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Background questions relate to the pathophysiology of a disease and query knowledge that is usually obtained early during training. In daily practice, urologists will mainly face foreground type questions, which is why these stand at the center of the EBM process. For example, a man aged 52 years may present in an outpatient clinic with colic pain caused by a 9 mm stone in the lower pole of the right kidney, reporting no fever and with serum creatinine within normal limits.

A background question that may arise from this scenario would concern the factors that promote the formation of renal calculi. Foreground questions on the other hand would be about how best to treat a patient with a 9 mm stone in the lower pole of the right kidney, how best to establish the diagnosis of kidney stone what is the natural history of a patient with 9 mm kidney stone or which management strategy would offer the optimal balance of therapeutic effectiveness and costs. The question should be structured in such a way that it will guide the subsequent literature search to the best available evidence.

Formulating a clinical question requires not only information about the clinical scenario eg, adult male with kidney stone , but also knowledge of applicable therapeutic measures, such as intervention and comparison [eg, Extracorporeal Shockwave Lithotripsy ESWL , Ureteroscopy URS , and Percutaneous surgery PNL ], and the outcome of interest eg, stone-free rate. In addition, the PICO format suggests specifying, which study design is likely to yield the highest level of evidence.

For questions of therapeutic effectiveness, for instance, this would be a systematic review with a meta-analysis of several RCTs with low heterogeneity. It is advisable to keep the PICO question as simple as possible. For example, based on the clinical scenario mentioned above, of a good clinical question using the PICO formula would be: Based on such a clear and relevant research question, a directed search of the literature databases can be performed.

Nowadays doctors are flooded by information from various sources. Medical journals, congresses, textbooks, and the internet provide a daily stream of useful and not so useful information. For clinicians it is important to direct all this information in an efficient way. Searching for evidence can either be done directly, for instance by entering relevant search words into a database, such as Medline, or by consulting databases that provide preappraised evidence, the most well known being those within the Cochrane Collaboration.

Furthermore, there is an increasing number of dedicated journals, such as Clinical Evidence , Evidence-based Healthcare , Evidence-based Cardiovascular Medicine , Evidence-based Obstetrics and Gynecology , Cancer Treatment reviews — Evidence based Oncology , so on, that can provide doctors with evidence-based information.

Last but not least, guidelines also constitute a convenient source of evidence. They can be found using the National Guidelines Clearing House website, which is an open access public resource [ Appendix 1 ]. Each of these resources is discussed briefly below.


The primary literature on original research provides the backbone of evidence for the practice of evidence-based urology. The drawback to primary literature sources, however, is the need to identify high-quality studies from a multitude of investigations on a particular topic. Relevant studies would be retrieved, and then critically appraised for their validity, impact, and applicability. To remain up-to-date, one can also register for a free e-mail service to receive all new trials in a specific search area on a daily, weekly, or monthly basis.

What should urologists know about evidence-based medicine?

These strategies can dramatically reduce the time required to identify high-quality research. The most renowned is probably the Cochrane database of Systematic Reviews. In this database, several urological issues can be found, such as early versus deferred androgen suppression in the treatment of advanced prostatic cancer, immunotherapy for advanced renal cell cancer, prostate cancer screening, and quinolone antibiotics for uncomplicated cystitis in women.

Guidelines have an important role in EBM and there are several guidelines available for urologists. The AUA and EAU, for example, provide guidelines addressing the most common urological problems, which can be very useful in clinical decision-making [ Appendix 1 ]. These guidelines usually represent the consensus among a panel of experts, who ideally applied a formal and critical appraisal process to assess the quality of the available evidence for a given clinical question, and who subsequently graded the strength of the recommendation.

While guidelines are used by many urologists, it is important to note that they also have certain drawbacks. Firstly, not all guidelines are based on the EBM approach. Secondly, guidelines are generic and mainly applicable to an idealized index patient with certain clinical characteristics. Thirdly, guidelines are not available for all topics. Moreover, there often is a considerable time lag between the publication of the latest clinical studies and their incorporation into professional guidelines.

Also, guidelines by different organizations can come to different conclusions, even when reviewing the same evidence. This is by the considerable variations of guidelines that address PSA-based prostate cancer screening. According to the definition of EBM, however, decisions should be based on the best available evidence.

