Evidence-based Urology: Trustworthy Guidelines

Clinical guidelines for guiding clinical decision-making must be trustworthy, especially when there is controversy or a shifting paradigm. In urology, the management of small renal masses is one area in which there is currently a paradigm shift towards active surveillance. A number of international guidelines address this paradigm shift to some extent, with varying degrees of rigor. To be trustworthy, guidelines should be developed by panels that include content experts - the traditional panel members - as well as methodologists with expertise in evidence interpretation, front-line clinicians who take care of the patients who constitute the target audience, and patient partners. At a minimum, panels should integrate four key concepts: (1) guidelines provide a systematic summary of evidence used to support answerable questions, including assessment of the quality of the evidence; (2) there is a clear and transparent link between the evidence and recommendations; (3) recommendations incorporate patient values and preferences; and (4) conflicts of interest are managed optimally. In this article we address several issues in four international guidelines, with an emphasis on guideline methods and implications for guidance statements. The strengths and limitations of available recommendations are reviewed and summarized with suggestions for improving the next iterations of guidelines on the management of small renal masses. PATIENT SUMMARY: Good clinical decision-making relies on trustworthy guidelines. We assessed four international guidelines on the management of small kidney tumors that illustrate some of the key issues in developing a trustworthy guideline. Patient values and preferences are under-represented in most clinical guidelines.