A Plea for Evidence-Based Medicine in Trauma and Reconstructive Urology

Fortunately, I was able to spend my residency at one of the most renowned urethral reconstruction centers in Europe, the University Medical Center Hamburg-Eppendorf (Hamburg, Germany), under the supervision of Margit Fisch and Roland Dahlem. During my residency, I did a uro-oncologic research fellowship specializing in bladder cancer with Shahrokh Shariat at Weill Medical College of Cornell University. Everything I found here was about evidence-based medicine, clinicians and researchers who would thoughtfully develop prospective study designs and validate the outcome of guideline-based recommended therapies in patients with bladder cancer.

Coming back from this fellowship, I was literally searching for this quality of evidence-based medicine in reconstructive urology, especially in urethral reconstruction. But I mostly found small retrospective studies, thus highly underpowered statistics, and inconsistency in diagnostic, treatment and followup between centers. Then I decided to open up a new Young Academic Urologists (YAU) Trauma and Reconstructive working party.

Never Underestimate the Importance of Institutional Standards and Surgical Schools in Reconstructive Urology

I remember being in the operating room with Roland Dahlem as a resident, where I constantly annoyed him with questions like, “why do we use that suture?” “why continuously, why not interrupted?” and “why do we keep the catheter for that time?” He always had a very reasonable argument, but it often sounded to me like, “because we do it this way (always).”

Looking back, I truly think this is what reconstructive urology is all about: a field that is highly based on surgical experience. After I started doing reconstructive cases myself, I understood that everything reconstructive surgeons do both in and outside the operating room (eg preoperative diagnosis, use of antibiotic prophylaxis, evaluation of postoperative success) matters, and it follows an institutional standard–in other words, a “surgical school.”

We believe it is important to publish these surgical schools, which play a key role in the understanding of different techniques and, more importantly, different outcomes. For example, a mid-term urethral stricture-free survival rate of 85% is a fantastic result for both patient and surgeon. But the number does not explain how the excellent success rate has been achieved. Instead of success rate-driven research only, we aim to focus on describing and comparing perioperative diagnostic algorithms, standardized reporting on peri-/postoperative complications and patient-reported outcomes between our centers.^1,2

Why Do We Need Young Academic Urologists in Trauma and Reconstructive Urology?

Because it is very difficult to find these trauma and reconstructive urologists who are interested in research. Personally, I believe it has something to do with age. The most productive time for any academic urologist will be the earlier years of her/his career. But first it takes time to deeply understand and thus address clinical problems in reconstructive urology, and second to provide sufficient data on patients you operated on. Once we reach the clinical expertise, we realize we are too old to do research. As an academic trauma and reconstructive urologist, you have to gain surgical experience and stay dedicated to research; in other words, you need a long breath.

Figure. Current members of the YAU Trauma and Reconstructive working party.

We Embrace the Heterogeneity and Diversity of Our Group, Which Widens the Spectrum of Research Interest and Allows Views from Different Angles on Each Project

Our YAU Trauma and Reconstructive Urology working party has constantly grown since we started in 2017 (with 2 members). Currently we have 10 members who are national and international clinical and scientific experts in the broad spectrum of urethroplasty, trauma surgery, incontinence surgery, fistula repair, ureteral repair, pyeloplasty, penile reconstructive surgery, corporoplasty, urinary diversion, transgender surgery, 3-dimensional modeling, tissue engineering, robotic surgery, andrology and sexual medicine (see figure).

One of our main projects is merging already existing retrospective institutional databases. However, each of our members is able to conceptualize a research idea and create prospective multi-institutional registries.

Furthermore, all members are highly active in other national and international scientific committees and working groups in their field of expertise. We understand YAU as a huge network platform for projects within the YAU (with other working groups),³ within the EAU (European Association of Urology) and with external partners. We collaborate with different institutions such as ESU (European School of Urology) and ESGURS (European Society of Genital Urinary Reconstructive Surgeons), and 3 members of our group are panel members of the new EAU Guidelines Office for Urethral Stricture Diseases.^4–6

We believe in the importance of international collaborations with well-established research groups such as TURNS (American Trauma Urologic Reconstructive Network Surgeons) and ESCAP (ESSM [European Society of Sexual Medicine] Scientific Collaboration and Partnership) to create high-quality projects.⁷

What Have We Learned So Far?

We need young practicing urologists in Europe with a major interest in trauma and reconstructive urology who are dedicated to academia. We want to actively collaborate, thereby creating a group of young “key opinion leaders” in the field of trauma and reconstructive urology in Europe.