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© 2022 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada.

Key Words Competing Interests Article Information

Urology, Syria, conflict zone  None declared. Soc Int Urol J.2022;3(5):294–295

DOI: 10.48083/IRJO4841

Urology in Syria: A View From Inside

Khaled Altopajee,1 Mohammed Shahait2

1 Department of Urology, Damascus University, Damascus, Syria 2 Department of Surgery, Clemenceau Medical Center, Dubai, United Arab Emirates

Damascus is the capital of Syria and one of the oldest 
continuously inhabited cities in the world. The city had 
an estimated population of 2 079 000 in 2019[1]. It is the 
birthplace of Ibn al-Nafis (1213 to 1288), who has been 
described as "the father of circulatory physiology." In his 
book, Al-Mugiza, Ibn al-Nafis distinguishes between 
kidney stones and bladder stones[2]. Moreover, he 
was the first to describe the vesicoureteral anti-reflux 
mechanism, which our contemporary understanding 
corroborates[3].

The school of medicine at Damascus University was 
founded in 1903 and is one of the top 10 international 
providers of licensed physicians in the United States[4]. 
In the last decade, the Syrian crisis has led to an exodus 
of Syrian physicians from different subspecialties, 
including urology[5]. It is mainly the young doctors 
who leave, because of concerns about safety and limited 
opportunities for comprehensive postgraduate training, 
as well as to avoid mandatory military service[6]. Conse-
quently, there is a shortage of specialized physicians 
outside major cities.

The Syrian crisis is not a traditional war. The whole 
society is a battlefield, with civilian facilities, including 
health care facilities, treated as targets[7].

Moreover, the devaluation of the local currency (in 
2009, 1 USD was worth 46 Syrian pounds; in 2022,  
1 USD is worth 4000 Syrian pounds) and the militariza-
tion of the health care system have impacted health 
care spending. For example, more funds and resources 
are allocated to treat war victims who suffer from 
life-threatening injuries, and less is invested in chronic 
disease care and screening programs[5].

All these things have directly and indirectly changed 
the urology disease spectrum in Syria, with increases in 
the number of complex urethral injuries, late presenta-
tions of prostate and kidney cancer, and the number of 
young patients with bladder cancer. At the same time, 
hospitals are less able to acquire or maintain equipment 
and disposables required for endourology surgery and 
laparoscopic surgery. The scarcity of resources has chal-
lenged practicing urologists in our country to tailor their 
practice accordingly.

While the international urolog y community is 
embracing mini-PCNL for staghorn stones, urologists 
in Syria are running backward in time to perform open 
pyelolithotomy and open nephrolithotomy. At the same 
time as international colleagues have the luxury of offer-
ing a cornucopia of procedures to treat BPH, traditional 
TURP in our part of the world might be canceled due to 
a shortage of irrigation fluid.

As the data from the PEACE-1 trial showed that a 
triplet combination improves overall survival of de novo 
metastatic castration-sensitive prostate cancer, surgical 
castration might be the only option the urologist can 
offer in Syria[8]. Sharing the news with patients that they 
have metastatic renal cell and bladder cancer is like shar-
ing a death sentence with them.

Even affluent citizens who can afford to travel to other 
countries for treatment and are lucky enough to get an 
entry visa are vulnerable to medical scams, to being 
overcharged, and to having unnecessary procedures 
recommended. Some of these patients come back to 
Syria without proper documentation of their treatment 
or a follow-up plan[9].

294 SIUJ  •  Volume 3, Number 5  •  September 2022 SIUJ.ORG

UROLOGY AROUND THE WORLD

https://orcid.org/0000-0002-6523-4428
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The training of future urologists locally is another 
challenge. Intelligent, dedicated residents have limited 
exposure to new technologies such as laser treat-
ment of kidney stones, PCNL, staplers, and sealing 
devices. Added to this, opportunities to close the gaps 
in residency training through hands-on courses at 
international urology society meetings are now non-ex-
istent—as are opportunities for advanced postgraduate 
training abroad.

Several humanitarian agencies have worked tirelessly 
with different parties to facilitate access to primary 
care medications such as antibiotics, painkillers, and 
vaccines for children. In addition, in specific scenar-
ios, these agencies were able to establish primary care 
centers and equip them with essential tools such as 

X-ray, CT, and hemodialysis machines[10]. We believe  
that international urology societies should coordinate 
with humanitarian agencies to play a role in ensuring 
that urologists in conflict zones have access to modern 
essential surgery tools and life-prolonging medications.

