Introduction

Endourology was developed in the late 20th century and is increasingly becoming the mainstay of urological practice across the globe. However, the disparity of endourology practice between high-income countries (HICs) compared to low- to middle-income countries (LMICs) is becoming increasingly evident. For example, in the management of upper tract urolithiasis, open surgery accounts for 1.5% of cases in developed countries (1) but around 69.5% of cases in Africa (2). Nigeria is the most populous country in Africa with a population of over 215 million people as of March 2024 (3). For this vast population, there are only 1.4 surgeons per 100,000 people and about 270 urologists (4, 5).
In Nigeria, urology training begins with the primary fellowship examination for one of two postgraduate medical colleges: the West African College of Surgeons (WACS) or the National Post-Graduate Medical College of Nigeria (NPMCN) (6). The next 3 years involve rotating through different surgical specialties including urology. The residents can then apply for membership examinations to become eligible for subspecialty training in urology (senior residency training), which also lasts 3 years (5, 6). There are approximately 110 urology senior residents currently training in Nigeria with an aim to write their fellowship examination in the coming years.
While endourology does feature in both the WACS and the NPMCN curricula, there is arguably a lack of detail on the level of training required. They both include lists of endourology procedures that trainees should gain experience in [such as cystoscopy, ureteroscopy, and transurethral resection of prostate (TURP)] and potential levels of proficiency (i.e., assisted, supervised, or performed). However, they do not go into details about competency or how many assessors should confirm a resident’s competency (7, 8). This differs from the curricula in other countries, which focus more on competency assessment frameworks. For example, in the UK, there is a list of critical index procedures that trainees must demonstrate competency in prior to becoming a consultant. These include endourology procedures such as TURP, transurethral resection of bladder tumor (TURBT), ureteroscopy, and laser lithotripsy (9). To prove competency in these procedures, an individual must be judged by at least three different assessors to be at the standard of level 4 “able and trusted to act at the level of a day 1 consultant” (10). Similarly, in Bulgaria, there is a dedicated 1-year endourology program during which trainees are expected to have completed 50 rigid ureteroscopies and 10 flexible ureteroscopies with assessment including audit and direct observation of these procedures (11).
The limitations of endourology in LMIC such as Nigeria are numerous but can be summarized into a lack of infrastructure, funding, and resources (12). To gain competency in endourology, like any surgical skill, there is a need for a structured training program with multiple avenues of learning to consolidate knowledge and skill, i.e., didactic learning, use of models, assisted, and then supervised procedures. A lack of resources in LMIC means that training is limited by expertise and equipment, which only exacerbates the availability of endourology at a service provision level within the country.
The objective of this study is to assess the perceptions of endourology training in Nigeria by surveying current senior urology residents. It acts as a needs assessment of the current state of endourology training, and the findings will thus highlight targetable areas for potential growth. This lends itself to creating evidence-based suggestions to policymakers on how to improve the current endourology training pathway in Nigeria.

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Materials and Methods

A cross-sectional survey was conducted among senior registrars in urology (Appendix A). An online structured questionnaire was distributed among all current senior registrars in Nigeria via WhatsApp groups consisting of senior trainees in different regions of Nigeria. The questionnaire was distributed in a WhatsApp group set up by the national association of urologists for all urology trainees. The questionnaire was sent with a message that outlined its goals and research potential; informed consent was thus implicit in the completion of the survey by participants. It was estimated that there were 110 eligible residents at the time of the study, working in a range of different training centers throughout Nigeria, and they all had access to the survey. Inclusion criteria included that they must be currently training in Nigeria and must have completed their first 3 years of surgical training, and passed part 1 examination, thus making them senior registrars. As this was a total population survey targeting all eligible senior residents (n=110), a priori sample size calculation was not performed. Sixty-two of the 110 eligible residents responded to the survey, and all were included in further analysis.
The questionnaire was developed using a pilot study among senior registrars in urology to ensure its clarity and fluency. It had 24 questions including a section on sociodemographic data including age, gender, stage of residency training, and training center location. A Likert scale was included to assess residents’ confidence in performing endourology procedures. They were also asked to quantify how many rigid cystoscopies, cystoscopic stent insertions, TURBTs, TURPs, and ureteroscopies they had assisted and performed independently. Additionally, questions focused on the current availability of endourology training and whether trainees would be open to paying for more training or attending a course at a designated training center. Lastly, there was a free-text option asking about whether the trainees had any suggestions on how endourology training in Nigeria could be improved.
Full ethical approval for this study was granted by the Health Research Ethics Committee of Nigeria University Teaching Hospital (IRB 00014024). The questionnaire was active from August to September 2024.
The results were analyzed using inferential and descriptive analysis on Microsoft Excel (Microsoft Corporation, Redmond, WA). The STROBE checklist for cross-sectional studies was used to enhance the quality and reproducibility of the study, a clear timeframe was defined, and no confounding factors were identified.

