|Year : 2005 | Volume
| Issue : 2 | Page : 70-73
J Chandra Singh
Department of Urology, Christian Medical College, Vellore, Tamilnadu, India
J Chandra Singh
Department of Urology, Christian Medical College,Vellore - 632 004, Tamilnadu.
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Singh J C. Evidence-based urology. Indian J Urol 2005;21:70-3
Evidence-based medicine is the process of systematically finding, appraising, and using contemporaneous research findings as the basis for clinical decisions. According to Sackett et al. the incorporation of evidence-based medicine into medical decision-making is the 'conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.' The emphasis on evidence-based practice is growing and urology is no exception. With the number of journals and newer treatments increasing in our specialty, urologists need to be aware of the principles of evidence-based practice in order to make full use of the available information and management options. Knowledge of clinical epidemiology and biostatistics enables one to draw reasonable conclusions from available literature and to involve actively in clinical research. Evidence-based medicine enables a clinician to integrate personal knowledge, experience, and clinical expertise with knowledge gained through review of available literature.
| Methods|| |
Recent publications on evidence-based medicine were reviewed. Impact of evidence-based practice on the evaluation and management of various urological disorders and their relevance to urologists was studied. The lacunae in our knowledge requiring evidence-based answers were highlighted.
History of evidence-based urology
A number of discrete case reports and 'points of technique' of urological intervention had been recorded in medical history since 273 B.C. but the first case series was that of Morrissey in 1878. The article published in the American Journal of the Medical Sciences in January 1878 described a sizable series of litholapaxies with a new instrument, a series with only one mortality. It created much excitement about his technique, as the mortality rates of his contemporaries was much higher. Morrissey recommended that no more than 15 or 20 min be utilized in carrying out the procedure and he made significant observations on the chemical contents of the stones and also noted that they were associated with prostatic changes. The procedure revolutionized the brutal type of treatment of vesical calculi, which was in vogue. About 125 years down the line, there have been a lot of new developments in our specialty but a few of the principles described long back still hold well.
Alternatives to evidence-based medicine
Isaacs and Fitzgerald, posed the question 'What would you do if you don't have randomized controlled trials?' to clinicians and seven alternatives to evidence-based medicine were identified. They include ' eminence-based medicine ' where the grey hair of the clinician speaks for himself and his talk is punctuated with 'in my experience". The second group practiced ' vehemence-based medicine ' and they proved their point by being firm dogmatic and vociferous. The third group practiced ' eloquence-based medicine ' and they mastered on the smoothness of their tongue and their vocabulary. The fourth group believed in ' providence-based medicine ' and they believed that all happenings are due to divine providence. The fifth group practiced ' diffidence-based medicine ' and their groans and sighs were heard all over. The sixth group believed in ' litigation-based medicine ' and the last group opted for ' confidence-based medicine '. Any alternative to evidence based medicine falls into one of these categories.
Is evidence-based medicine relevant?
Urology has a variety of treatments and techniques, which require a rational approach to diagnosis and management. Interpretations of the investigations and radiological images vary among urologists. The great diversity of disease entities adds opportunity for controversy. Management options vary from minimally invasive interventions to those associated with significant morbidity. Practicing urologists need to be aware of definite indications, contraindications, and controversies while choosing the investigations and interventions for their patients. Scientifically sound evidence-based principles form the backbone for such decisions. There are other areas where even a placebo may be beneficial in a good number of patients as in men with erectile dysfunction. A few interventions like high-dose androgens to enhance quality of erections have been shown to be harmful. Evidence that is tested and validated by others and that is added to the literature enriches and validates the information and our knowledge base.
Considerations in a study design
While obtaining information from scientific studies, it is essential to know how the study was designed and performed. A study done with the most appropriate design gives the required information and the basis for decision-making. Although a multi-centric double blind randomized controlled trial provides the reliable answer for most research questions, it may not be feasible in many situations due to ethical reasons and problems in randomization. The following table gives the important study designs and a few trials with valuable results from these designs [Table - 1].