Another avenue of support for the urologist commu-
nity in Syria and other conflict zones around the world is 
to invest in training a new generation of urologists. This 
can be achieved by granting these urologists unlimited 
access to e-courses, podcasts, recorded webinars, and 
surgical educational material. As more platforms are 
available to facilitate tele-proctoring, international urol-
ogy societies might collaborate to offer tele-proctoring 
programs to the global urology community.

References

1. Abu-Lughod JL. Damascus. In: Dumper MRT, Stanley BE, eds. Cities 
of the Middle East and North Africa: A Historical Encyclopedia. 
ABC-CLIO;2007. ISBN 978-1-5760-7919-5.

2. Ibn al-Nafis. Al-Mujaz fi al-Tibb. Al-Ezbawy A, ed. 4th ed. Cairo: Islamic 
Heritage Revival Committee, Supreme Council for Islamic Affairs, 
Ministry of Endowments.2004;239-241.

3. Abdel-Halim RE, Abdel-Maguid TE. The functional anatomy of 
the uretero-vesical junction. A historical review. Saudi Med 
J.2003;24:815-819.

4. Young A, Chaudhry HJ, Pei X, Arnhart K, Dugan M, Steingard SA. 
FSMB census of licensed physicians in the United States. J Med 
Regul. 2018;105 (2):7-23. Available at: ht tps://w w w.fsmb.org/
siteassets/advocacy/publications/2018census.pdf. Accessed April 
27, 2021.

5. Fouad M, Sparrow A, Tarakji A, Alameddine M, El-Jardali F, Coutts AP, 
et al. Health workers and the weaponisation of health care in Syria: 
a preliminary inquiry for The Lancet–American University of Beirut 
Commission on Syria. Lancet.2017;390(10111):2516-2526. doi: 10.1016/
S0140-6736(17)30741-9. Epub 2017 Mar 15.

6. Abbara A, Orcutt M, Gabbar O. Syria’s lost generation of doctors. 
BMJ.2015;350:h3479. doi: 10.1136/bmj.h3479.

7. Shahait M, Nasr RW. Contemporary management of urogenital injuries. 
In: Reconstructing the War Injured Patient.2017; Springer:119-129.

8. Fizazi K, Foulon S, Carles J, Roubaud G, McDermott R, Fléchon A, et al. 
Abiraterone plus prednisone added to androgen deprivation therapy 
and docetaxel in de novo metastatic castration-sensitive prostate 
cancer (PEACE-1): a multicentre, open-label, randomised, phase 3 
study with a 2× 2 factorial design. Lancet.2022;399(10336):1695-1707. 
doi: 10.1016/S0140-6736(22)00367-1. Epub 2022 Apr 8.

9. International Association for Medical Assistance for Travellers. How to 
avoid medical scams abroad. Travel Health Journal.2021. Available at: 
https://www.iamat.org/blog/how-to-avoid-medical-scams-abroad/. 
Accessed August 1, 2022.

10. United Nations Office for the Coordination of Humanitarian Affairs. 
Syria Humanitarian Response Plan 2021. Available at: ht tps://f ts.
uno cha.or g /ap p e als / 9 24 /p r oje c t s? f %5 B 0 %5 D = de s tina tion 
ClusterIdName%3A5226%3AHealth. Accessed August 1, 2022.

295SIUJ.ORG SIUJ  •  Volume 3, Number 5  •  September 2022

Urology in Syria: A View From Inside

https://www.fsmb.org/siteassets/advocacy/publications/2018census.pdf
https://www.fsmb.org/siteassets/advocacy/publications/2018census.pdf
https://www.iamat.org/blog/how-to-avoid-medical-scams-abroad/
https://fts.unocha.org/appeals/924/projects?f%5B0%5D=destinationClusterIdName%3A5226%3AHealth
https://fts.unocha.org/appeals/924/projects?f%5B0%5D=destinationClusterIdName%3A5226%3AHealth
https://fts.unocha.org/appeals/924/projects?f%5B0%5D=destinationClusterIdName%3A5226%3AHealth
http://SIUJ.org



