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Purpose: The purpose of this American Urological Association (AUA) Guideline amendment is to provide a useful reference on the effective evidence-based management of male lower urinary tract symptoms secondary/attributed to BPH (LUTS/BPH). Materials and Methods: The Minnesota Evidence Review Team searched Ovid MEDLINE, the Cochrane Library, and the Agency for Healthcare Research and Quality (AHRQ) database to identify studies relevant to the management of BPH. The guideline was updated in 2023 to capture eligible literature published between September 2020 and October 2022. When sufficient evidence existed, the body of evidence was assigned a strength rating of A (high), B (moderate), or C (low) for support of Strong, Moderate, or Conditional Recommendations. In the absence of sufficient evidence, additional information is provided as Clinical Principles and Expert Opinions. Results: The BPH amendment resulted in changes to statements/supporting text on combination therapy, photoselective vaporization of the prostate (PVP), water vapor thermal therapy (WVTT), laser enucleation, and prostate artery embolization (PAE). A new statement on temporary implanted prostatic devices (TIPD) was added. In addition, statements on transurethral needle ablation (TUNA) and transurethral microwave thermotherapy (TUMT) were removed and information regarding these legacy technologies was added to the background section. References and the accompanying treatment algorithms were updated to align with the updated text. Conclusion: This guideline seeks to improve clinicians' ability to evaluate and treat patients with BPH/LUTS based on currently available evidence. Future studies will be essential to further support these statements to improve patient care. [ABSTRACT FROM AUTHOR]

Purpose: We evaluate to what extent systematic reviews published in the urological literature follow best practices for the reporting of searches. Materials and Methods: Systematic reviews addressing questions of therapy/ prevention were sought out in 5 major urological journals from January 1998 to December 2021. Two members performed study selection and data abstraction independently and in duplicate. The methodological and reporting quality of these systematic reviews was assessed using operationalized criteria based on the PRISMA-S (Preferred Reporting Items for Systematic Reviews and Meta-analyseseliterature search extension) and PRISMA 2020 checklists. Proportions of systematic reviews that satisfied each criterion were compared based on period (1998-2012, 2013-2016, and 2017-2021) and journal of publication. Results: The search identified 483 systematic reviews that met inclusion criteria. Most systematic reviews searched 2 or more electronic databases (88.6%); few searched abstract proceedings (26.7%), clinical trial registries (15.1%), or dedicated databases of the “gray literature” (6.2%). Approximately 1 in 3 systematic reviews (32.3%) were explicit in not restricting searches by language. A few criteria demonstrated improved reporting over time including use of clinical trial registries (6.8% vs 14.4% vs 23.3%; P [ .001), searches unrestricted by language (37.3% vs 49.3% vs 55.1%; P[.006), and flow diagram reporting (34.8% vs 82.9% vs 93.2%; P[.001) but not the search of abstract proceedings (28.6% vs 24.0% vs 27.3%; P [ .647). Reporting characteristics across journals were similar. Conclusions: Systematic reviews published in the urological literature have considerable shortcomings regarding the reporting of their underlying search strategies. Efforts must be taken to improve search strategies in the form of better training in systematic review methods as well as the more stringent enforcement of reporting guidelines. [ABSTRACT FROM AUTHOR]

Purpose: Gender equity is a key performance metric in research, including systematic reviews, and is increasingly noted in publications. We performed this study to assess gender parity in scientific authorship of systematic reviews published in the urological literature. Materials and Methods: We identified all published systematic reviews addressing questions of therapy/prevention in 5 major urological journals (The Journal of Urology®, European Urology, Urology, BJU International, and World Journal of Urology) from 1998 to 2021. We determined gender of first, second, corresponding, and any author as a binary variable (woman or man) using a predefined algorithm. Results: We included 523 systematic reviews. The main journal contributors were European Urology (32.6%), BJU International (22.0%), and The Journal of Urology (19.5%). Slightly more than half (51.8%) of reviews included at least 1 woman coauthor, 37.5% did not, and in 10.7% it was unclear. First, second, and corresponding authors were women in 13.7%, 12.4%, and 4.7%, respectively, and the median number of women contributors was 1 (interquartile range 0-2). Women-first authorship for the time period 1998-2012 was 13.0% (P = .139), and senior authorship was 5.0% (P = .270). In 2013-2016 it was 11.0% and 4.1%, and in 2017-2021 it increased somewhat to 16.5% and 5.1% (P = .270), respectively. Conclusions: The number of women involved in systematic reviews is low and has not improved over time. Since scientific authorship is important for academic advancement, this finding may contribute to the underrepresentation of women in academic leadership positions. Efforts to improve gender diversity in urology should include more collaboration across genders. [ABSTRACT FROM AUTHOR]

Purpose Male lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) is common in men and can have negative effects on quality of life (QoL). It is the hope that this Guideline becomes a reference on the effective evidence-based surgical management of LUTS/BPH. Materials and Methods The evidence team searched Ovid MEDLINE, the Cochrane Library, and the Agency for Healthcare Research and Quality (AHRQ) database to identify studies indexed between January 2007 and September 2017. When sufficient evidence existed, the body of evidence was assigned a strength rating of A (high), B (moderate), or C (low) for support of Strong, Moderate, or Conditional Recommendations. In the absence of sufficient evidence, additional information is provided as Clinical Principles and Expert Opinions ( table 1 in supplementary unabridged guideline, http://jurology.com/ ). Results This Guideline provides updated, evidence-based recommendations regarding management of LUTS/BPH utilizing surgery and minimally invasive surgical therapies; additional statements are made regarding diagnostic and pre-operative tests. Clinical statements are made in comparison to what is generally accepted as the gold standard (i.e. transurethral resection of the prostate [TURP]–monopolar and/or bipolar). This guideline is designed to be used in conjunction with the associated treatment algorithm. Conclusions The prevalence and the severity of LUTS increases as men age and is an important diagnosis in the healthcare of patients and the welfare of society. This document will undergo additional literature reviews and updating as the knowledge regarding current treatments and future surgical options continues to expand. [ABSTRACT FROM AUTHOR]

Purpose Systematic reviews synthesize the current best evidence to address a clinical question. Given the growing emphasis on evidence-based clinical practice, systematic reviews are being increasingly sought after and published. We previously reported limitations in the methodological quality of 57 individual systematic reviews published from 1998 to 2008. We provide an update to our previous study, adding systematic reviews published from 2009 to 2012. Materials and Methods We systematically searched PubMed® and hand searched the table of contents of 4 major urological journals to identify systematic reviews related to questions of prevention and therapy. Two independent reviewers with prior formal evidence-based medicine training assessed the methodological quality using the validated 11-point AMSTAR (A Measurement Tool to Assess Systematic Reviews) instrument. We performed predefined statistical hypothesis testing for differences by publication period (1998 to 2008 vs 2009 to 2012) and journal of publication. We performed statistical testing using SPSS®, version 23.0 with a 2-sided α of 0.05 using the Student t-test, ANOVA and the chi-square test. Results A total of 113 systematic reviews published from 2009 to 2012 met study inclusion criteria. The most common topics were oncology (44 reviews or 38.9%), voiding dysfunction (26 or 23.0%) and stones/endourology (13 or 11.5%). The largest contributor was European Urology (46 reviews or 40.7%), followed by BJU International (31 or 27.4%) and The Journal of Urology ® (22 or 19.5%). The mean ± SD AMSTAR score for the 2009 to 2012 period was 5.3 ± 2.3 compared to 4.8 ± 2.0 for 1998 to 2008 with a mean difference of 0.5 (95% CI 0.2 to 1.2, p = 0.133). Conclusions While the number of systematic reviews published in the urological literature has increased substantially, the methodological quality of these studies remains suboptimal. Systematic review authors and editors should make every effort to adhere to well established methodological standards to enhance the impact of their research efforts. [ABSTRACT FROM AUTHOR]

