[Moderate recommendation] Clinicians should obtain tissue diagnosis from the primary tumor or site of metastases when clinically feasible in patients with suspicion of advanced prostate cancer and no prior histologic confirmation. [Very low evidence] Based on Clinical Principle (consensus without direct evidence).
[Moderate recommendation] Clinicians should discuss treatment options based on life expectancy, comorbidities, preferences, and tumor characteristics, and incorporate a multidisciplinary approach when available in advanced prostate cancer patients. [Very low evidence] Based on Clinical Principle.
[Moderate recommendation] Clinicians should optimize pain control or other symptom support and encourage engagement with professional or community-based resources, including patient advocacy groups, in advanced prostate cancer patients. [Very low evidence] Based on Clinical Principle.
[Moderate recommendation] Clinicians should inform patients with PSA recurrence after exhaustion of local therapy about metastatic disease risk and follow them with serial PSA and clinical evaluation; they may consider radiographic assessments based on PSA and kinetics. [Very low evidence] Based on Clinical Principle.
[Moderate recommendation] Clinicians should perform periodic staging evaluations with cross-sectional imaging (CT, MRI) and bone scan, and/or preferably PSMA PET imaging, in patients with PSA recurrence after failure of local therapy who are at higher risk for metastases (e.g., PSADT <12 months). [Very low evidence] Based on Clinical Principle.
[Weak recommendation] Clinicians should utilize PSMA PET imaging preferentially, where available, as an alternative to conventional imaging due to greater sensitivity, or after negative conventional imaging, in patients with PSA recurrence after failure of local therapy. [Expert opinion] Based on panel consensus.
[Moderate recommendation] Clinicians should offer observation or clinical trial enrollment to patients with a rising PSA after failure of local therapy and no demonstrated metastatic disease by imaging. [Very low evidence] Based on Clinical Principle.
[Strong recommendation against] ADT should not be routinely initiated in this population (based on expert opinion). [Conditional recommendation] If ADT is initiated in the absence of metastatic disease, intermittent ADT may be offered in lieu of continuous ADT (based on moderate evidence from Grade B studies).
[Moderate recommendation] Clinicians should assess the extent of metastatic disease (lymph node, bone, and visceral metastases) in newly diagnosed mHSPC patients. [Very low evidence] Based on Clinical Principle.
[Moderate recommendation] Clinicians should assess the extent of metastatic disease (low- versus high-volume) in newly diagnosed mHSPC patients, with high-volume defined as ≥4 bone metastases with one outside spine/pelvis and/or visceral metastases. [Moderate evidence] Based on Grade B studies.
[Moderate recommendation] Clinicians should assess if a newly diagnosed mHSPC patient is experiencing symptoms from metastatic disease at presentation to guide prognosis and management discussions. [Moderate evidence] Based on Grade B studies.
[Moderate recommendation] Clinicians should obtain a baseline PSA and serial PSAs at 3-6 month intervals after ADT initiation in mHSPC patients and consider periodic conventional imaging. [Very low evidence] Based on Clinical Principle.
[Moderate recommendation] In patients with mHSPC, clinicians should offer germline testing, and consider somatic testing and genetic counseling. [Very low evidence] Based on Clinical Principle.
[Strong recommendation] Clinicians should offer ADT with either LHRH agonists or antagonists or surgical castration in patients with mHSPC. [Moderate evidence] Based on Grade B studies.
[Strong recommendation] In patients with mHSPC, clinicians should offer ADT in combination with either androgen pathway directed therapy (abiraterone acetate plus prednisone, apalutamide, enzalutamide) or chemotherapy (docetaxel). [High evidence] Based on Grade A studies.
[Strong recommendation] In selected patients with de novo mHSPC, clinicians should offer ADT in combination with docetaxel and either abiraterone acetate plus prednisone or darolutamide. [High/moderate evidence] Based on Grade A for abiraterone and Grade B for darolutamide studies.
[Conditional recommendation] In selected mHSPC patients with low-volume metastatic disease, clinicians may offer primary radiotherapy to the prostate in combination with ADT. [Low evidence] Based on Grade C studies.
[Strong recommendation] Clinicians should not offer first generation antiandrogens (bicalutamide, flutamide, nilutamide) in combination with LHRH agonists in patients with mHSPC, except to block testosterone flare. [High evidence] Based on Grade A studies.
