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Contents

List of contributors

Anthony Addesa

Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, USA

Ashok Agarwal

Center for Reproductive Medicine, Glickman Urological and Kidney Institute, The Cleveland Clinic, Cleveland, OH, USA

Mitchell Anscher

Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, USA

Daniel A. Barocas

Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA

Jeanette Buckingham

John W. Scott Health Sciences Library, University of Alberta, Alberta, Canada

Benjamin K. Canales

Department of Urology, University of Florida, Gainesville, FL, USA

Sam S. Chang

Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA

Christopher R. Chapple

Sheffield Teaching Hospital NHS Trust, Royal Hallamshire Hospital, Urology Research, Sheffield, UK

Peter Chung

Department of Radiation Oncology, University of Toronto, and the Radiation Medicine Program, Princess Margaret Hospital, Toronto, Canada

J. Quentin Clemens

Department of Urology, University of Michigan, Ann Arbor, MI, USA

Michael S. Cookson

Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA

Jonathan C. Craig

School of Public Health, University of Sydney, New South Wales, Australia

Philipp Dahm

Department of Urology, University of Florida, Gainesville, FL, USA

Fnu Deepinder

Center for Reproductive Medicine, Glickman Urological and Kidney Institute, The Cleveland Clinic, Cleveland, OH, USA

Roger R. Dmochowski

Department of Urologic Surgery, Vanderbilt University, Nashville, TN, USA

Sean P. Elliott

Department of Urologic Surgery, University of Minnesota, Minneapolis, MN, USA

Martha M. Faraday

Four Oaks, LLC; Keedysville, MD, USA

Fernando Ferrer

Department of Urology, Connecticut Children’s Medical Center, Hartford, CT, USA

Susan F. Fesperman

Department of Urology, University of Florida, Gainesville, FL, USA

Robert A. Figlin

City of Hope National Medical Center, Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, CA, USA

John M. Fitzpatrick

Department of Urology and Surgical Professional Unit, Mater Misericordiae University Hospital, Dublin, Ireland

Alexander Gomelsky

Department of Urology, Louisiana State University Health Sciences Center, Shreveport, LA, USA

Michael Hagan

Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, USA

John M. Hollingsworth

University of Michigan, Department of Urology, Division of Health Services Research, Ann Arbor, MI, USA

Ryan Hutchinson

Department of Urologic Surgery, Vanderbilt Medical Center, Nashville, TN, USA

Alexander Karl

Department of Urology, School of Medicine, University of California-San Francisco, San Francisco, CA, USA

Melissa R. Kaufman

Department of Urologic Surgery, Vanderbilt University, Nashville, TN, USA

Bodo E. Knudsen

Department of Urology, Ohio State University Medical Center, Columbus, OH, USA

Badrinath R. Konety

Department of Urology, University of Munich LMU, Munich, Germany

Zoe S. Kopp

Pfizer Inc, New York, NY, USA

Jeffrey C. LaRochelle

Institute of Urologic Oncology and Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA

Ngoc-Bich Le

Department of Urology, University of Florida, Gainesville, FL, USA

Yair Lotan

Department of Urology, University of Texas Southwestern Medical Center at Dallas, TX, USA

Rustom P. Manecksha

Department of Urology and Surgical Professional Unit, Mater Misericordiae University Hospital, Dublin, Ireland

Malcolm D. Mason

Cochrane Urological Cancers Unit, Velindre NHS Trust, Cardiff, UK

Philip Masson

Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, Scotland

Bahaa S. Malaeb

Department of Urologic Surgery, University of Minnesota, Minneapolis, MN, USA

S.L. Matheson

Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia

Jack W. McAninch

Department of Urology, San Francisco General Hospital, San Francisco, CA, USA

James M. McKiernan

Department of Urology, Columbia University Medical Center, New York, NY, USA

Chris G. McMahon

University of Sydney, Australian Centre for Sexual Health, Sydney, Australia

Priya Mitra

Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, USA

Adam C. Mues

Department of Urology, Ohio State University Medical Center, Columbus, OH, USA

Alana M. Murphy

Department of Urology, Columbia University Medical Center, New York, NY, USA

Dominic Muston

Health Economic Modelling Unit, Heron Evidence Development Ltd, Luton, UK

Michael Myers

Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, USA

J. Curtis Nickel

Department of Urology, Queen’s University, Kingston, Ontario, Canada

Regina D. Norris

University of Pittsburgh Medical Center, Children’s Hosptial of Pittsburgh, Pittsburgh, PA, USA