Purpose Clinical practice guidelines are increasingly being used by leading organizations to promote high quality evidence-based patient care. However, the methodological quality of clinical practice guidelines developed by different organizations varies considerably. We assessed published clinical practice guidelines on the treatment of localized prostate cancer to evaluate the rigor, applicability and transparency of their recommendations. Materials and Methods We searched for English based clinical practice guidelines on treatment of localized prostate cancer from leading organizations in the 15-year period from 1999 to 2014. Clinical practice guidelines limited to early detection, screening, staging and/or diagnosis of prostate cancer were excluded from analysis. Four independent reviewers used the validated AGREE II instrument to assess the quality of clinical practice guidelines in 6 domains, including 1) scope and purpose, 2) stakeholder involvement, 3) rigor of development, 4) clarity of presentation, 5) applicability and 6) editorial independence. Results A total of 13 clinical practice guidelines met inclusion criteria. Overall the highest median scores were in the AGREE II domains of clarity of presentation, editorial independence, and scope and purpose. The lowest median score was for applicability (28.1%). Although the median score of editorial independence was high (85.4%), variability was also substantial (IQR 12.5–100). NICE and AUA clinical practice guidelines consistently scored well in most domains. Conclusions Clinical practice guidelines from different organizations on treatment of localized prostate cancer are of variable quality and fall short of current standards in certain areas, especially in applicability and stakeholder involvement. Improvements in these key domains can enhance the impact and implementation of clinical practice guidelines. [ABSTRACT FROM AUTHOR]

Purpose: We assessed the methodological and reporting quality of randomized, controlled trials of stone disease management and determined whether the reporting quality of randomized, controlled trials improved with time. Materials and Methods: We systematically searched the literature for randomized, controlled trials of urolithiasis treatment. We developed and pilot tested a data extraction checklist based on CONSORT (Consolidated Standards of Reporting Trials) criteria as well as a clinical checklist relevant to urolithiasis, each scored as 0 to 25. Our primary outcome measures were the mean differences in CONSORT and clinical summary scores with time. We performed statistical hypothesis testing using the Student t-test with 2-sided α = 0.05 to compare scores between 2002 to 2006 and 2007 to 2011. Results: A total of 104 randomized, controlled trials met study inclusion criteria. The most common procedure types studied were percutaneous nephrolithotomy (41.3%), ureteral stenting (28.8%) and shock wave lithotripsy (25.0%). Mean ± SE CONSORT summary scores were 11.4 ± 0.4 and 12.1 ± 0.3 in 2002 to 2006 and 2007 to 2011, respectively, with a mean difference of 0.7 (95% CI –0.3–1.6, p = 0.167). Mean clinical summary scores were 7.4 ± 0.5 and 9.3 ± 0.4 in 2002 to 2006 and 2007 to 2011, respectively, with a mean difference of 1.8 (95% CI 0.6–3.1, p = 0.004). Conclusions: While the number of randomized, controlled trials of urological devices used to treat stone disease substantially increased with time, methodological and clinical reporting quality remains suboptimal. This compromises their credibility and warrants efforts to promote appropriate performance of future endourological studies. [ABSTRACT FROM AUTHOR]

Purpose: This Guideline is intended to provide a rational basis for the management of patients with castration-resistant prostate cancer based on currently available published data. Materials and Methods: A systematic review and meta-analysis of the published literature was conducted using controlled vocabulary supplemented with keywords relating to the relevant concepts of prostate cancer and castration resistance. The search strategy was developed and executed by reference librarians and methodologists to create an evidence report limited to English-language, published peer-reviewed literature. This review yielded 303 articles published from 1996 through 2013 that were used to form a majority of the guideline statements. Clinical Principles and Expert Opinions were used for guideline statements lacking sufficient evidence-based data. Results: Guideline statements were created to inform clinicians on the appropriate use of observation, androgen-deprivation and antiandrogen therapy, androgen synthesis inhibitors, immunotherapy, radionuclide therapy, systemic chemotherapy, palliative care and bone health. These were based on six index patients developed to represent the most common scenarios encountered in clinical practice. Conclusions: As a direct result of the significant increase in FDA-approved therapeutic agents for use in patients with metastatic CRPC, clinicians are challenged with a multitude of treatment options and potential sequencing of these agents that, consequently, make clinical decision-making more complex. Given the rapidly evolving nature of this field, this guideline should be used in conjunction with recent systematic literature reviews and an understanding of the individual patient's treatment goals. In all cases, patients' preferences and personal goals should be considered when choosing management strategies. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this guideline is to provide a clinical framework for follow-up of clinically localized renal neoplasms undergoing active surveillance, or following definitive therapy. Materials and Methods: A systematic literature review identified published articles in the English literature between January 1999 and 2011 relevant to key questions specified by the Panel related to kidney neoplasms and their follow-up (imaging, renal function, markers, biopsy, prognosis). Study designs consisting of clinical trials (randomized or not), observational studies (cohort, case-control, case series) and systematic reviews were included. Results: Guideline statements provided guidance for ongoing evaluation of renal function, usefulness of renal biopsy, timing/type of radiographic imaging and formulation of future research initiatives. A lack of studies precluded risk stratification beyond tumor staging; therefore, for the purposes of postoperative surveillance guidelines, patients with localized renal cancers were grouped into strata of low- and moderate- to high-risk for disease recurrence based on pathological tumor stage. Conclusions: Evaluation for patients on active surveillance and following definitive therapy for renal neoplasms should include physical examination, renal function, serum studies and imaging and should be tailored according to recurrence risk, comorbidities and monitoring for treatment sequelae. Expert opinion determined a judicious course of monitoring/surveillance that may change in intensity as surgical/ablative therapies evolve, renal biopsy accuracy improves and more long-term follow-up data are collected. The beneficial impact of careful follow-up will also need critical evaluation as further study is completed. [ABSTRACT FROM AUTHOR]