[Weak recommendation] Clinicians should not offer oral androgen pathway directed therapy (e.g., abiraterone acetate plus prednisone, apalutamide, bicalutamide, darolutomide, enzalutamide, flutamide, nilutamide) without ADT for patients with mHSPC. [Expert opinion] Based on panel consensus.
[Moderate recommendation] In nmCRPC patients, clinicians should obtain serial PSA measurements at 3-6 month intervals and calculate a PSADT starting at castration-resistance development. [Very low evidence] Based on Clinical Principle.
[Weak recommendation] Clinicians should assess nmCRPC patients for development of metastatic disease using conventional or PSMA PET imaging at intervals of 6 to 12 months. [Expert opinion] Based on panel consensus.
[Strong recommendation] Clinicians should offer apalutamide, darolutamide, or enzalutamide with continued ADT to nmCRPC patients at high risk for developing metastatic disease (PSADT ≤10 months). [High evidence] Based on Grade A studies.
[Weak recommendation] Clinicians may recommend observation with continued ADT to nmCRPC patients, particularly those at lower risk (PSADT >10 months) for developing metastatic disease. [Very low evidence] Based on Clinical Principle.
[Moderate recommendation] Clinicians should not offer systemic chemotherapy or immunotherapy to nmCRPC patients outside the context of a clinical trial. [Very low evidence] Based on Clinical Principle.
[Moderate recommendation] In mCRPC patients, clinicians should obtain baseline labs (e.g., PSA, testosterone, LDH, Hgb, alkaline phosphatase) and review metastatic disease location, symptoms, and performance status to inform prognosis and treatment decisions. [Very low evidence] Based on Clinical Principle.
[Weak recommendation] In mCRPC patients without PSA progression or new symptoms, clinicians should perform imaging at least annually. [Expert opinion] Based on panel consensus.
[Weak recommendation] In mCRPC patients with disease progression after docetaxel and androgen pathway inhibitor who are considering 177Lu-PSMA-617, clinicians should order PSMA PET imaging. [Expert opinion] Based on panel consensus.
[Moderate recommendation] In patients with mCRPC, clinicians should offer germline (if not already performed) and somatic genetic testing to identify DNA repair deficiency, MSI status, tumor mutational burden, and other mutations for prognosis and targeted therapy guidance. [Very low evidence] Based on Clinical Principle.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation based on expert opinion] In mCRPC patients, clinicians should obtain baseline labs and review metastatic disease location, symptoms, and performance status to inform prognosis and treatment decisions.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation based on expert opinion] In mCRPC patients without PSA progression or new symptoms, clinicians should perform imaging at least annually.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation based on expert opinion] In mCRPC patients with disease progression after prior docetaxel and androgen pathway inhibitor, who are considering 177Lu-PSMA-617, clinicians should order PSMA PET imaging.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation based on expert opinion] In patients with mCRPC, clinicians should offer germline and somatic genetic testing to inform prognosis and guide targeted therapies.
[STRONG recommendation, HIGH evidence] [Strong recommendation based on high evidence] In newly diagnosed mCRPC patients without prior androgen receptor pathway inhibitors, clinicians should offer continued ADT with abiraterone acetate plus prednisone, docetaxel, or enzalutamide.
[CONDITIONAL recommendation, MODERATE evidence] [Conditional recommendation based on moderate evidence] In mCRPC patients who are asymptomatic or minimally symptomatic, clinicians may offer sipuleucel-T.
[STRONG recommendation, MODERATE evidence] [Strong recommendation based on moderate evidence] Clinicians should offer radium-223 to patients with symptoms from bony metastases from mCRPC and without known visceral disease or lymphadenopathy >3cm.
[STRONG recommendation, MODERATE evidence] [Strong recommendation based on moderate evidence] Clinicians should offer 177Lu-PSMA-617 to patients with progressive mCRPC having previously received docetaxel and androgen pathway inhibitor with a positive PSMA PET imaging study.
[CONDITIONAL recommendation, MODERATE evidence] [Conditional recommendation based on moderate evidence] In mCRPC patients who received prior docetaxel chemotherapy with or without prior abiraterone acetate plus prednisone or enzalutamide, clinicians may offer cabazitaxel.
[STRONG recommendation, MODERATE evidence] [Strong recommendation based on moderate evidence] In mCRPC patients who received prior docetaxel chemotherapy and abiraterone acetate plus prednisone or enzalutamide, clinicians should recommend cabazitaxel rather than an alternative androgen pathway directed therapy.