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Results

Sixty-two of the 110 senior residents responded, equating to a 56% response rate. All responses were included in the final analysis of the study. All 62 respondents were male, with the most common age being between 35 and 40 years (48.4%). The teaching centers with the most responses (six responses each) were Aminu Kano Teaching Hospital (AKTH) and Ahmadu Bello University Teaching Hospital (ABUTH). Only senior urology residents were included in this survey—that is, those who have passed the examinations qualifying them to commence specialist urology training. Of the 62 responders, 18 (29%) were 1 year into specialty training, 11 (17.7%) were 2 years, 19 (30.6%) were 3 years, 12 (19.4%) were 4 years, and 1 each (1.6%) was 5 and 6 years into specialty training. It is noted that although senior urology training is a 3-year program, some individuals take longer to achieve completion for various reasons.
Thirty-four trainees (54.8%) responded “middle ground” when asked about their levels of confidence in endourology, with only 10 (16.1%) feeling confident and 18 (29%) feeling not confident at all.
The residents’ experience of endourology varied considerably among training centers. However, most were not able to independently perform core endourology procedures. Figure 1 summarizes the experience of urology residents by showing the percentage of how many individuals had completed specific endourology procedures independently. The most performed procedure was rigid cystoscopy (63%), and the least performed were TURBTs (3%) and ureteroscopic fragmentation (3%).

 

Figure 1.

Percentage of Nigerian senior urology residents who had performed specific endourology procedures independently. TURBT, transurethral resection of bladder tumor; TURP, transurethral resection of prostate.

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Supplementary Figure 1.

Histograms and Q–Q plots for each procedure count. This helps visualize the distribution and assess the normality of the data for the following:
•    Rigid cystoscopy
•    Cystoscopic stent insertion
•    TURP
•    TURBT
•    Ureteroscopy
•    Ureteroscopic fragmentation
TURBT, transurethral resection of bladder tumor; TURP, transurethral resection of prostate.

A one-way analysis of variance (ANOVA) was performed to compare the average number of different endourology procedures performed independently by senior residents. Visual inspection of histograms and Q-Q plots along with Shapiro–Wilk tests confirmed that the distributions of procedure counts were approximately normal, allowing for the use of ANOVA (Supplementary Figure 1). There was a statistically significant difference [p = 7.62-15, F(5366)=16.67], which suggests that there is a difference in independent practice based on the procedure. In addition to the statistically significant p value (p < 0.001), the effect size for the ANOVA was large (partial η²=0.19), suggesting a substantial difference in independent procedure performance by procedure type. Post hoc analysis using Tukey’s honestly significant difference test suggests that all procedures when paired with the number of rigid cystoscopies are statistically significant, highlighting that this is the most commonly performed procedure.
Regarding specific endourology procedures, it is notable that no procedure had been performed independently by all residents included in the survey. The mean number of rigid cystoscopies performed independently by residents was 12.23 [±19.57 standard deviation (SD)] with one individual completing 100 independent procedures, and they were 4 years into their urology training. Similarly, the mean number of independent cystoscopic stent insertions was 4.55 (±10.68 SD). The most being completed by one individual (also 4 years into training) was 50, but once again a majority had completed none independently. When quantifying independent TURBTs, it was noteworthy that only two individuals had completed this procedure independently—both from Lagos State University Teaching Hospital (LASUTH) and 3 and 4 years into their senior residency. Likewise, only 11 residents had independently completed a TURP—most from ABUTH (4 out of 11 individuals), the highest number of procedures being 20 by a year 4 individual at LASUTH. Most of these individuals (5 out of 11) were 4 years into their senior residency, four were 3 years into training, and two were only 2 years into training.
When it came to ureteroscopies and ureteroscopic stone fragmentations, only six individuals had performed ureteroscopies independently, and most (three out of six) were from LASUTH, with 20 being the highest number of procedures performed by one individual who was 4 years into their residency at AKTH. Similarly, only two individuals had performed ureteroscopic stone fragmentations independently—one was 2 years into training and the other was 3 years into training. Table 1 shows the percentage of senior urology residents who have performed specific endourology procedures independently, divided by year into senior residency.