Purpose: We critically assessed the methodological and reporting quality of published studies of ablative techniques for small renal masses. Materials and Methods: We performed a systematic PubMed® and EMBASE® literature search from January 1966 to March 2010 to identify all full text, original research publications on ablative therapy for renal masses. Six reviewers working independently in 3 teams performed duplicate data abstraction using Strengthening the Reporting of Observational Studies in Epidemiology criteria, which were pilot tested in a separate sample. Results: A total of 117 original research publications published in a 15-year period (1995 to 2009) met eligibility criteria. No randomized, controlled trials were identified. All studies were observational and 88.9% had 1 arm with no comparison group. Median sample size was 18 patients (IQR 5.5, 40.0) and 53.8% of studies included 20 or fewer patients. Median followup was 14.0 months (IQR 8.0, 23.8) and only 19.7% of studies had an average followup of greater than 24 months. Of the studies 20.5% mentioned the number of operators involved and only 6.0% provided information on their experience level. Of the studies 66.7% addressed the recurrence rate. Disease specific and overall survival was reported in only 15.4% and 16.2% of studies, respectively. Conclusions: The published literature on the therapeutic efficacy of ablative therapy for renal masses is largely limited to uncontrolled, 1-arm observational studies. In the absence of higher quality evidence ablative therapy outside research studies should be limited to select patients who are not candidates for surgical intervention. [Copyright &y& Elsevier]

Purpose: Well done systematic reviews provide the highest quality evidence for clinical questions of therapeutic effectiveness. We assessed the methodological quality of systematic reviews in the urological literature. Materials and Methods: We systematically investigated all systematic reviews published in 4 major urological journals from 1998 to 2008. Studies were identified using a predefined search strategy in PubMed® and confirmed by a hand search of journal tables of contents. A validated 11-point instrument to assess the methodological quality of systematic reviews was applied by 2 independent reviewers after a pilot testing phase. Disagreements were discussed and resolved by consensus. Results: The systematic literature search identified 217 individual systematic reviews, of which 57 ultimately met study eligibility criteria. Ten (17.5%), 20 (35.1%) and 27 (47.4%) systematic reviews were published in 1998 to 2001, 2002 to 2005 and 2006 to 2008, respectively. Using the measurement tool to assess systematic reviews the mean ± SD score was 4.8 ± 2.0 points. Fewer than half of all systematic reviews performed a systematic literature search that included at least 2 databases (49.1%) or unpublished studies (31.6%), or provided a list of included and excluded studies (45.6%). Of the systematic reviews 63.2% assessed and documented the methodological quality of included studies. Systematic reviews with The Cochrane Collaboration authorship affiliation had a higher mean score than those with no such reported affiliation (6.5 ± 1.2 vs 4.4 ± 1.9 points, p <0.001). Conclusions: Results suggest that an increasing number of systematic reviews are published in the urological literature. However, many systematic reviews fail to meet established methodological standards, raising concerns about validity. Increased efforts are indicated to promote quality standards for performing systematic reviews among the authors and readership of the urological literature. [Copyright &y& Elsevier]

Purpose: We assessed the quality of randomized, controlled trial reporting in abstracts from the annual meetings of the American Urological Association and determined whether the information provided is consistent with subsequent full text publications. Materials and Methods: All randomized, controlled trials presented in abstract form at the 2002 and 2003 American Urological Association annual meetings were identified for review. A systematic PubMed® search based on authorship and key words from the study title was done to identify all subsequent full text publications. A standardized evaluation form was developed based on the published literature, pilot tested in a separate sample and applied by 2 independent reviewers. Results: A total of 126 randomized, controlled trials were identified for review, including 56 in 2002 and 70 in 2003. Approximately a third of the trials (43 or 34.1%) identified the study design as a randomized, controlled trial in the abstract title. The method of randomization, allocation concealment and blinding was reported in 0% (0), 0% (0) and 40.5% (51) of studies, respectively. Mean/median followup was provided in 27.0% of studies (34). Of 126 randomized, controlled trials presented in abstract form 62.7% (79) were subsequently published as full text articles. Study sample size and the number of randomized subjects differed in 24.1% and 28.9% of abstracts, respectively. From the small proportion of randomized, controlled trials (23 or 29.1%) that identified a single primary end point results differed in 9 of 23 (39.1%). Conclusions: Most abstracts fail to provide the necessary information to assess methodological quality. Organizers of urological meetings should consider implementing a more structured abstract format that requires authors to provide the necessary study details, thereby allowing urologists to critically appraise study validity. [Copyright &y& Elsevier]

Purpose: Evidence-based decision making seeks to balance potential benefits and harms (adverse effects) of health care interventions for an individual patient. We determined the prevalence and completeness of harm reporting in randomized controlled trials in the urological literature. Materials and Methods: We performed a systematic literature search of all randomized controlled trials of therapeutic interventions published in The Journal of Urology®, Urology®, European Urology and BJU International in 1996 and 2004. Each article was reviewed by 2 independent investigators for 10 harm reporting criteria recommended by the CONSORT group. Discrepancies were settled by discussion and consensus. Results: A total of 152 randomized controlled trials met the inclusion criteria, of which 109 (72%) reported adverse event outcomes. The median number of harm reporting criteria satisfied improved marginally from 1996 to 2004 (2.8 to 3.3, p = 0.36). A large proportion of studies failed to address harm in the abstract (55, 36%), introduction (71, 47%) and discussion (52, 34%). Few studies specified which adverse events were evaluated (21, 14%), when harm information was collected (32, 21%) or how the harm was attributed to the intervention (5, 3%). Only 48 (32%) articles provided reasons for patient withdrawal and 1 in 5 (33, 22%) reported the severity of adverse events. Conclusions: Randomized controlled trials published in the urological literature contain significant deficiencies in adverse event reporting. These findings suggest the need for reporting standards for harm in urological journals. Improvements in adverse event reporting would permit a more balanced assessment of interventions and would enhance evidence-based urological practice. [Copyright &y& Elsevier]

Purpose: This article in the Users'' Guide to the Urological Literature series examines studies that provide information about prognosis for evidence-based clinical practice. Materials and Methods: Studies of prognosis are introduced to the reader in the context of a clinical scenario that raises questions about the expected outcome for a patient. Critical appraisal of prognostic studies addresses the 3 questions. 1) Are the results valid? 2) What are the results? 3) Can I apply the results to the care of my patients? Results: To assess the validity of a cohort study that addresses a question of prognosis, the reader should first ask whether the sample of patients under investigation were representative and sufficiently homogeneous with respect to prognostic risk. Investigators should measure all plausible determinants of outcome (prognostic or risk factors) and present results for all subgroups in which the prognosis differs substantially. The reader should ask whether followup was sufficiently complete, and whether investigators used objective, unbiased and patient relevant outcomes. The results should address the likelihood of the outcomes of interest and the precision of the estimates. Finally the reader should ask how similar the study patients and treatment are to his/her patients, and whether followup was sufficiently long. Conclusions: Questions of prognosis have an important role in the practice of urology and are usually best answered by nonrandomized, observational studies. Urologists should critically appraise these studies for validity, impact and applicability before using the results to guide patient care. [Copyright &y& Elsevier]

