Letter to the editor: Korean clinical practice guideline for benign prostatic hyperplasia

To the editor: We welcome the recent publication of the Korean clinical practice guidelines on the management of lower urinary tract symptoms attributable to benign prostatic hyperplasia, which represents an important milestone for Korean patients [1]. Notable strengths of the guideline development process include the critical appraisal of existing guidelines, a systematic review of the relevant literature, the incorporation of different stakeholder perspectives as well as a grading of the strength of recommendations as "strong" or "weak", which resembles the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach [2,3]. At the same time, we believe that there are several shortcomings of this document that deserves the readers' attention. First, it is noteworthy that all but one recommendation are rated as "strong" (defined as "most or all individuals will be best served by the recommended course of action") which is unusual. The guideline panel used a Delphi technique, which is useful for developing consensus of opinion on a given topic. It is a well-suited approach for engaging a group of individuals in research, fact-finding, and issue exploration but less so for determining the strength of recommendations [4]. Second, wording of recommendations appears inconsistent within the same level of recommendation; terminology for strong recommendation varies between "should be offered", "is recommended," "might be considered" to "should be advised" which may distract the guideline user from the fact that all of these recommendation are intended to be similarly actionable. Lastly, some of the recommendations, such as the strong recommendation for transurethral resection of prostate over other surgical treatment modalities in benign prostatic hyperplasia could be better explained; while the authors report the performance of systematic reviews, none of the underlying evidence profiles were provided. This guidance document underscores the many challenges facing guideline developers in the rapidly evolving field of urology. While it is nearly universally accepted that systematic reviews should provide the foundation for evidence-based guideline, their development takes time and is resource intense. Meanwhile, different approaches to the rating of the quality of evidence and the strength of recommendations used by urological organizations worldwide make it hard to share evidence profiles or collaborate in guideline development. While a guideline that specifically addresses the disease characteristics of lower urinary tract symptoms in Korean men, addresses potentially different values and preferences, and considers local practice patters is of critical importance, it appears a wasteful use of resources to have organizations such as the American Urological Association, European Association of Urology, National Institute for Health and Care Excellence, and the Korean Urological Association to duplicate efforts in the production of evidence profiles. While many urological organizations continue to employ competing guideline framework, there has been a remarkable uptake of the GRADE framework by over 90 professional organizations. GRADE is the closest the medical community has come to arriving at a methodologically rigorous, comprehensive and unified system for moving from evidence to recommendations [2,3,5]. It offers great promise for future collaboration and resource-sharing and may serve the Korean Urological Association well in the future.