No one of us is as smart as all of us


For as long as I remember, most endourological procedures have been in the ‘shadow of prestige’ of advanced surgical oncological cancer managements. Whereas radical cystectomy is considered a complicated and critical oncological procedure, the endoscopic part of diagnosis and treatment of urothelial tumours is contemplated a residents or junior staff procedure. It comes as no surprise that for transurethral resection of bladder tumour (TURBT) less attention has been paid to quality control including training and outcomes. We are studying in detail morbidity, positive surgical margins, health economics, and training for cystectomy but fail to do so for TURBT.

However, there is a wind of change that is going to impact on our daily work. The community no longer just accepts the statement that we are professionals providing the best possible care according to best practice. If this is correct, can we provide any proof for that? Administrative databases provided by third parties have become the main source of insight in our clinical practice. This harbours a big danger, as those databases are created with a certain aim: to serve the third parties to steer and control our practice. So the question arises: Why should we not be able to provide the evidence of the quality of our work and why should we not aim to further improve the quality of our work?

Therefore at present the main question is not ‘if’ but ‘how’ we can achieve this. The initiative of Gan et al. [1] deserves to be applauded. The beauty of their work is captured in its simplicity. It is attractive in its design with a rather unique methodology. It truly provides a snapshot of TURBT in the UK. The downside of the present work is that the response rate is fairly low. With the data available; however, one has new information that invites to move this initiative to the next level: encourage more colleges to join and create a truly national network on TURBT.

But how can we achieve our goal and encourage participation? The answer is very simple and embedded in the answer to the question: What is in it for me? The answer can be multifold including an altruistic contribution to research, providing data to national registries to be used to present and defend the position of urologists, to receive recognition and, to be able to improve one's practice.

Within this context the Endourological Society launched a comparable project in 2008 called the CROES (Clinical Research Office of the Endourological Society) [2]. The Endourological Society was established to facilitate dialogue between endourologists globally. The CROES is responsible for organising, structuring and assisting a worldwide network for endourological research. The CROES has been a very successful initiative and proven to be able to create high-quality databases based on daily practice. These databases provide wide proprietorship and high generalizability through the participation of many clinicians. Other advantages include relatively low costs per study, the ability to generate large samples fast and the provision of accurate information for clinical practice, audit and administration. The first studies undertaken include a registry on percutaneous nephrolithotomy (96 centres with almost 6000 cases), a registry on ureterorenoscopy (114 centres with >11 000 cases), a registry on Renal Mass (98 centres with almost 5000 cases). Data from these projects are currently mined to answer multiple questions. Those data are complementary to data collected from randomised controlled trials and interestingly a collaborative platform such as CROES is in the best position to do so. Recently the CROES launched a randomised study comparing narrow-band imaging to White light during TURB to assess recurrence of bladder cancer in term of safety and efficacy [3]. Essential to the success of such a work is to provide the optimal infrastructure to support and conduct studies. To facilitate entry of patient data at each CROES site, a paperless, centralised web-based data collection system has been established [4].

Clearly, priorities and choices must be made. By drawing on the expertise and experience of researchers, the urological community can fully capitalise on diverse intellectual resources to make lasting contributions to global health. By now it is clear that CROES provides a platform enabling a critical analysis of current patterns of practice on a global base and providing data upon which decisions can be made for the fiscally responsible and future delivery of effective healthcare.

STUKA shows the quality of TURBT in the UK and highlights the importance of urological collaboration. It carefully reveals areas for improvement including the timelines of diagnosis and treatment, and improved care of patients with intermediate and advanced bladder cancer. Most importantly this work elegantly shows that widening participation is a priority. Within this perspective it is appropriate to conclude that ‘No one of us is as smart as all of us’.

Conflict of Interest

None declared.