Purpose: We determined the rate of duplicate research presentations at recent American Urological Association and European Urological Association annual meetings. Materials and Methods: We cross-referenced all clinical research presentations related to prostate cancer presented at the 2006 American Urological Association and European Urological Association annual meetings with those presented at the corresponding annual meetings in 2005, 2006 and 2007 using a defined search strategy based on author names, abstract titles, study design and objectives. All data abstraction was performed in duplicate by 2 independent reviewers to ensure accuracy. Results: We identified 282 and 312 abstracts on prostate cancer clinical research at the 2006 European Urological Association and American Urological Association annual meetings, respectively. The overall duplication rate of American Urological Association abstracts was 19.2% (60 of 312). Of duplicated abstracts 80.0% (48 of 60) were presented at the European Urological Association annual meeting the same year. Duplication of European Urological Association abstracts was identified in 20.9% (59 of 282). Authors who presented the same research (71 duplicate abstracts) at the 2 meetings altered the presentations in various ways, including a different study title in 40.8%, a different first and senior author in 14.1% and 18.3%, and increased or decreased sample size in 8.5% and 14.1%, respectively. Conclusions: Approximately a fifth of clinical research abstracts on prostate cancer presented at the American Urological Association annual meeting were also presented at the European Urological Association meeting and vice versa. Inconsistencies between duplicate abstracts raise concerns about the integrity of the underlying studies. Stricter submission guidelines and improved dissemination of research findings from the 2 meetings may help limit this practice. [Copyright &y& Elsevier]

Purpose: Properly conducted clinical trials provide essential evidence about the benefits and harms of a therapeutic intervention. To ensure accurate interpretation of study findings urologists should understand measures of effect and their precision. In this segment of the Users'' Guide to the Urological Literature series we provide guidance on how measures of effect and precision should be interpreted and used in the evidence-based practice of urology. Materials and Methods: Using an example from the urology literature we define commonly used measures of effect and describe how these statistics can be readily generated from the results of a clinical trial. We also highlight the importance of confidence interval interpretations when critically appraising study findings. Results: The effect of an intervention can be described in absolute or relative terms. Risk of an event, risk difference and number needed to treat are easy to interpret, and allow the patient and urologist to assess the impact of an intervention in absolute terms. Relative measures of effect (relative risk, relative risk reduction) also characterize the treatment effect and can be applied to patients with varying baseline risk. The degree of precision within which the study estimated the actual effect size may be ascertained from the associated confidence interval. Confidence intervals are also useful when interpreting the benefit and harm of an experimental intervention and, therefore, are preferred compared to p values. Conclusions: Urologists do not need to rely on author interpretations of the effectiveness or harmfulness of a given intervention alone, but may interpret the result of the study themselves. An understanding of measures of effect size and precision is important to the interpretation of the urological literature and facilitates evidence-based clinical practice. [Copyright &y& Elsevier]

Purpose: We investigated the attitudes and opinions of urologists toward evidence-based medicine to help guide future efforts of the American Urological Association and other organizations vested in the education and training of urologists. Materials and Methods: From August to November 2006 we performed a mail survey of a random sample of 2,000 members of the American Urological Association. Questions in the survey addressed the role of evidence-based medicine in urology, participants'' self-assessed understanding of evidence-based medicine related terminology, their familiarity with and use of web based evidence-based medicine resources, as well as their evidence-based medicine competence based on their understanding of core concepts such as randomization and blinding. Results: A total of 889 respondents completed the survey resulting in a response rate of 45%. There was widespread agreement that practicing evidence-based medicine improves patient care (median score 8; IQR 7, 10) and that every urologist should be familiar with critical appraisal techniques (median score 9; IQR 8, 10). The percentage of respondents who indicated that they “understand and could explain to others” the terms number needed to treat, power and level of evidence was 42%, 29% and 18%, respectively. The American Urological Association Guidelines were used regularly by 35% and on occasion by 51% of respondents. Of the participants 44% were unaware of the PubMed® search engine and only 14% used it regularly, while 76% were unaware of the Cochrane Database of Systematic Reviews and only 8% had ever used it. The mean evidence-based medicine competence score for all respondents was 67.2% ± 17.0%. Conclusions: The findings of this survey confirm that urologists have a favorable attitude toward evidence-based medicine. However, understanding of evidence-based medicine terminology, concepts and use of related resources among American Urological Association members leaves room for improvement. Increased efforts to promote an understanding of evidence-based medicine through workshops, publications and web based resources specifically for a urological audience appear indicated. [Copyright &y& Elsevier]

Purpose: Leading organizations increasingly recognize clinical practice guidelines as an important approach in promoting an evidence-based clinical practice of urology. In light of their considerable clinical, economic and medicolegal impact, guideline users should be confident that the guidelines were rigorously developed and address relevant patient questions. In this article we outline a practical approach for critically appraising a clinical practice guideline. Materials and Methods: We outline a 3-step approach to the assessment of a clinical practice guideline that answers the questions of whether the recommendations are valid, what the recommendations are and whether they will help in the treatment of an individual patient. Results: To determine the adequacy of a clinical practice guideline, urologists should carefully review the rigor of the development process and its content. Important questions that relate to the validity of a guideline are whether, for specific questions, all important management options and outcomes were considered, and whether there was an explicit and sensible process to identify, select and combine all relevant evidence. Clinical practice guidelines should formally grade the quality of the available evidence for a given clinical question and outline a formal process of how the recommendations were derived. Value judgments made in the guideline development process about the relative importance of the potential benefits and harms of a given health care intervention should be made transparent to the reader. The recommendations made should be practical and should address important clinical issues. Furthermore, their strength should be graded to reflect the underlying uncertainty about the evidence and the values applied in the guideline development process. Conclusions: The systematic approach presented in this article will allow urologists to critically appraise clinical practice guidelines. Determining the validity of the recommendations, understanding the recommendations and assessing their applicability to patients are 3 fundamental steps toward an evidence-based approach to using clinical practice guidelines. [Copyright &y& Elsevier]

Purpose: Most surgical interventions have inherent benefits and associated risks. Before implementing a new therapy we should ascertain the benefits and risks of the therapy and assure ourselves that the resources consumed in the intervention will not be exorbitant. Materials and Methods: We suggest a 3-step approach to using an article from the urological literature to guide patient care. We recommend asking whether the study can provide valid results, reviewing the results and considering how the results can be applied to patient care. Results: Key methodological characteristics that have an impact on the validity of a surgical trial include randomization, allocation concealment, stratification, blinding, completeness of followup and intent to treat analysis. To the extent that the quality is poor inferences from this study are weakened. However, if its quality is acceptable, one must determine the range within which the true treatment effect lies (95% CI). One must then consider whether this result can be generalized to a patient and whether the investigators have provided information about all clinically important outcomes. It is then necessary to compare the relative benefits of the intervention with its risks. If one perceives that the benefits outweigh the risks, the intervention may be of use to the patient. Conclusions: Given the time constraints of busy urological practices and training programs, applying this analysis to every relevant article would be challenging. However, the basics of this process are essentially what we all do hundreds of times each week when treating patients. Making this process explicit with guidelines to assess the strength of the available evidence will serve to improve patient care. It will also allow us to defend therapeutic interventions based on available evidence and not on anecdote. [Copyright &y& Elsevier]

