
==== Front
Eur Urol Open Sci
Eur Urol Open Sci
European Urology Open Science
2666-1691
2666-1683
Elsevier

S2666-1683(24)00637-2
10.1016/j.euros.2024.08.012
Opinion: Open Science
An Obituary for the European Association of Urology Guidelines on Thromboprophylaxis in Urological Surgery (2017–2023)
Dahm Philipp a
Antonio González Padilla Daniel dgonzalezp@unav.es
b⁎
a Division of Urology, Minneapolis VA Health Care System, Minneapolis, MN, USA
b Department of Urology, Clínica Universidad de Navarra, Madrid, Spain
⁎ Corresponding author. Department of Urology, Clínica Universidad de Navarra, Madrid, Spain. dgonzalezp@unav.es
12 9 2024
11 2024
12 9 2024
69 56
5 8 2024
© 2024 The Author(s)
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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pmcThe development of clinical practice guidelines (CPGs) is a major endeavor, requiring a tremendous amount of work and time, not to mention the continued effort required to keep them updated. While major urological associations strive to produce high-quality CPGs, not all of them fulfill all of the criteria expected from trustworthy guidelines [1].

In 2017 the European Association of Urology (EAU) published an ad hoc guideline on thromboprophylaxis in urological surgery, which was probably the most rigorous, transparent, and actionable urological guideline published up to then, filling an important gap and providing urologists with the first evidence-based guidance on the best management practices for venous thromboembolism (VTE) prophylaxis. Since then, the American Society of Hematology has published a guideline on VTE prophylaxis across surgical specialties but this only included two urological procedures, transurethral resection of the prostate and robot-assisted laparoscopic prostatectomy [2]. The Canadian Urological Association (CUA) endorsed this guideline and published a version adapted to the Canadian context [3].

In the latest 2024 scheduled update of the EAU guidelines, the CPG on thromboprophylaxis in urological surgery has been archived as a “discontinued topic“. As we mourn the premature departure of this valuable guidance document, it is worth pointing out what made it so special.

First, this EAU guideline was pioneering in its engagement of a broad spectrum of stakeholders, namely physicians not only from urology but also from internal medicine, hematology, and gynecology who also had a background in clinical epidemiology and guideline methodology.

Second, the guideline panel fully applied the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach for assessing the quality of evidence and grading of recommendations [4]. GRADE has become the framework most widely used for creating trustworthy guidelines and has been selectively applied by other urological organizations such as the American Urological Association (AUA) for rating the certainty of evidence and by the CUA for a few guidelines, and has been the intended framework for all EAU guidelines since 2018, although actual implementation has been challenging.

Third, individual recommendations were informed by separate systematic reviews of observational studies of the risk of thrombosis and bleeding in urological surgery in the ROTBUS study [5], [6], [7].

Lastly, the guideline provided a clear explanation as to what assumptions the panel made about patients’ values and preferences and how they weighed the potential benefits and harms of different forms of VTE prophylaxis for each procedure.

While the EAU has improved the transparency of its CPG methodology, it remains unknown when and how it chooses to discontinue a topic, as neither the Guidelines Office Development Handbook nor the EAU Guidelines Strategy 2022 to 2027 [8] goes into detail about this issue.

It is noteworthy that out of 11 discontinued guidelines on the EAU website, six have been fully incorporated into other guidelines, three have been partly incorporated into other guidelines, and only two have been fully discontinued (Pain management and Thromboprophylaxis in urological surgery; Table 1) [9].Table 1 Summary of discontinued topics among the European Association of Urology guidelines [7]

Topic	Years published	Current status	
Thromboprophylaxis in urological surgery	7 (2017–2023)	Fully discontinued	
Urinary incontinence	20 (2001–2020)	Now included in the non-neurogenic female LUTS guideline	
Male sexual dysfunction	19 (2000–2018)	Now included in the sexual and reproductive health guideline	
Male infertility	19 (2001–2019)	Now included in the sexual and reproductive health guideline	
Male hypogonadism	15 (2005–2019)	Now included in the sexual and reproductive health guideline	
Lasers and technology	5 (2011–2015)	Partly incorporated into other guidelines	
Pain management	13 (2003–2015)	Fully discontinued	
Robotic- and single-site surgery in urology	3 (2013–2015)	Partly incorporated into other guidelines	
Priapism	4 (2014–2017)	Now included in the sexual and reproductive health guideline	
Penile curvature	6 (2012–2017)	Now included in the sexual and reproductive health guideline	
Laparoscopy	1 (2002)	Partly incorporated into other guidelines	
LUTS = lower urinary tract symptoms.

We recognize that the publication of each guideline is time-consuming and requires a large financial investment; such a scenario could represent an excellent opportunity for collaboration and cost-sharing, for example with the AUA, which does not have a corresponding guideline in its portfolio, or the CUA, which formally endorsed and adapted the EAU document [3]. There remains huge untapped potential for greater collaboration among guideline developers [10].

As we mourn the discontinuation of the guideline on thromboprophylaxis in urological surgery, may this Editorial serve as an obituary to remember it forever.

May it rest in peace.



Conflicts of interest: The authors have nothing to disclose.
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References

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