fistulae, glandular amputations, penile degloving injuries and fatal hemorrhage from ill-performed circumcision. Moreover, detractors have argued that circumcision leads to deprivation of the pleasure of sexual congress and may even yield less than adequate erections. Others have opined that in communities still burdened by urethral stricture disease, it is imprudent to discard the prepuce that facilitates urethral reconstruction as described by Quartey and others. The perfection of buccal mucosal graft techniques for urethral reconstruction should allay fears of preputial shortage. Luckily, with the perspective of diminishing STDs from the all out crusade against HIV/AIDS, the incidence of non-traumatic urethral stricture is decreasing exponentially. The paucity of randomized clinical trials and inconclusive meta-analyses of male circumcision literature has bolstered the in-activists (anti male circumcision) camp especially in communities with low HIV prevalence rates2.However, the passionate debate on male circumcision being a cultural ritual with no real medical value has been challenged by growing evidence that it may prevent neonatal UTI, diminish HIV transmission as well as decrease the incidence of cancer of the uterine cervix. The excision of the preputial hood frees the glandular crease of smegma, a hide out for human papilloma virus serotypes often incriminated as causal agents for cancer of the cervix and penile tumors. It can also be argued that circumcision performed early in the neonatal period is protective against penile cancer.Given the high HIV/AIDS prevalence and mortality, coupled with precious little access to ARVs, and the ineffectiveness of other preventive measures; it is imperative that male circumcision exits the centre stage of controversy and sets off to diminish the yoke of HIV-AIDS and cervical cancer in high disease burden countries3. Indeed the WHO has tailored male circumcision programs in some countries to address the high rates of sexually transmitted HIV4,5. Such a laudable effort ought to be a continent-wide adjuvant preventive measure and in this regard the procedure needs to be standardized, it's practice regulated and restricted to skilled hands from approved training programs.The potential public health benefits of male circumcision can in no way be compared with the unethical, psychological, physically disfiguring and maiming outcomes of female genital mutilation (FGM) even in its "milder forms" of clitorectomy or female circumcision. Moreover scarring from infibulations renders not only sexual intercourse painful and burdensome but may even jeopardize vaginal delivery in the rare event of a pregnancy. It has been suggested that obstetric fistulae are more common in victims of FGM so delivery by cesarean section is advised. Unfortunately the psychological scars and social isolation make for lifelong challenges for FGM victims.After circumcision, African urology was influenced by Arabian care of urethral strictures with the development of sounds (bougies). This heritage became the seed for Greek and Roman medicine. Unfortunately the trans-Saharan and trans-Atlantic slave trades contributed to the said morose and lackluster evolution of urology in the region.The discipline of urology (the oldest surgical specialty) grew from its genital focus to the care of the urinary tract, the male genital tract and several programs incorporated renal replacement care (transplantation). Its spectrum runs the gamut of genitourinary and adrenal diseases of the male and female from conception to death. It has given off shoots of andrology and sexual medicine, pediatric urology, urologic oncology, urodynamics and female urology, urolithiasis, reconstructive urology etc. These sub-specialties of urology in their diversity bind the specialty intimately to other specialties such that competences in gastro-intestinal, plastic and general surgery as well as pediatrics, nephrology, oncology and general internal medicine are requisite for standard practice.In the past, urologic practice was largely hospital based with some outpatient office care. Further, there was a gulf between hospital clinical research and the laboratory which was often distant and dissociated with the community. This concentration of health care in its fundamental tenets of health promotion, disease prevention, clinical therapy and research in the hospital alienates the greater population. The limited availability of health financing and absence of third party health insurance accounts in part for the detection of disease in the late stage. This has motivated the community outreach approach of detecting and arresting disease early in its natural history. Breaking barriers between the hospital and the community in this instance would potentially be expected to diminish morbidity and mortality.With the growth of multi-disciplinary clinical research teams in Africa in addition to the consideration of the tightly knit community African spirit, the void between the hospital, the clinic, the laboratory and especially the community is gradually being effaced. It is in this regard that the horizons of urology have broaden with detection of pre-prostate cancer markers from cases in the community6. An interesting fallout from genomic studies of prostate cancer polymorphism was the mapping of shared alleles between indigenous West African and Caribbean populations which suggested precise geographic origins in Africa of African-Americans and African-Caribbeans7. Genetic mapping of African, African-American and Caribbean populations of African descent as well as historical and linguistic correlates corroborate theories that implicate migratory and slave trade routes. This was the birth of the African Ancestry project that has seen thousands of African-Americans and African-Caribbean make pilgrimages to ethnic groups and/or villages of origin on the African continent8. This far reaching development uniting humanity in its intimacy could only have happened when research is designed to factor in the individual, his community and finally the wider human community around the world.The retarded evolution of urologic practice in its home of origin has often been attributed to the technological divide. Whereas the last century has seen the invention and growth of endoscopy, endo-urology, laparoscopy, robotic urology, genomic and now nano medicine, uropathology and the clinical paradigm have undergone precious but little change. Since urologic care must evolve with techniques and technologies, it is imperative that training paradigms and African context specificities are re-visited so as to reclaim the reputation of yester centuries! The regrouping of training, care and research in a scheme that unites the hospital and the community is a fast track to better health for our populations.Training principles have evolved from knowledge to information acquisition to transformation so that professionals are agents of positive change. The scheme of knowledge, attitudes and practice that was yester year transmitted from master to apprentice has given way to surrogate knowledge and skill transfer through mannequins, robots and simulators. All of this under the watchful eye of the mentor-facilitator. The growth of virtual social networks has given an unimaginable dimension to research and collaboration worldwide with the fusion of historical, geographic, cultural, health system and scientific frontiers. Barriers to the global human medical and scientific experience have hitherto been broken. The cross pollination of teams in the African region and beyond is imperative as African if not human salvation depends upon fertile networking!