 

Table 1.

Percentage of senior urology residents who have completed specific endourology procedures independently

TURBT, transurethral resection of bladder tumor; TURP, transurethral resection of prostate.

Regarding changes to current endourology training, 91.8% of individuals said that they would be open to spending time at a dedicated endourology training center. 73.3% said that they would be open to paying for and attending a 3-day intensive course on basic skills, 25% responded “maybe,” and 1.7% (one person) said “no.” They were asked about how long they believe a specific endourology rotation should last. Forty-one percent responded with 6 months, 34.4% responded with 3 months, 21.3% responded with 1 year, and the rest chose “other.” When asked if they would be open to traveling for training, most (69.4%) chose another state in Nigeria, 66.1% chose India, 64.5% chose the UK, and 59.7% chose another African country.
Lastly, when asked about suggestions on improving endourology training in Nigeria, 35% suggested changes to the current teaching program to give endourology more of a focus and to create a structured program (potentially as a post-fellowship program) so that trainers could more easily assess and teach others. Thirty-two percent highlighted a need for more equipment and resources in different centers, with 18% also suggesting cross-center collaboration to allow those in lower-output areas to have dedicated endourology training at appropriate centers. Eight percent suggested simulation to provide more endourology training, with 4% also touching on collaboration with international providers. Four percent also suggested patient subsidy to improve access to endourology for patients and thus increase the patient load.​

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Discussion

Training Landscape

Traditionally, urology training in Nigeria focuses on the acquisition of knowledge and open surgical skills. This study has shown that most current urology trainees in Nigeria are unable to independently perform core endourology procedures. Only 3% of senior residents were able to perform TURBT independently compared to 89.6% of those in the UK and Ireland as quantified in 2015 (13). This is a complex procedure, and the striking disparity highlights that without basic endourology skill exposure, the skill acquisition gap only grows higher up the training pathway. It is important to acknowledge that surgeons in HIC have significantly less exposure and experience in open surgery compared to LMIC due to their increasing reliance on minimally invasive techniques (14). There is a plethora of reasons that contribute to the disparity between HIC and LMIC; the primary issues are limitations in equipment availability, paucities in training, and the high cost of procedures to patients.
Our survey shows that this disparity is even present between centers within Nigeria itself. A majority of those performing independent endourology procedures were from LASUTH, AKTH or ABUTH. This may reflect the variation in equipment availability across hospitals in Nigeria, meaning that those in higher-output centers have more exposure to endourology procedures and thus have more training opportunities. The reason for low procedural competency could also be attributed to a lack of a structured competency-based framework for endourology training in Nigeria. This exacerbates the minimal exposure to endourology that several residents report and thus stunts their procedural ability.

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Resource limitations
As aforementioned, one of the major limitations to endourology in Nigeria is limited resources. In 2024, Nedjim et al. evaluated endourology practice in Africa, and found that out of 46 centers in sub-Saharan Africa, only 30 provided endourology treatment, with 34 having endourology equipment available; this incongruence may be secondary to a lack of trained staff (15). This disparity of equipment availability can directly explain why, as highlighted by this study, there is more endourology training in some centers than others as aforementioned.