Purpose: Randomized controlled trials potentially provide the highest level of evidence to inform clinical decision making. Appropriate use of statistical methods is a critical aspect of all clinical research, including randomized controlled trials. We report the first formal evaluation to our knowledge of the statistical methods of randomized controlled trials published in the urological literature in 1996 and 2004. Materials and Methods: All human subjects randomized controlled trials published in 4 leading urology journals in 1996 and 2004 were identified for formal review. A standardized evaluation form was developed based on the Consolidated Standards of Reporting Trials statement. Each article was evaluated by 2 independent reviewers with formal training in research design and biostatistics who were blinded to study authors and institution. Discrepancies were settled by consensus. Results: A total of 152 randomized controlled trials were reviewed (65 in 1996, 87 in 2004). The median sample size (IQR) per arm of parallel design randomized controlled trials published in 1996 and 2004 was 36 (11, 96) and 50 (26, 134) study subjects, respectively (p = 0.157). Sample size justifications were provided by 19% of studies in 1996 and 47% of studies in 2004 (p = 0.001). Of randomized controlled trials 16 (25%) vs 32 (37%) identified a single primary outcome variable (p = 0.110). Effect size estimates for primary or secondary outcome variables were provided by 5% vs 13% (p = 0.090) and the precision of the effect was detailed by 5% vs 10% of randomized controlled trials (p = 0.195). Conclusions: This formal review suggests that statistical analysis in urological randomized controlled trials has improved. However, considerable deficiencies remain. Ongoing education in applied statistics may further improve urological randomized controlled trial reporting. [Copyright &y& Elsevier]

Purpose: This article introduces practicing urologists to the critical appraisal of systematic reviews and meta-analyses to guide their evidence-based clinical practice. Materials and Methods: Using a urological clinical case scenario we introduce a 3-step process in evaluating systematic reviews and meta-analyses by considering 1) the validity of the review results, 2) what the results are, and 3) the extent to which the results can and should be applied to patient care. Results: A systematic review seeks to synthesize the medical literature about a specific clinical question using explicit methods to perform a comprehensive literature search, identify and select eligible studies, critically appraise their methods, and judiciously summarize the results considering how they vary with study characteristics. When this summary involves statistical methods, ie a meta-analysis, reviewers can offer a pooled estimate that will have greater precision and will apply more broadly than the individual studies. The quality of the underlying studies, the consistency of results across studies and the precision of the pooled estimate can considerably affect the strength of inference from systematic reviews. Conclusions: Valid systematic reviews of high quality studies can increase the confidence with which urologists and patients make evidence-based decisions. Thus, urologists need to recognize the inherent limitations, understand the results and apply them judiciously to patient care. [Copyright &y& Elsevier]

Purpose: Urologists frequently confront diagnostic dilemmas, prompting them to select, perform and interpret additional diagnostic tests. Before applying a given diagnostic test the user should ascertain that the chosen test would indeed help decide whether the patient has a particular target condition. In this article in the Users'' Guide to the Urological Literature series we illustrate the guiding principles of how to critically appraise a diagnostic test, interpret its results and apply its findings to the care of an individual patient. Materials and Methods: The guiding principles of how to evaluate a diagnostic test are introduced in the setting of a clinical scenario. We propose a stepwise approach that addresses the question of whether the study results are likely to be valid, what the results are and whether these results would help urologists with the treatment of their individual patients. Results: Some of the issues urologists should consider when assessing the validity of a diagnostic test study are how the authors assembled the study population, whether they used blinding to minimize bias and whether they used an appropriate reference standard in all patients to determine the presence or absence of the target disorder. Urologists should next evaluate the properties of the diagnostic test that indicate the direction and magnitude of change in the probability of disease for a particular test result. Finally, urologists should ask a series of questions to understand how the diagnostic test may impact the care of their patients. Conclusions: Application of the guides presented in this article will allow urologists to critically appraise studies of diagnostic tests. Determining the study validity, understanding the study results and assessing the applicability to patient care are 3 fundamental steps toward an evidence-based approach to choosing and interpreting diagnostic tests. [Copyright &y& Elsevier]

Purpose: Increasingly there is a recognized need for the development of high quality, evidenced-based clinical guidelines to assist clinicians and patients in critically important treatment related decision making. We review the different approaches used by leading urological organizations to develop guidelines for the management of clinically localized prostate cancer and their specific recommendations for case management. Materials and Methods: Guidelines for the management of localized prostate cancer developed by leading professional organizations were identified through the National Guidelines Clearinghouse™, PubMed®, cited references and personal communication with prostate cancer experts. A structured data abstraction was applied to assess how the guideline was developed, what type of professionals and stakeholders were involved in the development process, how the primary evidence was identified and graded, and what specific final recommendations were reported. Results: Clinical practice guidelines on the management of clinically localized prostate cancer demonstrate major differences in their specific recommendations. Few recommendations are based on high level evidence, and there are considerable discrepancies among the systems used to grade the quality of the evidence and the strength of the recommendations. Conclusions: There appears to be a need to standardize the process used by leading urological organizations to develop clinical guidelines for the management of prostate cancer. A unified approach may offer considerable rewards in terms of efficiency, guideline credibility and optimal clinical decision making. Furthermore, increased efforts are indicated to promote studies that yield high quality evidence to guide the management of prostate cancer. [Copyright &y& Elsevier]

Purpose: We investigated urologist perceptions of barriers to implementing evidence-based medicine in clinical practice. Materials and Methods: In April 2005 an Internet survey was conducted to assess American Urological Association member attitudes toward evidence-based medicine. This analysis presents the responses to an open-ended question about perceived barriers to implementing evidence-based clinical practice in urology. Two raters developed a coding scheme with 5 main categories of evidence concerns, system level factors, physician factors, patient factors and other barriers. Each rater independently assigned a category to each response. Discrepancies were resolved by consensus. Results: A total of 365 participants (72%) responded to the open-ended question, each providing up to 4 codable responses. Of the group 53% cited concerns about the evidence including the lack thereof, low quality, limited applicability and biased presentation. In addition, 37% reported system level factors such as issues of reimbursement, fear of litigation, problems with implementation, interference/bias by third parties, and expectations and attitudes of other providers as important issues. Physician factors and patient factors were further cited by 28% and 9%, respectively. In terms of the legitimacy of evidence-based medicine 9% expressed skepticism whereas 5% of respondents indicated that they saw no barriers to implementing evidence-based medicine in urology. Conclusions: Efforts to promote evidence-based medicine in urology should focus not only on the generation of high quality clinical research but also on its unbiased reporting and timely dissemination. Concerted efforts should be made to reduce system level factors that hinder the implementation of evidence-based care. [Copyright &y& Elsevier]

