Year : 2011 | Volume
: 27 | Issue : 4 | Page : 435--436
Evidence-based urology: Overrated or need of the hour
Nitin S Kekre
Department of Urology, Christian Medical College, Vellore, Tamil Nadu, India
Nitin S Kekre
Department of Urology, Christian Medical College, Vellore, Tamil Nadu
|How to cite this article:|
Kekre NS. Evidence-based urology: Overrated or need of the hour.Indian J Urol 2011;27:435-436
|How to cite this URL:|
Kekre NS. Evidence-based urology: Overrated or need of the hour. Indian J Urol [serial online] 2011 [cited 2020 Oct 19 ];27:435-436
Available from: https://www.indianjurol.com/text.asp?2011/27/4/435/91428
Traditionally, surgery has been learnt by apprenticeship. Innovations are usually born out of necessity. With the rapid advancement of science over the last 25 years, surgery in general, and urology in particular, have become more technology driven. The World Wide Web has ensured rapid dissemination of ideas without peer review. New surgical procedures are adopted, often without enough scrutiny or comparison with previous methods of management. Even as evidence-based urology seeks to bridge these gaps, many obstacles exist. Surgical procedures are not easily randomized. Both surgeons and patients usually 'lack equipoise' and are reluctant to participate in a randomized controlled trial (RCT). 
The cornerstone of evidence-based medicine is the RCT. It was devised almost a century ago in psychology, then in agriculture, and later modified in the 1940s, by Bradford Hill, to evaluate the effectiveness of streptomycin in tuberculosis. 
The RCT is best suited to evaluate mature therapies. It is difficult to use for rapidly changing technology or where follow-up is likely to be long. It requires skill, effort, and considerable expense, not to speak of time. The RCT is best suited for research in which the biases are obvious, differences in results do not differ very much from the mean, and randomization is required only once.  Good randomization is difficult. Bad randomization is easy, and common. Adopting surgical trials to the format of a RCT poses unique problems. The problems are often too complex to be addressed in a single RCT. The trial is usually conducted in specialized centers. The trial subject is not the average patient. The experience and the skill of the surgeons involved is usually not equivalent to the average surgeon. Significant ethical issues exist, particularly in novel therapies and studies of harm. More than 60 years ago Daniels stated, "To accept only patients approved by an independent team, to conform to an agreed plan of treatment, and to submit results for analysis by an outside investigator involves a considerable sacrifice."  Little has changed to this day. Independent scrutiny of results is still the exception. Poor research makes for poor science. A poorly designed, ill-executed RCT adds little to knowledge. There is a case for good observational studies with rigorous criteria(to eliminate bias) to supplement the RCT. Robust methodology is available to compare patients from different databases and adjust for bias and confounding factors. A well-designed observational study remains a very valuable tool to fill the gaps in the existing evidence.
Implementing evidence-based practice in the environment of a busy clinical practice is difficult. It requires commitment, manpower, and expense. Even as progress on this front has been slow, there is a growing realization of the need to scrutinize the plethora of industry-driven technology, before universal adoption. This issue of the Indian Journal of Urology (IJU) has a symposium by a very distinguished group of academicians on evidence-based practice. This issue is guest-edited by Dr. Chandrasingh along with Dr. Philipp Dahm and I am extremely grateful to them for their contribution. I am sure it will go a long way in helping us incorporate critical thinking into our practice. This issue has two interesting review articles on very rare clinical problems. Dysfunctional voiding is an important voiding dysfunction which is usually missed unless one has high index of suspicion and has access to video urodynamics. Dr. Sanjay Sinha has reviewed this complex problem in a most comprehensive fashion. Dr, Juan A. Ramos has provided a short review on a very rare entity of melanoma of the female urethra.
Let me take this opportunity to wish you all a very happy and a prosperous New Year. Hope to see you all at Bangalore.
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|2||Hill AB. The clinical trial. N Engl J Med1952;247:113-9.|
|3||Fyfe IM. The randomized clinical trial: Panacea or placebo?Can Med Assoc J 1984;131:1336-9.|
|4||Daniels M. Scientific appraisement of new drugs in tuberculosis.Am Rev Tuberc 1950;61:751-6.|