[MODERATE recommendation, LOW evidence] [Moderate recommendation based on low evidence] Clinicians should offer a PARP inhibitor to patients with deleterious or suspected deleterious germline or somatic homologous recombination repair gene-mutated mCRPC after prior enzalutamide or abiraterone acetate, and/or taxane-based chemotherapy.
[MODERATE recommendation, LOW evidence] [Moderate recommendation based on low evidence] In patients with mismatch repair deficient or MSI-H mCRPC, clinicians should offer pembrolizumab.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation based on expert opinion] Clinicians should discuss the risk of osteoporosis associated with ADT and assess the risk of fragility fracture in patients with advanced prostate cancer.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation based on expert opinion] Clinicians should recommend preventative treatment for fractures and skeletal-related events, including supplemental calcium, vitamin D, smoking cessation, and weight-bearing exercise, to advanced prostate cancer patients on ADT.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation based on expert opinion] In advanced prostate cancer patients at high fracture risk due to bone loss, clinicians should recommend preventative treatments with bisphosphonates or denosumab and consider referral to specialists.
[MODERATE recommendation, MODERATE evidence] [Moderate recommendation based on moderate evidence] Clinicians should prescribe a bone-protective agent (denosumab or zoledronic acid) for mCRPC patients with bony metastases to prevent skeletal-related events.
[MODERATE recommendation] Clinicians should obtain a medical history, conduct a physical exam, use the IPSS, and perform a urinalysis. [EXPERT OPINION evidence] Based on clinical principles.
[MODERATE recommendation] Patients should be counselled on options including behavioral modifications, medical therapy, or referral. [EXPERT OPINION evidence] Based on expert consensus.
[MODERATE recommendation] Patients should be evaluated 4-12 weeks after treatment initiation, including IPSS, and optionally PVR and uroflowmetry. [EXPERT OPINION evidence] Based on clinical principles.
[MODERATE recommendation] Patients should undergo further evaluation and consider changing management or surgical intervention. [EXPERT OPINION evidence] Based on expert consensus.
[MODERATE recommendation] Clinicians should consider assessment via ultrasound, cystoscopy, or cross-sectional imaging. [EXPERT OPINION evidence] Based on clinical principles.
[MODERATE recommendation] Clinicians should perform a PVR assessment prior to intervention. [EXPERT OPINION evidence] Based on clinical principles.
[MODERATE recommendation] Clinicians should consider uroflowmetry prior to intervention. [EXPERT OPINION evidence] Based on clinical principles.
[MODERATE recommendation] Clinicians should consider pressure flow studies when diagnostic uncertainty exists. [EXPERT OPINION evidence] Based on expert consensus.
[MODERATE recommendation] Clinicians should inform patients of treatment failure possibilities and need for additional treatments. [EXPERT OPINION evidence] Based on clinical principles.
[MODERATE recommendation] Clinicians should offer alpha blockers such as alfuzosin, doxazosin, silodosin, tamsulosin, or terazosin. [HIGH evidence] Based on multiple RCTs with consistent results.
[CONDITIONAL recommendation, EXPERT OPINION evidence] [Conditional recommendation] 5-ARIs may be considered as a treatment option to reduce intraoperative and postoperative bleeding after TURP or other surgeries for BPH. [Expert opinion] Based on expert consensus.
[MODERATE recommendation, MODERATE evidence] [Moderate recommendation] Tadalafil 5mg daily should be discussed as a treatment option for patients with LUTS/BPH, irrespective of comorbid ED. [Moderate evidence] Based on Grade B evidence.
[STRONG recommendation, HIGH evidence] [Strong recommendation] Combination therapy with a 5-ARI and an alpha blocker should be offered as a treatment option only for patients with LUTS and demonstrable prostatic enlargement (e.g., prostate volume >30g, PSA >1.5ng/mL). [High evidence] Based on Grade A evidence.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Anticholinergic agents, alone or with alpha blockers, may be offered as a treatment option for patients with moderate to severe predominant storage LUTS. [Low evidence] Based on Grade C evidence.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Beta-3-agonists in combination with alpha blockers may be offered as a treatment option for patients with moderate to severe predominant storage LUTS. [Low evidence] Based on Grade C evidence.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] The combination of low-dose daily tadalafil 5mg with alpha blockers may be offered for the treatment of LUTS/BPH. [Low evidence] Based on Grade C evidence.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] The combination of low-dose daily tadalafil 5mg with finasteride may be offered for the treatment of LUTS/BPH. [Low evidence] Based on Grade C evidence.