Purpose: Evidence based clinical practice seeks to integrate the current best evidence from clinical research with physician clinical expertise and patient individual preferences. We outline a stepwise approach to an effective and efficient search of electronic databases and introduce the reader to resources most relevant to the practicing urologist. Materials and Methods: The need for additional research evidence is introduced in the context of a urological clinical scenario. This information need is translated into a focused clinical question using the PICOT (population, intervention, comparison, outcome and type of study) format. This PICOT format provides key words for a literature search of pre-appraised evidence and original research studies that address the clinical scenario. Results: Available online resources can be broadly categorized into databases that focus on primary research studies, ie randomized, controlled trials, cohort studies, case-control or case series, such as MEDLINE® and those that focus on secondary research that provides synthesis or synopsis of primary studies. Examples of such sources of pre-appraised evidence that are becoming increasingly relevant to urologists include BMJ Clinical Evidence, ACP Journal Club, The Cochrane Library and the National Guideline Clearinghouse™. Conclusions: The ability to search the medical literature in a time efficient manner represents an important part of an evidence based practice that is relevant to all urologists. The use of electronic databases of pre-appraised evidence can greatly expedite the search for high quality evidence, which is then integrated with urologist clinical skills and patient individual circumstances. [Copyright &y& Elsevier]

Purpose: Birdwell Finlayson was a talented researcher and clinician whose pioneering work in the field of urolithiasis led him to worldwide prominence in urology. We researched his life and accomplishments to provide a historical account of his career. Materials and Methods: The archives of the Department of Urology and the University of Florida Health Science Center Library were searched for publications, photographs and other records relating to Doctor Finlayson. Additionally, we interviewed many of his friends and colleagues for more information. Results: Birdwell Finlayson was born in Pocatello Bannock, Idaho. He completed a urology residency and obtained a Ph.D. in biophysics at the University of Chicago. In 1967 he joined the faculty at the University of Florida. His interest in understanding the fundamentals of stone formation led to the discovery that crystal retention at a site of nephron injury was essential for stone formation. This fixed particle hypothesis continues to serve to as the foundation for urolithiasis research today. His computer model EQUIL is the gold standard for calculating urinary supersaturation with respect to kidney stone formation. Finlayson was 1 of the 6 original coinvestigators for shock wave lithotripsy in the United States. He is also remembered for his wit and his love of aeronautics, as he was a flight instructor and stunt pilot. Finlayson died unexpectedly of idiopathic hypertrophic cardiomyopathy on July 22, 1988. Conclusions: Birdwell Finlayson was an internationally renowned surgeon and stone disease expert whose research continues to serve as the basis of urolithiasis research at the University of Florida and worldwide. [Copyright &y& Elsevier]

Purpose: We determined study characteristics, authorship and institutional origin of studies presented in abstract form at the Southeastern Section of the American Urological Association annual meetings and identified predictors of full text publication. Materials and Methods: All abstracts of poster and podium presentations from the Southeastern Section of the American Urological Association annual meetings from 1996 to 2005 were reviewed. A standardized evaluation form was developed and tested in 2 subsets of 50 abstracts, and then applied by 2 individual reviewers with specific coding instructions. Predictor variables analyzed included study origin, design, topic, domain, presentation form, number of patients, reporting of statistical analysis and gender. Univariate and multivariate analysis was applied using SPSS® version 14.0. Results: A total of 1,195 abstracts were found eligible for review. The mean number of abstracts presented per year was 120 ± 16 (range 107 to 146). In clinical studies (1,068) approximately three-quarters of the abstracts reported case series (801, 75.0%). Cohort studies accounted for 11.2% of the abstracts and 4.0% were randomized controlled trials or systematic reviews/meta-analyses. Median followup was 64 months (range 17 to 126) and the overall publication rate was 33.5%. First and senior female authorship were identified in 6.2% (74) and 5.4% (64) of abstracts presented, respectively. Conclusions: A majority of studies presented at the Southeastern Section of the American Urological Association annual meetings continue to represent small case series that may not be well suited to guide clinical decision making. Only a third of studies are subsequently published in the peer reviewed literature. The percentage of abstracts with female authorship remains low suggesting that increased efforts to involve women in urological research are indicated. [Copyright &y& Elsevier]

Purpose: The concept of levels of evidence is one of the guiding principles of evidence based clinical practice. It is based on the understanding that certain study designs are more likely to be affected by bias than others. We provide an assessment of the type and levels of evidence found in the urological literature. Materials and Methods: Three reviewers rated a random sample of 600 articles published in 4 major urology journals, including 300 each in 2000 and 2005. The level of evidence rating system was adapted from the Center of Evidence Based Medicine. Sample size was estimated to detect a relative increase in the proportion of studies that provided a high level of evidence (I and II combined) from 0.2 to 0.3 with 80% power. Results: Of the 600 studies reviewed 60.3% addressed questions of therapy or prevention, 11.5% addressed etiology/harm, 11.3% addressed prognosis and 9.2% addressed diagnosis. The levels of evidence provided by these studies from I to IV were 5.3%, 10.3%, 9.8% and 74.5%, respectively. A high level of evidence was provided by 16.0% of studies in 2000 and by 15.3% in 2005 (p = 0.911). Conclusions: This study suggests that a majority of studies in the urological literature provide low levels of evidence that may not be well suited to guide clinical decision making. We propose that editors of leading urology journals should promote awareness for this guiding principle of evidence based clinical practice by providing a level of evidence designation with each published study. [Copyright &y& Elsevier]

Purpose: Evidence based clinical practice has been defined as the conscientious, explicit and judicious use of the current best evidence in making decisions about the care of individual patients. It refers to a broad set of principles and methods intended to ensure that medical decisions, guidelines and health policy are based on well designed studies of therapeutic effectiveness and benefit. Materials and Methods: We review the principles and practice of evidence based clinical practice using examples from the urology literature. We further provide a guide to currently available web based evidence based clinical practice resources and guidelines for urologists. Results: Evidence based clinical practice integrates a hierarchy of evidence and patient values with practitioner judgment to guide decision making for the individual patient. Important steps in the evidence based clinical practice process include the formulation of an answerable question and a systematic search of the literature. In the absence of pre-appraised evidence or disease specific guidelines, the practice of evidence based clinical practice relies heavily on the evaluation of the primary literature by the individual urologist. Depending on the question domain (therapy/prevention, etiology/cause/harm, diagnosis or prognosis) and study design, a given study is critically appraised for validity, impact and applicability. Evidence is then integrated with clinical judgment, and patient circumstances and preferences. Finally, the practice of evidence based clinical practice includes a self-assessment of provider performance. Conclusions: Knowledge, practice and documentation of evidence based clinical practice are of increasing importance to every urologist. Urologists should embrace evidence based clinical practice principles by acquiring the necessary skills to critically appraise the literature for the best evidence applicable to patient care. [Copyright &y& Elsevier]

