[9] Agha R, Cooper D, Muir G. The reporting quality of randomised controlled trials in surgery: a systematic review. Int J Surg 2007;5:413–22. [10] Mamoulakis C, Schulze M, Skolarikos A, et al. Midterm results from an international multicentre randomised controlled trial compar- ing bipolar with monopolar transurethral resection of the prostate. Eur Urol 2013;63:667–76. [11] Mamoulakis C, Skolarikos A, Schulze M, et al. Results from an international multicentre double-blind randomized controlled trial on the perioperative efficacy and safety of bipolar vs monopolar transurethral resection of the prostate. BJU Int 2012;109:240–8. [12] Rassweiler J, Teber D, Kuntz R, Hofmann R. Complications of transurethral resection of the prostate (TURP)–incidence, manage- ment, and prevention. Eur Urol 2006;50:969–80, discussion 980. [13] De la Rosette JJ, Rassweiler JJ. Bipolar TURP treatment for BPH refractory to medication:the past, present, and future surgical reference standard. J Endourol 2008;22:2111–2, discussion 2123. [14] Bachmann A, Woo HH, Wyler S. Laser prostatectomy of lower urinary tract symptoms due to benign prostate enlargement: a critical review of evidence. Curr Opin Urol 2012;22:22–33. http://dx.doi.org/10.1016/j.eururo.2012.10.052 Platinum Priority Reply from Authors re: Alexander Bachmann, Gordon H. Muir, Stephen F. Wyler, Malte Rieken. Surgical Benign Prostatic Hyperplasia Trials: The Future is Now! Eur Urol 2013;63:677–9 Best Available Evidence in 2012 on Bipolar Versus Monopolar Transurethral Resection of the Prostate for Benign Prostatic Obstruction: It’s About Time to Decide! Charalampos Mamoulakis a,b, *, Michael Schulze c , Andreas Skolarikos d , Gerasimos Alivizatos d , Roberto M. Scarpa e , Jens J. Rassweiler c , Jean J.M.C.H. de la Rosette a , Cesare M. Scoffone e a Department of Urology, Academic Medical Center, University of Amster- dam, Amsterdam, The Netherlands; b Department of Urology, University Hospital of Heraklion, University of Crete Medical School, Heraklion, Crete, Greece; c Department of Urology, SLK Kliniken Heilbronn, University of Heidelberg, Heilbronn, Germany; d Second Department of Urology, Sisma- noglio Hospital, University of Athens Medical School, Athens, Greece; e Department of Urology, San Luigi Hospital, University of Turin, Orbassano, Turin, Italy We would like to thank the authors for commenting on our article [1]. It is unfortunately true that high-quality surgical–urologic randomized controlled trials (RCTs) are scarce in several fields, including surgical management of lower urinary tract symptoms secondary to benign prostatic obstruction [2]. A majority of studies in the urologic literature provide a low level of evidence (LoE) that may not be well suited to guiding clinical decisions. Many barriers exist, including flaws related to design, conduct, and reporting. Such flaws jeopardize the validity of many RCTs and create uncertainty about risk of bias and surgical research value. Thorough evaluations of novel surgical interventions are difficult because of challenges related to surgical practice, but they are achievable and necessary. It is clear that particular problems exist related to the conduct of surgical RCTs, and study designs to evaluate medications do not always fit surgical interventions well because of their procedural complexity [3]. To explore barriers to high- quality surgical research and seek potential solutions, an expert forum—the Balliol Colloquium—was initiated in 2007. Within 2 yr, the IDEAL framework (Idea, Develop- ment, Exploration, Assessment, Long-term study) was established, and specific proposals were made for appro- priate designs to improve evidence collection before incorporating innovations into surgical practice [3]. The IDEAL recommendations are expected to solve the problem to a great extent by serving as accepted guidelines tailored to surgical research; as a platform for systematic data generation from well-designed, well-conducted, and well- reported studies; and as a regulatory framework to protect patients from the potential harms of novel procedures. Accurate LoE grading represents another crucial issue. Systematic reviews (SRs) provide transparent and robust summaries of existing research, but the information may be insufficient for making well-informed decisions, without implementation of a systematic and explicit approach to making judgments on LoE. Unfortunately, a variety of grading systems are often used, resulting in miscommuni- cation. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system provides concise and precise information [4]. This framework has been adopted as a standard by many organizations including the World Health Organization and the Cochrane Collaboration. An important feature is that LoE is split into four categories (high, moderate, low, very low) in an outcome-specific manner. Certain study limitations may affect some outcomes more than others. RCT-derived evidence starts as high quality but may be downgraded if specific strict criteria are not met. Clinical decision making should ideally be based on the highest LoE. Nevertheless, we fully agree with the authors in acknowledging that, under certain circumstances, we may have to compromise by accepting lower LoE and just relying on the best evidence available. Regarding the debate about bipolar transurethral resection of the prostate (B-TURP) versus monopolar transurethral resection of the prostate (M-TURP), the fact is that we currently have >30 RCTs DOIs of original articles: http://dx.doi.org/10.1016/j.eururo.2012.10.003, http://dx.doi.org/10.1016/j.eururo.2012.10.052. * Corresponding author. Department of Urology, University Hospital of Heraklion, PO Box 1031, 71001, Heraklion, Crete, Greece. Tel. +30 6944 568862. E-mail address: c.mamoulakis@med.uoc.gr (C. Mamoulakis). EUROPEAN UROLOGY 63 (2013) 677–680 679