[MODERATE recommendation, MODERATE evidence] [Moderate recommendation] An oral alpha blocker should be prescribed prior to a voiding trial for patients with acute urinary retention related to BPH. [Moderate evidence] Based on Grade B evidence.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Patients should complete at least three days of alpha blocker therapy before attempting a trial without catheter for acute urinary retention. [Expert opinion] Based on expert consensus.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] Clinicians should inform patients who pass a successful trial without catheter for acute urinary retention due to BPH that they remain at increased risk for recurrent retention. [Low evidence] Based on Grade C evidence.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Surgery is recommended for patients with BPH who have complications such as renal insufficiency, refractory urinary retention, recurrent UTIs, bladder stones, gross hematuria, or LUTS refractory to other therapies. [Expert opinion] Based on clinical principles.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Surgery should not be performed solely for an asymptomatic bladder diverticulum; however, evaluation for bladder outlet obstruction should be considered. [Expert opinion] Based on clinical principles.
[MODERATE recommendation, MODERATE evidence] [Moderate recommendation] TURP should be offered as a treatment option for patients with LUTS/BPH. [Moderate evidence] Based on Grade B evidence.
[CONDITIONAL recommendation, EXPERT OPINION evidence] [Conditional recommendation] Clinicians may use either monopolar or bipolar TURP as a treatment option, depending on their expertise. [Expert opinion] Based on expert consensus.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] Open, laparoscopic, or robotic assisted prostatectomy should be considered as treatment options for patients with large to very large prostates, depending on clinician expertise. [Low evidence] Based on Grade C evidence.
[MODERATE recommendation, MODERATE evidence] [Moderate recommendation] TUIP should be offered as an option for patients with prostates ≤30g for the surgical treatment of LUTS/BPH. [Moderate evidence] Based on Grade B evidence.
[CONDITIONAL recommendation, MODERATE evidence] [Conditional recommendation] Bipolar TUVP may be offered as an option for the treatment of LUTS/BPH. [Moderate evidence] Based on Grade B evidence.
[MODERATE recommendation, MODERATE evidence] [Moderate recommendation] PVP using 120W or 180W platforms should be offered as an option for the treatment of LUTS/BPH. [Moderate evidence] Based on Grade B evidence.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] PUL should be considered as a treatment option for patients with LUTS/BPH who have prostate volume 30-80g and no obstructive middle lobe. [Low evidence] Based on Grade C evidence.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] PUL may be offered as a treatment option to eligible patients who desire preservation of erectile and ejaculatory function. [Low evidence] Based on Grade C evidence.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] WVTT should be considered as a treatment option for patients with LUTS/BPH who have prostate volume 30-80g. [Low evidence] Based on Grade C evidence.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] WVTT may be offered as a treatment option to eligible patients who desire preservation of erectile and ejaculatory function. [Low evidence] Based on Grade C evidence.
[MODERATE recommendation, MODERATE evidence] [Moderate recommendation] HoLEP or ThuLEP should be considered as options for the treatment of LUTS/BPH, regardless of prostate size, depending on clinician expertise. [Moderate evidence] Based on Grade B evidence.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] RWT may be offered as a treatment option for patients with LUTS/BPH who have prostate volume 30-80g. [Low evidence] Based on Grade C evidence.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] PAE may be offered for the treatment of LUTS/BPH, performed by trained clinicians after discussing risks and benefits. [Low evidence] Based on Grade C evidence.
[CONDITIONAL recommendation, EXPERT OPINION evidence] [Conditional recommendation] TIPD may be offered as a treatment option for patients with LUTS/BPH who have prostate volume 25-75g and no obstructive median lobe. [Expert opinion] Based on expert consensus.
[CONDITIONAL recommendation, EXPERT OPINION evidence] [Conditional recommendation] 5-ARIs may be an appropriate and effective treatment alternative for men with refractory hematuria presumably due to prostatic bleeding, after excluding other causes. [Expert opinion] Based on expert consensus.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] HoLEP, PVP, and ThuLEP should be considered as treatment options for patients with LUTS/BPH who are at higher risk of bleeding. [Expert opinion] Based on expert consensus.