Purpose: We investigated the impact of nerve sparing technique on erectile function, urinary continence and health related quality of life after radical perineal prostatectomy using a validated self-assessment questionnaire. Materials and Methods: The Expanded Prostate Cancer Index Composite questionnaire was administered preoperatively and at defined intervals after surgery to 265 patients who underwent radical perineal prostatectomy at 2 institutions between January 2001 and December 2004. Of these patients 153 (57.7%) and 112 (42.3%) underwent nonnerve sparing and nerve sparing approaches, respectively. Kaplan-Meier analysis was used to determine time to recovery of erectile function (erections firm enough for intercourse) and urinary continence (0 pads per day). Results: Median patient age was 60.6 years. Median followup was 15 months. In multivariate analysis preoperative erectile function (p = 0.005) and preservation of the neurovascular bundle (p = 0.018) were independent predictors of earlier recovery of erectile function, with hazard ratios of 2.3 (95% CI 1.2–4.6) and 4.0 (95% CI 1.5–10.3), respectively. Median time to recovery of urinary continence was 4.8 months in the nerve sparing group and 6.1 months in the nonnerve sparing group (p = 0.001). In multivariate analysis nerve sparing technique (p = 0.001, HR 1.4, 95% CI 1.1–1.9) and age (p = 0.012, HR 1.7, 95% CI 1.3–2.2) were independent predictors of recovery of continence. Conclusions: This analysis suggests that nerve sparing radical perineal prostatectomy is associated with improved recovery of urinary continence and favorable health related quality of life scores and, therefore, should be considered a viable alternative to other nerve sparing approaches. [Copyright &y& Elsevier]

Purpose: We determined the potential influence of an early adopter bias in patients undergoing robot assisted laparoscopic prostatectomy. Materials and Methods: We compared baseline demographic, clinical and health related quality of life characteristics of patients undergoing 3 different surgical procedures for clinically localized prostate cancer following the introduction of robot assisted laparoscopic prostatectomy at our institution. Patients included in this analysis were participating in a prospective health related quality of life study using the SF-12® and Expanded Prostate Cancer Index Composite validated questionnaires. Results: Of 402 patients 159 (39%) underwent robot assisted laparoscopic, 144 (36%) underwent radical perineal and 99 (25%) underwent radical retropubic prostatectomy. There were no statistically significant associations between procedure type and patient age (p = 0.267), race (p = 0.725), number of medical comorbidities (p = 0.490), income (p = 0.056) and level of education (p = 0.495). Mean prostate specific antigen was 5.9 ± 3.3, 7.3 ± 5.5 and 5.7 ± 5.0 ng/ml for robot assisted laparoscopic, radical perineal and radical retropubic prostatectomy, respectively (p = 0.030). The proportion of robot assisted laparoscopic, radical perineal and radical retropubic prostatectomy patients with a final Gleason score of 4-6 was 55%, 45% and 39%, respectively (p = 0.037). The proportion of robot assisted laparoscopic, radical perineal and radical retropubic prostatectomy patients with stage T2 disease was 91%, 68% and 80%, respectively (p = 0.001). Statistically significant associations of higher income and education with higher baseline health related quality of life scores were seen in the sexual and physical domains (each p <0.01). Conclusions: We failed to find evidence of an early adopter bias for patients undergoing robot assisted laparoscopic prostatectomy. Nevertheless, observational studies comparing robot assisted laparoscopic prostatectomy to radical perineal and radical retropubic prostatectomy should account carefully for patient baseline characteristics to allow meaningful comparisons of surgical outcomes. [Copyright &y& Elsevier]

Purpose: Randomized, controlled trials are the gold standard for evidence based assessment of therapeutic interventions. In 1996 the Consolidated Standards of Reporting Trials statement was published in an effort to standardize the reporting of clinical trials. To our knowledge we report the first systematic assessment of randomized, controlled trial quality in the urology literature by Consolidated Standards of Reporting Trials standards. Materials and Methods: All human subject randomized, controlled trials published in 4 leading urology journals in 1996 and 2004 were identified for formal review. A standardized evaluation form was developed based on the Consolidated Standards of Reporting Trials statement. Each article was evaluated by 2 independent reviewers and discrepancies were settled by consensus. A Consolidated Standards of Reporting Trials criteria summary score was calculated on a scale of 0 to 22. Results: A total of 152 randomized, controlled trials met inclusion criteria. The mean ± SEM Consolidated Standards of Reporting Trials summary score was 10.2 ± 0.3 (median 10.3) and 12.0 ± 0.3 (median 12.2) in 1996 and 2004, respectively, with a mean difference of 1.8 (95% CI 1.0, 2.6; p = 0.001). Reporting of important methodological criteria, eg sample size justification and randomization implementation, improved from 1996 to 2004. Improvement notwithstanding, reporting of key methodological criteria remained consistently below 50% in 2004. Conclusions: This formal review suggests that randomized, controlled trial reporting in the urology literature has improved since the publication of the Consolidated Standards of Reporting Trials statement in 1996. Certain areas, such as reporting of trial methods, continue to meet Consolidated Standards of Reporting Trials criteria in fewer than half of publications. Ongoing graduate and postgraduate education in trial design and evidence based practice may result in further improvement in randomized, controlled trial reporting. [Copyright &y& Elsevier]

Purpose: Many abstracts presented at scientific meetings never come to full text publication, which is a prerequisite for the critical appraisal of a given study for its validity, impact and generalizability. We determined factors associated with the publication of abstracts presented at the American Urological Association national meeting. Materials and Methods: All abstracts addressing clinical research accepted for presentation at the 2002 and 2003 meetings of the American Urological Association were reviewed. A comprehensive MEDLINE® search was performed for evidence of publication in full manuscript form. Data abstraction and literature searches were done between June 15 and August 30, 2005. Univariate and multivariate analyses were performed to determine the association between abstract characteristics and time to publication. Results: Of the 1,683 abstracts reviewed 740 (44.0%) were published within a median followup of 27.8 months (range 25.9 to 39.7). Time to publication was associated with abstract origin in the United States and the reporting of statistical testing (HR 1.2, 95% CI 1.0–1.4, p = 0.040 and HR 1.2, 95% CI 1.1–1.4, p = 0.010, respectively). Other variables, such as presentation type, study design, clinical question type and negative outcome, were not predictive. Conclusions: Nonpublication of research findings is a problematic issue that affects more than half of studies 2 years after presentation at the American Urological Association national meeting. Abstracts from the United States and those providing statistical testing were more likely to be published in full text form. Further efforts are warranted to identify and eliminate factors that hinder publication of research to bring it to the scrutiny of a broad audience of urologists. [Copyright &y& Elsevier]

