Low quality of evidence for robot-assisted laparoscopic prostatectomy: a problem not only in the robotic literature.

The call for standardised and higher quality reports on surgical techniques and outcomes is becoming louder [1]. The reason for this is that the number of low-quality papers is increasing; however, the body of evidence and the knowledge we have about the reported outcomes, unfortunately, is not. In this issue of European Urology, Kang and coworkers present a systematic review of the literature on robotassisted laparoscopic prostatectomy (RALP) [2]. They observed that RALP is displacing radical retropubic prostatectomy as the gold standard surgical approach for clinically localised prostate cancer in the United States and is also being used increasingly in Europe and in other parts in the world. One would expect that this remarkable change in treatment pattern with its significant financial implications would be based on evidence of the superiority of RALP. However, having performed an extensive literature search and a thorough evaluation of each retrieved paper, the authors conclude this is not the case. Two important aspects in this review need to be considered separately. First, the authors state that the published literature on RALP is limited to observational studies of mostly low methodological quality, and they question to what extent valid conclusions about the relative superiorityofRALPcomparedwithother existingapproaches can be drawn at all. Second, and just as important, they question whether the published results on oncologic and functional outcomes could be generalised to a broader community. The vast majority of the published papers on RALP are authored by a small number of very high-volume surgeons, and I am convinced that the excellent outcomes reported do not derive from use of the robot but from surgeons who are experienced and specialised [3,4]. When outcomes in these series are comparedwith outcome reports