2.1. Guideline methodology
The EAU Guidelines on Thromboprophylaxis in Urological Surgery Panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach for assessment of quality of evidence and grading of recommendations [10-12].
GRADE offers four levels of evidence quality, reflecting the degree of certainty or confidence in the evidence: high, moderate, low, and very low . For relative treatment effect, RCTs are high-quality evidence and observational studies are low-quality evidence. For baseline risk (such as risk of VTE post-surgery), observational studies are high-quality evidence. Quality may be rated down as a result of limitations in study design or implementation (risk of bias), imprecision of estimates (wide confidence intervals), inconsistency (variability in results), indirectness of evidence, or publication bias. Quality may be rated up on the basis of a very large magnitude of effect, a dose-response gradient, and if consideration of all plausible biases would reduce an apparent treatment effect, or create an effect when none is apparent. The lowest quality of any critical outcome represents the overall quality of evidence.
The strength of a recommendation reflects the extent to which we can be confident that desirable effects of an intervention outweigh undesirable effects. GRADE classifies recommendations as strong or weak . Strong recommendations mean that all or virtually all informed patients would choose the recommended management and that clinicians can structure their interactions with patients accordingly. Weak recommendations mean that patients’ choices will vary according to their values and preferences, and that clinicians must ensure that patients’ care is in keeping with their values and preferences through shared decision-making. Strength of recommendation is determined by the balance between desirable and undesirable consequences of alternative management strategies, quality of evidence (certainty in estimates), and nature and variability of values and preferences.
Post-operative thromboprophylaxis and peri-operative management of antithrombotic agents in urology are discussed seperately. Specific methods are presented in the context of the relevant recommendations.