Purpose: We identified age adjusted prostate specific antigen and prostate specific antigen velocity cut points for prostate cancer biopsy. Materials and Methods: A cohort of 33,643 men was retrieved from the Duke Prostate Center database. Of this group 11,861 men with 2 or more prostate specific antigen values within 2 years were analyzed for age adjusted prostate specific antigen and prostate specific antigen velocity performance in cancer risk assessment using a receiver operating characteristic curve. Results: In the 11,861 men prostate cancer prevalence was 273 (8.0%), 659 (14.9%) and 722 (17.9%) in the groups of men 50 to 59 years old, 60 to 69 and 70 years old or older. In prostate cancer groups median prostate specific antigen and prostate specific antigen velocity in men 50 to 59 vs 70 years old or older were 5.6 vs 8.1 ng/ml and 1.37 vs 1.89 ng/ml per year (<0.0001). In men 50 to 59 years old the sensitivity and specificity were 82.1% and 80.7% at prostate specific antigen 2.5 ng/ml, and 84.3% and 72.4% at prostate specific antigen velocity 0.40 ng/ml per year, higher than those in men 70 years old or older at prostate specific antigen 4.0 ng/ml or prostate specific antigen velocity 0.75 ng/ml per year. Decreasing the prostate specific antigen cut point to 2.0 ng/ml and the prostate specific antigen velocity cut point to 0.40 ng/ml per year in men 50 to 59 years old improved the cancer detection rate but decreased the positive predictive value. Conclusions: Current biopsy guidelines (prostate specific antigen 4.0 ng/ml or greater, or prostate specific antigen velocity 0.75 ng/ml or greater per year) underestimated cancer risk in men 50 to 59 years old. Prostate specific antigen and prostate specific antigen velocity cut points should be age adjusted. In men 50 to 59 years old prostate specific antigen and prostate specific antigen velocity cut points could be decreased to 2.0 ng/ml and 0.40 ng/ml per year, respectively. Factors of age, sensitivity, specificity, positive predictive value and cancer prevalence are critical for obtaining the desired balance between cancer detection and negative biopsy. [Copyright &y& Elsevier]

Purpose: Obesity is associated with more advanced disease and worse outcomes in men with prostate cancer. To our knowledge the relationship between obesity and prostate cancer screening behavior in men 40 or older is unknown. Thus, we examined associations between body mass index and prostate cancer screening behavior. Materials and Methods: We used the 2002 Behavioral Risk Factor Surveillance System to study prostate cancer screening in a representative sample of 57,827 men 40 years or older. Primary outcomes were the proportion of men ever screened and the proportion screened in the last year for prostate cancer. Results: Obese men were more likely than normal weight men to have had a prostate specific antigen test (62.1% vs 56.1%, p <0.001) and to have had a prostate specific antigen test in the last year (44.2% vs 38.2%, p <0.001). After controlling for sociodemographic characteristics obese men remained more likely than normal weight men to have had a prostate specific antigen test (OR 1.46, 95% CI 1.33–1.61) and to have had a prostate specific antigen test in the last year (OR 1.42, 95% CI 1.30–1.55). Respondents reporting an ongoing relationship with a physician (OR 2.88, 95% CI 2.57–3.22) and black nonHispanic men vs white men (OR 1.58, 95% CI 1.38–1.81) were also more likely to have had a prostate specific antigen test in the last year. Conclusions: Obese men are more likely than normal weight men to be screened for prostate cancer. Associations between advanced stage, worse outcomes and obesity may not be explained by disparities in the screening of obese men for prostate cancer. [Copyright &y& Elsevier]

Purpose: Knowledge of statistical terminology and the ability to critically interpret research findings are critical skills in the practice of evidence based medicine. Materials and Methods: We provide a series of nontechnical explanations of basic statistical concepts commonly encountered in the urological literature. In addition, we provide examples of common statistical pitfalls to increase awareness of limitations to consider when applying research findings to practice. Results: Statistical goals encountered in the urological literature can be broadly categorized as summarizing outcome variables, comparing 2 or more groups, measuring association among variables or predicting 1 variable from another. Errors frequently include the use of an inappropriate test for the data type of interest or using statistical testing in a manner that increases the likelihood of false-positive results. Such errors pose a threat to the validity of research findings and they may undermine study conclusions. Conclusions: Editors and reviewers alike should strive for high standards of statistical analysis and reporting, and promote the publication of high quality evidence in the urological literature. The understanding of basic statistical concepts and the principles of the hypothesis testing framework is essential to the critical appraisal process and, therefore, important to all urologists. Statistical literacy should be fostered through educational materials and courses in the urological community. [Copyright &y& Elsevier]

Purpose: We investigated the attitudes and opinions of urologists toward evidence-based medicine. Materials and Methods: In April of 2005 we contacted members of the American Urological Association listed with an e-mail address to participate in a web based survey. Participants were asked to characterize their level of agreement with statements referring to the role of evidence-based medicine in urology, to indicate their level of understanding of 15 evidence-based medicine related terms and to report their familiarity with 6 evidence-based medicine related resources. Results: Of 8,100 American Urological Association members 714 (8.8%) responded to this survey. There was widespread agreement (median score 9) with the concept that evidence-based medicine improves patient care and that every urologist should be familiar with critical appraisal techniques. Select terms such as median/mean, selection bias and type I error were well understood (“understand and could explain to others”) by 86%, 57% and 17%, respectively. The American Urological Association Best Practice Guidelines were the single best known resource that 91% of respondents reviewed or used regularly. Conclusions: To our knowledge this survey represents the first evidence-based medicine survey of a large international group of urologists. Its results indicate that evidence-based medicine is viewed favorably and that the American Urological Association Best Practice Guidelines present a well accepted instrument for the dissemination of evidence-based medicine in urology. However, given the low response rate and the potential for selection bias, interpretation of these results must be performed with caution. Future efforts should be directed toward providing increased opportunities for urologists to learn the principles of critical appraisal, facilitating the application of evidence-based medicine in the community and promoting high quality research. [Copyright &y& Elsevier]

PURPOSE:: We assessed the feasibility of radical perineal prostatectomy (RPP) in morbidly obese patients with clinically organ confined prostate cancer.MATERIALS AND METHODS:: Of 1,265 consecutive patients who underwent RPP at our institution from 1992 to 2003 we identified 18 with a body mass index (BMI) of 40 kg/m or greater. Demographic and clinical patient characteristics were obtained from the medical records, which were further reviewed to identify the perioperative incidence of surgical and anesthesia related complications.RESULTS:: Median BMI was 41.7 kg/m (range 40.2 to 62.6). Five patients had a BMI of 45.0 kg/m or greater. No intraoperative or anesthesia related complication occurred. Mean operative time ± SD was 188 ± 32 minutes and estimated blood loss was 573 ± 285 ml. None of the 18 patients received blood transfusions. During the immediate postoperative period 4 complications occurred in the form of lower extremity neuropraxia in 2 patients, local skin bleeding in 1 and early sepsis in 1 requiring rehospitalization for intravenous antibiotics. Mean operative time and estimated blood loss were significantly lower when surgery was performed by a highly experienced surgeon compared with experienced surgeons (174 ± 21 vs 235 ± 10 minutes and 485 ± 258 vs 838 ± 197 ml, p = 0.001 and 0.027, respectively).CONCLUSIONS:: RPP in morbidly obese patients is feasible and it is associated with acceptable perioperative morbidity. The perineal approach should be considered in morbidly obese patients seeking surgical treatment for clinically localized prostate cancer. [ABSTRACT FROM AUTHOR]