The American Urologic Association guidelines for urologists attempt to link body of evidence strength, level of certainty, and magnitude of benefit to patterns of urologic practice. The strength of the recommendations are made based on the strength of the evidence. Strong recommendations can be based on A, B and C grade evidence with the difference between them being the level of certainty defining the confidence level of the recommendation. Evidence Strength “A” (High Certainty) applies to most patients in most circumstances and future research is unlikely to change the confidence level. The majority of recommendations are based on grade B and C strength (rarely used to support a strong recommendation), and a few on Grade A strength. A review of the latter follow.
Clinically Localized Prostate Cancer: AUA/ASTRO/SUO Guideline (2017)
Shared Decision Making – Counseling of patients to select a management strategy for localized prostate cancer should incorporate shared decision making and explicitly consider cancer severity (risk category), patient values and preferences, life expectancy, pre-treatment general functional and genitourinary symptoms, expected post-treatment functional status, and potential for salvage treatment. (Strong Recommendation; Evidence Level: Grade A)
Care Options by Risk Group
1. Clinicians should recommend active surveillance as the best available care option for very low-risk localized prostate cancer patients. (Strong Recommendation; Evidence Level: Grade A)
2. Clinicians should recommend radical prostatectomy or radiotherapy plus androgen deprivation therapy (ADT) as standard treatment options for patients with intermediate-risk localized prostate cancer. (Strong Recommendation; Evidence Level: Grade A)
3. Clinicians should recommend observation or watchful waiting for men with a life expectancy ≤5 years with intermediate-risk localized prostate cancer. (Strong Recommendation; Evidence Level: Grade A)
4. Clinicians should recommend radical prostatectomy or radiotherapy plus ADT as standard treatment options for patients with high-risk localized prostate cancer. (Strong Recommendation; Evidence Level: Grade A)
5. Clinicians should counsel localized prostate cancer patients that nerve-sparing is associated with better erectile function recovery than non-nerve sparing. (Strong Recommendation; Evidence Level: Grade A)
Prostatectomy
6. Clinicians should not treat localized prostate cancer patients who have elected to undergo radical prostatectomy with neoadjuvant ADT or other systemic therapy outside of clinical trials. (Strong Recommendation; Evidence Level: Grade A)
Radiotherapy
7. Clinicians should offer 24-36 months of ADT as an adjunct to either external beam radiotherapy alone or external beam radiotherapy combined with brachytherapy to patients electing radiotherapy for high-risk localized prostate cancer. (Strong Recommendation; Evidence Level: Grade A)
Treatment Side Effects/Quality of Life
8. Clinicians should inform localized prostate cancer patients that temporary urinary incontinence occurs in most patients after prostatectomy and persists long-term in a small but significant subset, more than during observation or active surveillance or after radiation. (Strong Recommendation; Evidence Level: Grade A)
Clinicians should inform localized prostate cancer patients that temporary proctitis following radiation persists in some patients long-term in a small but significant subset and is rare during observation or active surveillance or after prostatectomy. (Strong Recommendation; Evidence Level: Grade A)
Advanced Prostate Cancer: AUA/ASTRO/SUO Guideline
In patients with mHSPC, clinicians should offer continued ADT in combination with either androgen pathway directed therapy (abiraterone acetate plus prednisone, apalutamide, enzalutamide) or chemotherapy (docetaxel). (Strong Recommendation; Evidence Level: Grade A)
Clinicians should not offer first generation antiandrogens (bicalutamide, flutamide, nilutamide) in combination with LHRH agonists in patients with mHSPC, except to block testosterone flare. (Strong Recommendation; Evidence Level: Grade A)
Adjuvant and Salvage Radiotherapy after Prostatectomy: ASTRO/AUA Guideline (2013, amended 2018 & 2019)
Physicians should offer adjuvant radiotherapy to patients with adverse pathologic findings at prostatectomy including seminal vesicle invasion, positive surgical margins, or extraprostatic extension because of demonstrated reductions in biochemical recurrence, local recurrence and clinical progression. (Standard; Evidence Strength: Grade A)
Clinicians should offer hormone therapy to patients treated with salvage radiotherapy (postoperative PSA ≥0.2 ng/mL). Ongoing research may someday allow personalized selection of hormone or other therapies within patient subsets. (Standard; Evidence Strength: Grade A)
Incontinence after Prostate Treatment: AUA/SUFU Guideline (2019)
Clinicians should inform patients undergoing radical prostatectomy that incontinence is expected in the short-term and generally improves to near baseline by 12 months after surgery but may persist and require treatment. (Strong Recommendation; Evidence Level: Grade A)
Evaluation, Management, and Follow-up for Renal Mass and Localized Renal Cancers
Patients with a history of a renal neoplasm presenting with acute neurological signs or symptoms must undergo prompt neurologic cross-sectional CT or MRI scanning of the head or spine based on localization of symptomatology. (Standard; Evidence Strength: Grade A)
Surgical Treatment of Female Stress Urinary Incontinence (SUI): AUA/SUFU Guideline (2017)
In index patients considering surgery for stress urinary incontinence, physicians may offer the following options: (Strong Recommendation; Evidence Level: Grade A)
- Midurethral sling (synthetic)
- Autologous fascia pubovaginal sling
- Burch colposuspension
- Bulking agents
In index patients who select midurethral sling surgery, physicians may offer either the retropubic or transobturator midurethral sling. (Moderate Recommendation; Evidence Level: Grade A)
Diagnosis and Treatment Interstitial Cystitis/Bladder Pain Syndrome (2014)
Appropriate manual physical therapy techniques (e.g., maneuvers that resolve pelvic, abdominal and/or hip muscular trigger points, lengthen muscle contractures, and release painful scars and other connective tissue restrictions), if appropriately-trained clinicians are available, should be offered to patients who present with pelvic floor tenderness. Pelvic floor strengthening exercises (e.g., Kegel exercises) should be avoided. Clinical PrincipleStandard (Evidence Strength Grade A)
Medical Management of Kidney Stones (2019)
Clinicians should obtain periodic blood testing to assess for adverse effects in patients on pharmacological therapy. Standard; Evidence Strength Grade: A
Evaluation and Treatment of Cryptorchidism (2014)
Providers must immediately consult an appropriate specialist for all phenotypic male newborns with bilateral, nonpalpable testes for evaluation of a possible disorder of sex development (DSD). (Standard; Evidence Strength: Grade A)
Evaluation and Management of Testosterone Deficiency (2018)
Diagnosis
The diagnosis of low testosterone should be made only after two total testosterone measurements are taken on separate occasions with both conducted in an early morning fashion. (Strong Recommendation; Evidence Level: Grade A)
Serum prolactin levels should be measured in patients with low testosterone levels combined with low or low/normal luteinizing hormone levels. (Strong Recommendation; Evidence Level: Grade A)
Patients with persistently high prolactin levels of unknown etiology should undergo evaluation for endocrine disorders. (Strong Recommendation; Evidence Level: Grade A)
Prior to offering testosterone therapy, clinicians should measure hemoglobin and hematocrit and inform patients regarding the increased risk of polycythemia. (Strong Recommendation; Evidence Level: Grade A)
Counseling
The long-term impact of exogenous testosterone on spermatogenesis should be discussed with patients who are interested in future fertility. (Strong Recommendation; Evidence Level: Grade A)
Treatment
Exogenous testosterone therapy should not be prescribed to men who are currently trying to conceive. (Strong Recommendation; Evidence Level: Grade A)
Clinicians should discuss the risk of transference with patients using testosterone gels/creams. (Strong Recommendation; Evidence Level: Grade A)
