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It is an undisputed fact that scientific progress would not be possible without active collaboration between academia and industry. Governments and the public sector cannot cover the costs involved in drug discovery or development of new technology, and without an ultimate profit motive, charity alone will not be sufficient to sustain this growth. However, this also causes an undesirable plethora of management options, surgical techniques, and modalities of treatment, which make decisions difficult. In our everyday practice, we come across situations where we fail to provide “the best” option to deal with a particular problem, be it prostate cancer, small stone in the kidney, or symptomatic prostatic enlargement.
Plenty of options, often each with “level 1 evidence,” instead of providing clarity lead to ambiguity on our part to decide the best treatment for patients. While counseling patients, it has become increasingly difficult to help them choose the best treatment option or technique. When we ourselves are not clear about the best, how can we expect them to decide, particularly in an era of “Google” derived knowledge? May be it is time that instead of talking about techniques, we should talk about the outcome. For example, a patient who comes to us for stone removal, apart from providing knowledge about options, we should also advise him what would be the best in our hands.
An example of such difficult choices is in the management of hypospadias. There are a large number of techniques with large amounts of data in their support. However, patient-reported outcomes which would include cosmetic and psychological satisfaction are often lacking. Adams and Bracka present a systematic review of such outcomes which summarizes the problems in getting uniform, good quality data addressing these issues, and suggest that we are far from achieving a universal satisfactory outcome for our patients. Continuing on the theme of patient-reported outcomes, Keys et al. summarize the currently available tools for assessing lower urinary tract dysfunction and highlight their lacunae in assessing outcomes.
Stone diseases, a common problem treated by urologists in India, continue to have its share of controversies. While the advocates of flexible ureteroscopy believe most stones should be managed without any percutaneous punctures, the high cost and maintenance of such scopes and the time required for clearance for larger stones mean that percutaneous nephrolithotomy (PCNL) will continue to be a widely used option. One approach to diminishing the morbidity of PCNL is believed to be decreasing the size of the access tract. While this in itself is not unequivocally accepted, Agrawal et al. present outcomes with their small sheath PCNL for kidney stones of 8–20 mm size and provide a substantive alterative to shock wave lithotripsy and flexible ureteroscopy. Again, there may be little to choose between the three modalities in terms of efficacy, but what works in one surgeon's hand may be what is best for that patient.
Prostate cancer is another area where we have failed to find the Holy Grail. Most of our clinical decision making is based on Western data, but knowing the much lower incidence that the disease has in India as compared to the West, is this approach truly correct? The aging population in India is likely to increase with improving life expectancy. According to the 2011 census, we had 45 million men over 60 years of age and this would be higher today. With this population of men and increasing longevity, we need to focus on this malignancy as well. A welcome change is the review article in this issue of the journal by Hariharan and Padmanabha who look at the national prostate cancer data and try to provide some insight about the incidence of prostate cancer in India. They have reviewed epidemiological studies on prostate cancer in India and suggest an increasing incidence in the urban population in comparison with rural populations, possibly due to changing life styles and health-care practices.