To examine low- and middle-income country (LMIC) representation within urology research and highlight disparities that limit equitable, inclusive, and context-specific investigation.

A systematic review was performed using Scopus to identify all urology articles published from 2013-2023 across 117 urology journals. Country affiliations were based on abstract, title, or author institution. Publications were categorized by country income level based on World Bank classifications. Trends in first authorship across income settings were analyzed using separate linear regression models and compared using multiple linear regression analysis with interaction terms. Population-adjusted Poisson regression models assessed for associations between income category and first author research output.

A total of 128,949 articles were included. 0.99% were affiliated with low-income (LIC), 7% with middle-income (MIC), 23% with upper-middle-income (UMIC), and 79% with a high-income country (HIC). The top country from each income-category was Niger, India, China, and USA, respectively. LICs first-authored 0.4% of all publications. HICs produced 95-times more first-authored articles than LICs, while UMICs and MICs produced 13- and 3-times more, respectively (IRR = 94.8, IRR = 12.7, IRR = 3.1, all P -values < .001). Over the 10-year, the proportion of first-authored articles from LIC, MIC and UMICs increased significantly, but variably. On average, HIC publications increased at a rate of 145 more articles/year than LICs and UMICs increased at a rate of 189 more articles/year (both P < .001).

Major disparities exist in urology research output and authorship across income settings. Addressing these inequities will require deliberate efforts to strengthen research infrastructure, expand international collaborations, and create more inclusive opportunities for publication.