European Urology

Editorials

The Department of Urology of the Charité Hospital, Berlin, has reported its experience in laparoscopic radical prostatectomy: 1000 patients operated on by eight surgeons over a period of almost 6 yr [1].

This article illustrates the high levels of innovation, technology development, and surgical skills that, during this period, were found mainly at European academic medical centres. The article describes one institution's experience and this analysis confirms that the efficiency of laparoscopic radical prostatectomy is no longer in question; indeed, the authors report data on the short-term oncologic efficacy. These data are welcome because very few biochemical recurrence-free survival curves have been published, even though the procedure has been performed since 1998 and thousands of patients have been operated on [2], [3], and [4]. In addition, the authors confirm the feasibility and the reproducibility of the technique and describe the perioperative morbidity of the procedure. Moreover, the team at Charité has demonstrated its ability to develop a renowned teaching programme, but more importantly, they have demonstrated their ability to rapidly recruit for their clinical project a large number of patients with localised prostate cancer. These strengths are impressive and should inspire all of us.

But this article also leads us to raise some questions. Indeed, the urologic community is still waiting for more conclusive evidence that the laparoscopic approach is an important advance in surgical techniques for prostate cancer. For the evidence-based medicine that is needed nowadays, patient series, no matter how large, are not enough. Nor can we continue to set the hypothesis after data collection or be satisfied with comparisons with data from the medical literature.

If it is indispensable to continue the tradition of surgical innovation, in the broad sense, a tradition that the European academic centres have inherited, it is also indispensable to adopt the means to answer as accurately as possible the medical question that every urologist raises. The question is simple and well known: “How do we take better care of our patients?” The answer is equally simple and well known—that is, comparisons—but comparisons in the recent urologic surgical literature are too little used. At the beginning of this century, feelings, personal experience, or enthusiasm are no longer ways to convince anybody, neither the urologists nor the health care providers.

Daily practice in prostate surgery is changing dramatically, but without definitive evidence of clinical advantage and without regard to cost. Until urologists, myself included, set up clinical trials, until the data are prospectively collected with validated methods and questionnaires and are correctly recorded in databases, until the data are analysed by independent biostatisticians, all claims we are publishing in terms of “benefits,” “advantages,” and “advancement,” in other words, all comments that imply comparisons, are meaningless. Meanwhile, individual urologists may make clinical judgements (e.g., “I am sure that this surgical technique will benefit this group of patients”), but certainly this is not adequate for the whole urological community, which cannot yet use these data to improve patient care. Then, too, the experience and expertise accumulated over the years by surgeons, involving thousands of patients and requiring significant personal involvement and significant financial resources, becomes ultimately non-transmissible, and therefore unfortunately wasted.

It is probably the right time for urologists to raise the essential questions prospectively and to use the means needed to provide answers. Many prospective randomised trials have been conducted in medical and radiation oncology, and even the field of surgical oncology has successfully recruited patients for prospective randomised trials [5]. It is really questionable why urologists have been unable to conduct such trials. Conducting such trials is one of the main roles of academic medicine.

Laparoscopic surgery will find its definitive place within the surgical armamentarium only when the urologists involved in its evaluation provide the data that answer two basic questions: What are the benefits? Which patients will benefit? Meanwhile, we are all condemned to reading about phase 1 and 2 surgery studies that do not provide enough evidence to generate any changes in daily surgical practice. Or even worse: if we accept as evidence what are only hypotheses, the drift to the world of the nonacademic medicine will open Pandora's box, and one can bet that soon, we would accept our medical practice being driven by advertising arguments, commercial objectives, and soon by business plans of companies, the NASDAQ or CAC 40 indexes. Personally, I am not convinced that the economic market is the best regulator of medical quality.

Now that laparoscopic radical prostatectomy has proven to be a feasible and mature technique, now that the experience reported in this article brings additional factors to our thoughts in terms of possible benefits and possible disadvantages, it is time for all of us to become committed to answering these medical questions.