This is an open access article under the terms of a license that permits non-commercial use, provided the original work is properly cited. © 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 https://orcid.org/0000-0003-2609-5629 mailto:mshahait%40yahoo.com?subject=SIUJ http://SIUJ.org 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