[MODERATE recommendation, HIGH evidence] [Moderate recommendation] Clinicians should discuss low-intensity extracorporeal shockwave therapy with patients with CP/CPPS. [High evidence] This recommendation is based on multiple randomized controlled trials and meta-analyses showing benefit.
[CONDITIONAL recommendation, MODERATE evidence] [Conditional recommendation] Clinicians may offer transcutaneous electrical nerve stimulation for pain control in patients with CP/CPPS. [Moderate evidence] This recommendation is based on Cochrane reviews and systematic reviews showing pain reduction, though the quality of evidence is low.
[CONDITIONAL recommendation, MODERATE evidence] [Conditional recommendation] Clinicians may offer acupuncture to patients with CP/CPPS. [Moderate evidence] This recommendation is based on randomized controlled trials and meta-analyses showing efficacy, particularly in relieving pain.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Clinicians may offer individualized manual physical therapy techniques for men with pelvic floor myalgia or abdominopelvic muscle myalgia. [Low evidence] This recommendation is based on feasibility RCTs with very low quality evidence, though benefits are thought to outweigh harm.
[WEAK recommendation, EXPERT OPINION evidence] [Weak recommendation] Clinicians may utilize electromyography biofeedback training to improve pelvic floor muscle resting tone and relaxation in patients with increased tone. [Expert opinion] This recommendation is based on expert consensus and uncontrolled studies, as evidence quality is low.
[Strong recommendation] Providers should obtain gestational history at initial evaluation of boys with suspected cryptorchidism. [Moderate evidence] Based on RCTs with some weaknesses or generally strong observational studies.
[Strong recommendation] Primary care providers should palpate testes for quality and position at each recommended well-child visit. [Moderate evidence] Based on RCTs with some weaknesses or generally strong observational studies.
[Strong recommendation] Providers should refer infants with cryptorchidism who do not have spontaneous testicular descent by six months (corrected for gestational age) to a surgical specialist. [Moderate evidence] Based on RCTs with some weaknesses or generally strong observational studies.
[Strong recommendation] Providers should refer boys with newly diagnosed (acquired) cryptorchidism after six months (corrected for gestational age) to a surgical specialist. [Moderate evidence] Based on RCTs with some weaknesses or generally strong observational studies.
[Strong recommendation] Providers must immediately consult a specialist for all phenotypic male newborns with bilateral nonpalpable testes for DSD evaluation. [High evidence] Based on well-conducted RCTs or exceptionally strong observational studies.
[Strong recommendation] Providers should not perform ultrasound or other imaging modalities in boys with cryptorchidism prior to referral, as these studies rarely assist in decision making. [Moderate evidence] Based on RCTs with some weaknesses or generally strong observational studies.
[Moderate recommendation] Providers should assess the possibility of DSD when there is increasing severity of hypospadias with cryptorchidism. [Low evidence] Based on observational studies that are inconsistent or have small sample sizes.
[Conditional recommendation] In boys with bilateral nonpalpable testes without CAH, providers should measure MIS/AMH and consider additional hormone testing to evaluate for anorchia, based on individual patient factors. [Low evidence] Based on observational studies that are inconsistent or have small sample sizes.
[Strong recommendation] In boys with retractile testes, providers should monitor the position of the testes at least annually to monitor for secondary ascent. [Moderate evidence] Based on RCTs with some weaknesses or generally strong observational studies.
[Strong recommendation] Providers should not use hormonal therapy to induce testicular descent due to low response rates and lack of evidence for long-term efficacy. [Moderate evidence] Based on RCTs with some weaknesses or generally strong observational studies.
[Strong recommendation] Specialists should perform surgery within the next year after 6 months (corrected for gestational age) if no spontaneous testicular descent occurs. [Moderate evidence] Based on RCTs with some weaknesses or generally strong observational studies.
[Strong recommendation] Surgical specialists should perform scrotal or inguinal orchidopexy in prepubertal boys with palpable cryptorchid testes. [Moderate evidence] Based on RCTs with some weaknesses or generally strong observational studies.
[Strong recommendation] Surgical specialists should perform examination under anesthesia to reassess palpability; if nonpalpable, surgical exploration and, if indicated, abdominal orchidopexy should be performed. [Moderate evidence] Based on RCTs with some weaknesses or generally strong observational studies.