Susan L. Norris

Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, OR, USA

Ann Oldendorf

Department of Urology, University of Michigan, Ann Arbor, MI, USA

Allan J. Pantuck

Institute of Urologic Oncology and Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA

Dipen J. Parekh

Department of Urology, University of Texas Health Sciences Center at San Antonio, San Antonio, TX, USA

Margaret S. Pearle

Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA

David F. Penson

Department of Urologic Surgery, Vanderbilt University and VA Tennessee Valley Healthcare System, Nashville, TN, USA

Frédéric Pouliot

Institute of Urologic Oncology and Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA

Glenn M. Preminger

Comprehensive Kidney Stone Center, Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA

Puneeta Ramachandra

Division of Urology, University of Connecticut Health Center, Farmington, CT, USA

Jay D. Raman

Division of Urology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA

Amanda Beth Reed

Department of Urology, University of Texas Health Sciences Center at San Antonio, San Antonio, TX, USA

Kristin C. Reed

South Texas Veterans Health Care System, San Antonio, TX, USA

Monique J. Roobol

Erasmus University Medical Centre, Rotterdam, The Netherlands

Charles J. Rosser

Department of Urology, University of Florida, Gainesville, FL, USA

Edmund S. Sabanegh, Jr

Center for Reproductive Medicine, Glickman Urological and Kidney Institute, The Cleveland Clinic, Cleveland, OH, USA

Charles D. Scales, Jr

Division of Urology, Department of Surgery, Duke University Medical Center, Durham, NC, USA

Harriette Scarpero

Department of Urologic Surgery, Vanderbilt Medical Center, Nashville, TN, USA

Fritz H. Schröder

Erasmus University Medical Centre, Rotterdam, The Netherlands

Holger J. Schünemann

Department of Clinical Epidemiology and Biostatistics, McMaster University Health Sciences Centre, Hamilton, Ontario, Canada

Mark Shaw

Department of Radiation Oncology, University of Toronto, and the Radiation Medicine Program, Princess Margaret Hospital, Toronto, Canada

Mike D. Shelley

Cochrane Urological Cancers Unit, Velindre NHS Trust, Cardiff, UK

Elizabeth Soll

University of Michigan, Department of Urology, Division of Health Services Research, Ann Arbor, MI, USA

Mathew D. Sorensen

Department of Urology, University of Washington School of Medicine, Seattle, WA, USA

James Thomasch

Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA

Timothy Y. Tseng

Comprehensive Kidney Stone Center, Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA

Przemyslaw W. Twardowski

City of Hope National Medical Center, Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, CA, USA

Pim J. van Leeuwen

Erasmus University Medical Centre, Rotterdam, The Netherlands

Bryan B. Voelzke

Department of Urology, Harborview Medical Center, Seattle, WA, USA

Padraig Warde

Department of Radiation Oncology, University of Toronto, and the Radiation Medicine Program, Princess Margaret Hospital, Toronto, Canada

Angela C. Webster

School of Public Health, University of Sydney, New South Wales, Australia

John T. Wei

University of Michigan, Department of Urology, Division of Health Services Research, Ann Arbor, MI, USA

Hunter Wessells

Department of Urology, University of Washington School of Medicine, Seattle,

WA, USA

John S. Wiener

Departments of Surgery and Pediatrics,

Duke Univesity Medical Center, Durham, NC, USA

Lawrence L. Yeung

Department of Urology, University of Florida, Gainesville, FL, USA

Preface

Evidence-based clinical practice has been defined in many different ways, but fundamentally relates to the use of systematically appraised evidence to guide clinical decision-making while incorporating the values, preferences and specific circumstances of an individual patient. This evidence may, in the future, become the critical determining factor in the development of comparative effectiveness as it applies to the field of urology. Evidence-Based Urology was conceptualized to address focused, clinical questions across all domains of our specialty to help urologists practice according to the current best evidence.

We have asked authors to identify the most relevant clinical questions in their sub-specialty, perform systematic literature searches, appraise the quality of available evidence using the GRADE framework, and make practical recommendations that reflect this evidence. We hope that the reader will find this text useful not only as a free-standing urology textbook, but as a valuable resource in their day-to-day practice.