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Systemic barriers
Furthermore, while the patient load in Nigeria is large in terms of pathology, this is not mirrored in the number of patients presenting to healthcare providers due to several barriers limiting accessibility. These factors include financial concerns, sociocultural attitudes toward orthodox healthcare, and geographical limitations. In fact, it has been determined that only about 57.7% of the Nigerian population can access a hospital within 2 hours that can perform all three Bellwether procedures (used by the Lancet as an indicator of adequate surgical care), with most of these individuals being close to urban centers (6, 16).
Moreover, it is predicted by the World Bank that by the end of 2024 about 40.7% of Nigeria will be living below the international poverty line (17). This level of poverty is especially significant as a majority of the population pays for their own healthcare or needs to rely on other sources such as family support or community donors (5). Nigeria does have its own National Health Insurance Agency; however, it is only available to about 5% of the population due to the opt-in nature of the scheme compounded by a lack of awareness (18). In fact, many members of the population do not enlist in this scheme due to their sociocultural attitudes toward healthcare. Some prefer to seek traditional medicine or spiritual help as a first line in illness due to financial concerns or wariness toward conventional medicine (19).
The relatively low patient load is only exacerbated by medical tourism, which is carried out by approximately 60,000 Nigerians every year (20). The wider ripples of medical tourism can unfortunately stunt the growth of the healthcare system in the consumer’s home country due to curtailing demand and flow of money into the system (21).
The healthcare system in Nigeria remains chronically underfunded, which unfortunately stunts both healthcare education and provision due to a lack of resources and inability to build infrastructure. In contrast, many HICs have post-fellowship training available in which individuals can further develop a chosen subspecialty skill. This includes the Royal College of Surgeons England Senior Clinical Fellowship Scheme, which was developed in 2012 and provides programs both in the UK and overseas (22). The availability of post-fellowship urology training in LMIC is few and far between, often leading to trainees pursuing opportunities elsewhere. Furthermore, it cannot be denied that the emigration of doctors in Nigeria continues to be on the rise. In 2018, a survey revealed that 57.4% of resident doctors in Nigeria had emigration intentions. The reasons for emigration were multifaceted but included financial motivation, research opportunities, and the availability of more advanced techniques for patient care (23).

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Study limitations
It is noted that this study has its limitations; while the differences in procedural exposure between types were statistically significant, caution should be taken in interpreting these results as definitive due to the lack of power calculation and potential self-reporting bias.
There was a relatively low uptake with only around 56% of current urology senior residents responding and those who responded are more likely to have strong opinions about current endourology training. However, the observed effect sizes suggest these are not only statistically but also practically meaningful. This response rate is also similar to other national studies.

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Potential interventions
Those who took part in the study identified several potential targets for improving endourology training in Nigeria. It is unsurprising that 32% highlighted the need for more resources, both equipment and funding to allow for growth. However, even more (35%) suggested changing the current teaching program to give endourology more emphasis. This could focus on more proficiency-based curricula in order to ensure adequate progression in clinical skills throughout training, which has been shown to demonstrate better surgical outcomes compared to traditional training (24). This would likely emulate endourology training programs in other countries such as in the UK, which requires completion of specific numbers of procedures, with trainees undergoing validated assessment by experienced assessors (11). Furthermore, 18% suggested cross-center collaboration to allow those in centers with a low endourology caseload to have time in the higher-output centers for skill acquisition. This could be incorporated into training as a compulsory or voluntary placement requirement; with 41% of those surveyed believing that 6 months would be a sufficient placement time.
Responses also touched on the potential for international collaboration to further address the endourology disparity between HIC and LMIC. This could be in the form of simulation; for example, a Rwandan–Canadian partnership allowed for the development of the first simulation center at the University Teaching Hospital of Kigali in 2013 and successfully demonstrated improved operative skills over a 3-month period (25). Simulation-based training is becoming more commonplace as it allows for efficient skill acquisition with little impact on patient safety (11). Other options would be training courses either in Nigeria or abroad. In our survey, most residents would rather travel to another state within Nigeria for training (69.4%); however, many were also open to going to India or the UK.
Endourology training in Nigeria remains an area that would benefit from ongoing research to assess knowledge gaps and the steps being taken to address them. For example, longitudinal studies assessing the effectiveness of a dedicated endourology placement or exploring simulation-based endourology training in Nigeria in comparison to other international training models.
 

Conclusion

This study suggests that the current state of endourology training in Nigeria is significantly limited, with disparities even noted between centers within the country itself; this is drawn from perceptions of those currently undergoing endourology training in Nigeria. This is principally due to a lack of funding, equipment, and facilities but also highlights the need for more standardized, proficiency-based training among current trainees. It is proposed that this could be achieved through dedicated skill acquisition placements in higher-output centers within the country and, for those who are able to afford it, dedicated international postings in endourology. Increased interest and subsequent government funding for endourology equipment would also help bridge this disparity.

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Author contributions

LJ led a literature review and writing of the original draft. AB, CA, MI, and MA led conceptualization and data collection. All authors contributed to the visualization and editing of the manuscript.

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