If no RCT exists, one has to solve the case based on lower grade evidence leading to a weaker recommendation. Consequently, EBM is not cookbook medicine as another popular misconception would have it. Urologists, like all trained doctors, are the experts in combining clinical features, patient preferences, and available evidence from the urological literature.

Therefore, urologists make the decision, not the literature. The six As described above illustrate this process. Clinical expertise is key in developing answerable questions, finding suitable literature, appraising manuscripts, and combining this knowledge with patient preferences and local clinical settings. Thus, EBM starts with the patient and ends with the patient. A third misconception is that EBM practitioners should be statisticians. Indeed, some basic knowledge on statistical concepts is helpful.

However, understanding study methodology and finding sources of bias during critical appraisal are most important. Unfortunately, evidence-based medicine is not yet widely used in urology. Most published studies in the urological journals have a low level of evidence and, as a consequence, a low grade of recommendation, as in other surgical fields. The vast majority of publications consists of single-center case-series.

A study conducted by Bowraski et al. A critical assessment of the quality of reporting of RCTs in the urology literature conducted by Scales et al. In recent years, however, some progress has been made. In the urology literature today there is more attention to the concepts of EBM.

Especially the work of the American urologist Dahm and his coworkers introduced a broad awareness of the basic principles of EBM urology. An International Evidence-based Urology Working Group has been established and is reporting on all kinds of topics regarding EBM in the urology literature. The editors of some leading urology journals have recognized that EBM is essential for their readers resulting in a series of publications about the concepts of EBM in their journals. To spread the understanding of EBM among urologists even further, workshops are being organized for the members of the AUA.

Furthermore, there are several online resources that can help urologist to expand their knowledge on EBM [ Appendix 2 ]. The practice of EBM means integrating individual clinical expertise with the best available external evidence. Since the introduction of EBM over 20 years ago, the concept has been broadly embraced and increasingly implemented in daily decision-making, both in medical specialties and more recently in surgical specialties.

In urology EBM is still in its infancy. However, it is clear that EBM will have an increasing role for urologists and that an understanding of its underlying principles is highly relevant to their clinical practices. EBM will have an increasing importance for urologists and understanding its underlying principles is highly relevant to our clinical practices. National Center for Biotechnology Information , U. Journal List Indian J Urol v. Mazel and Rudolf W. Author information Copyright and License information Disclaimer.

This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3. Evidence-based medicine, integrating evidence in to clinical practice, urology. Open in a separate window. Integrating individual patient values and circumstances with the evidence To apply EBM to clinical patient care requires a systematic approach. The physician needs to understand the patient's problem and to determine the full context of patient characteristics, demographics, and differential diagnosis to be able to formulate a clear research question.

Compose a clear research question for the patient's problem. Table 2 PICO clinical patient-oriented questions. The third step is to retrieve the evidence from literature databases. Librarians can help if the PICO is well designed; they can also help focus the question or even develop it further to assist in finding the most appropriate articles. Another option is to use the key validity questions as advocated by Guyatt et al [ 3 ] Although originally designed to evaluate RCTs, parts of these guidelines are also applicable to other study designs, as they evaluate possible methodological safeguards.

For example, even in case series, outcome assessment could be done by an independent outcome assessor. Primary guides Was the assignment of patients to treatments randomized? Were all patients who entered the trial properly accounted for and attributed at its conclusion? Webster, and Jonathan C. Otto, and Benjamin K. Raman, and Margaret S. Roobol, and Phillip D. Mertan, Samuel Borofsky, Arvin K. George,Abhinav Sidana, Peter L.

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What should urologists know about evidence-based medicine?

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Abram McBride, Culley C. Evidence-based Urology, 2nd Edition. Read an Excerpt Excerpt 1: Added to Your Shopping Cart. Description An updated and revised resource to evidence-based urology information and a guide for clinical practice The revised and updated second edition of Evidence-Based Urology offers the most current information on the suitability of both medical and surgical treatment options for a broad spectrum of urological conditions based on the best evidence available. Goldman Part 2 General urology and stone disease Charles D.

Dmochowski 11 Prophylaxis and treatment of urinary tract infections in adults, Gabrielle J. Craig 12 Medical management of stone disease, Timothy Y. Tseng and Glenn M.