We further hope that this text will assist readers to update their knowledge in specific content areas for their own continuous medical education by using the techniques employed in this text (formulating a clinically relevant question, systematic literature search and rating of the quality of evidence). Finally, our wish is that this text will stimulate further interest in evidence-based urology, thus promoting the best possible care to our patients.

Philipp Dahm MD, MHSc, FACS

University of Florida

Gainesville, Florida, USA

Roger R. Dmochowski MD

Vanderbilt University

Nashville, Tennessee, USA

Foreword

Evidence-based medicine (EBM) – or evidence-based surgery, or evidence-based urology (EBU) – is about solving clinical problems. In particular, EBU provides tools for using the medical and surgical literature to determine the benefits and risks of alternative patient management strategies, and to weigh those benefits and risks in the context of an individual patient’s experiences, values and preferences.

The term evidence-based medicine first appeared in the medical literature in 1991; it rapidly became something of a mantra. EBM is sometimes perceived as a blinkered adherence to randomized trials, or a health-care managers’ tool for controlling and constraining recalcitrant physicians. In fact, EBM and EBU involve informed and effective use of all types of evidence, but particularly evidence from the medical literature, in patient care.

EBM’s evolution has included outward expansion. We now realize that optimal health care delivery must include evidence-based nursing, physiotherapy, occupational therapy, and podiatry – and specialization. We need evidence-based obstetrics, gynecology, internal medicine and surgery – and indeed, orthopedics, and neurosurgery. And of course, we need evidence-based urology.

Applying EBU to management decisions in individual patients involves use of a hierarchy of study design, with high-quality randomized trials showing definitive results directly applicable to an individual patient at the apex, to relying on physiological rationale or previous experience with a small number of similar patients near the bottom rung. Ideally, systematic reviews and meta-analyses summarize the highest quality available evidence. The hall-mark of evidence-based practitioners is that, for particular clinical decisions, they know the strength of the evidence, and therefore the degree of uncertainty.

What is required to practice EBU? Practitioners must know how to frame a clinical quandary to facilitate use of the literature in its resolution. Evidence-based urologists must know how to search the literature efficiently to obtain the best available evidence bearing on their question, to evaluate the strength of the methods of the studies they find, extract the clinical message, apply it back to the patient, and store it for retrieval when faced with similar patients in the future.

Traditionally, neither medical schools nor postgraduate programs have taught these skills. Although this situation has changed dramatically in the last decade, the biggest influence on how trainees will practice is their clinical role models, few of whom are currently accomplished EBU practitioners. The situation is even more challenging for those looking to acquire the requisite skills after completing their clinical training.

This text primarily addresses the needs of both trainees and of this last group, practicing urologists. Appearing 20 years after the term EBM was coined, the text represents a landmark in a number of ways. It is the first comprehensive EBU text. The book represents a successful effort to comprehensively address the EBU-related learning needs of the urology community, and summarize the key areas of urological practice.

To achieve its goals of facilitating evidence-based urologic practice, the text begins with chapters that introduce the tools for evaluating the original urologic literature. Those interested in delving deeper into issues of how to evaluate the literature, and apply it to patient care, can consult a definitive text (see ).

The bulk of the current text, however, provides evidence summaries to guide each of the key common problems of urologic practice. Thorough and up to date at the time of writing, they provide a definitive guide to evidence-based urologic practice today. That evidence will, of course, change – and in some areas change quickly. Clinicians must therefore use Evidence-Based Urology not only as a text for the present, but as a guide for updating their knowledge in the future. That future will hopefully hold the advent of an evidence-based secondary journal similar to those that have been developed in other areas including Evidence-based Mental Health, Evidence-based Nursing, and the ACP Journal Club – which does the job for internal medicine – survey a large number of journals relevant to their area and choose individual studies and systematic reviews that meet both relevance and validity screening criteria. These journals present the results of these studies in structured abstracts that provide clinicians with the key information they need to judge their applicability to their own practices. Fame and fortune await the enterprising group who applies this methodology to produce evidence-based urology.

Whatever the future holds for the increasing efficiency of evidence-based practice, the current text provides an introduction to a system of clinical problem-solving that is becoming a pre-requisite for modern urologic practice.

Gordon Guyatt BSc (Toronto), MD (McMaster).

MSc (McMaster) FRCPC

Professor, Department of Clinical

Epidemiology & Biostatistics

Joint Member, Department of Medicine

Member, CLARITY (Clinical Advances

through Research and Information Translation)