Health economics and evidence-based urology
Health economics is another vital dimension of evidence-based medical practice. Decisions based on economical implications play a vital role in management of diseases like end stage renal disease with renal transplantation or investing on equipment with high-capital costs. It incorporates the economical aspects of the various treatment options and also the economical impact a treatment option has on those who are treated. For example, in a revolutionary article published by Goyal et al. in the JAMA on the economical impact of selling a kidney in India, the authors have concluded based on this well conducted study that selling a kidney in order to run away from economical crisis does not solve the problem and the quality of life worsens after selling a kidney. The inference of this paper has far reaching consequences, especially while deciding on the ethical issues involved in selling one's organs to salvage an economic crisis in developing countries like India.
Economic evaluation includes cost-effectiveness analysis, cost benefit analysis and cost-utilization analysis that facilitates judicious utilization of resources and to derive the maximum outcome from the investment. This is relevant when decisions about procuring new equipment have to be made or if a programme is planned with a desire to have an impact on the community. For example, Bonzani et al. have done a cost-effectiveness analysis comparing bilateral orchidectomy and hormone suppression for metastatic carcinoma prostate. They concluded that hormone suppression by LH-RH treatment translates to a 15 times cost increase. They have calculated that with western standards and the cost of surgery, in a patient with expected survival more than 9 months, medical management will be more expensive. In India, it will be many times more considering the cost of the drugs in comparison to performing an orchidectomy.
Impact of evidence-based practice in modern urology
The impact of evidence-based approach is evident in most areas of urology. In testicular neoplasms, various chemotherapy and radiotherapy protocols have been studied and the 5-year survival has improved steadily over the years, even for nonseminomatous germ cell tumours. For stages I and II, it was 61% in 1973 but it is more than 90% now. The focus has shifted from increasing survival to reducing morbidity and options like nerve sparing retroperitoneal lymph node dissection are being attempted even in metastatic testicular tumour and the response from oncological point of view has been acceptable.
Management of urolithiasis has become less and less invasive and the clearance rates have been progressively improving. Evidence-based studies have enabled comparing various treatment modalities and to arrive at a protocol for the different kinds of stones. There has been a revolutionary change in our approach to erectile dysfunction after the advent of phosphodiesterase inhibitors and randomized trials have conclusively proven their efficacy in erectile dysfunction. With the availability of better alpha blockers with lesser adverse effects being proven in clinical trials, medical management of obstructive voiding has been more rewarding than before.
Lacunae in modern urology - is there a ray of hope?
There are a few areas, which are haunting the urologist and evidence-based studies are likely to give definite answers. Which group of men will definitely benefit from radical prostatectomy and have a definite reduction in cause specific mortality? Although radical prostatectomy has been shown to be beneficial in early prostate cancer, can the results be generalized to screening detected cancer? In a country like ours where tuberculosis is rampant, the ideal investigative protocol for early detection of genitourinary tuberculosis is not available. In the vast majority of stone formers, the effective strategy to prevent stone formation is an area of interest to urologist and the available options are not satisfactory for most patients.
Evidence-based training in urology
Evidence-based medicine ought to be incorporated early into urology training curricula. Most effective learning occurs when specific information is sought and applied to an authentic case or problem at hand. Every clinical scenario with a diagnostic dilemma or a difficult management should be looked at as an opportunity to gain knowledge and the best possible evidence for the next step of action. The urology trainee should learn to use literature search to directly link the practical information to the case problem that was analysed. When residents present cases in conference, the cases should be accompanied by evidence as often as possible. Journal clubs provide the opportunity to complete exercises in literature evaluation and critical appraisal, which include the evaluation of the study design, the statistical application, the interpretation and the applicability of study results to a clinical problem. A resident leading the discussion on each topic provides a learning opportunity in controversial discussions.
| Conclusion|| |
Evidence-based practice has made a difference in the urologist's understanding, approach and management. It has enabled the urologist to standardize management protocols and to measure treatment outcome, thus improving the quality of care. Basic understanding of epidemiological principles and biostatistics is vital for every practicing urologist to make sense out of the high-quality literature available from the journals and the Internet. We can eagerly anticipate a breakthrough in our understanding in the near future as more clinicians involve in research and experimental studies. Let us, as urologists, be followers of evidence-based medicine now and always!
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[Table - 1]