[Weak recommendation] Surgical specialists should identify the status of the testicular vessels during exploration for a nonpalpable testis to help determine the next course of action. [Expert opinion] Based on clinical consensus and experience.
[Conditional recommendation] Surgical specialists may perform orchiectomy in boys with a normal contralateral testis if there are very short testicular vessels and vas deferens, a dysmorphic or very hypoplastic testis, or postpubertal age. [Expert opinion] Based on clinical consensus and experience.
[Weak recommendation] Providers should counsel boys with a history of cryptorchidism/monorchidism and their parents about potential long-term risks, including infertility and cancer risk. [Expert opinion] Based on clinical consensus and experience.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Men with ED symptoms should undergo comprehensive history, physical exam, and selective lab testing. [Expert opinion evidence] This is based on clinical consensus as standard practice.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Validated questionnaires are recommended to assess ED severity, measure treatment effectiveness, and guide management. [Expert opinion evidence] This is based on expert consensus.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Men with ED should be counseled that ED is a risk marker for underlying cardiovascular disease and other health conditions. [Expert opinion evidence] This is based on clinical consensus.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] Morning serum total testosterone levels should be measured in men with ED. [Low evidence] This is based on low-quality evidence from observational studies.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] For some men with ED, specialized testing and evaluation may be necessary to guide treatment. [Expert opinion evidence] This is based on expert consensus.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] Referral to a mental health professional should be considered for men being treated for ED to promote adherence, reduce anxiety, and integrate treatments. [Low evidence] This is based on low-quality evidence from observational studies.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] Clinicians should counsel men with ED and comorbidities that lifestyle modifications (diet and exercise) improve overall health and may improve erectile function. [Low evidence] This is based on low-quality evidence from observational studies.
[STRONG recommendation, MODERATE evidence] [Strong recommendation] Men with ED should be informed about the treatment option of FDA-approved oral PDE5i, including benefits and risks, unless contraindicated. [Moderate evidence] This is based on moderate-quality evidence from randomized controlled trials.
[STRONG recommendation, LOW evidence] [Strong recommendation] Instructions should be provided to men prescribed oral PDE5i to maximize benefit and efficacy. [Low evidence] This is based on low-quality evidence from observational studies.
[STRONG recommendation, MODERATE evidence] [Strong recommendation] The dose of PDE5i should be titrated to provide optimal efficacy for men with ED. [Moderate evidence] This is based on moderate-quality evidence from randomized controlled trials.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] Men post-RP or RT should be informed that early PDE5i use may not improve spontaneous, unassisted erectile function. [Low evidence] This is based on low-quality evidence from observational studies.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] Men with ED and TD should be informed that PDE5i may be more effective if combined with testosterone therapy. [Low evidence] This is based on low-quality evidence from observational studies.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] Men with ED should be informed about the treatment option of vacuum erection devices, including benefits and risks. [Low evidence] This is based on low-quality evidence from observational studies.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Men with ED should be informed about the treatment option of intraurethral alprostadil, including benefits and risks, depending on individual circumstances. [Low evidence] This is based on low-quality evidence from observational studies.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] For men considering IU alprostadil, an in-office test should be performed. [Expert opinion evidence] This is based on clinical consensus for safety and efficacy assessment.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] Men with ED should be informed about the treatment option of intracavernosal injections, including benefits and risks. [Low evidence] This is based on low-quality evidence from observational studies.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] For men considering ICI therapy, an in-office injection test should be performed. [Expert opinion evidence] This is based on clinical consensus for safety and efficacy assessment.
[STRONG recommendation, LOW evidence] [Strong recommendation] Men with ED should be informed about the treatment option of penile prosthesis implantation, including benefits and risks. [Low evidence] This is based on low-quality evidence from observational studies.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Men with ED who have decided on penile implantation surgery should be counseled regarding post-operative expectations. [Expert opinion evidence] This is based on clinical consensus for patient education.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Penile prosthetic surgery should not be performed in the presence of systemic, cutaneous, or urinary tract infection. [Expert opinion evidence] This is based on clinical consensus for safety.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] For young men with ED and focal arterial occlusion without generalized vascular disease, penile arterial reconstruction may be considered. [Low evidence] This is based on low-quality evidence from observational studies and depends on individual factors.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] Penile venous surgery is not recommended for men with ED. [Low evidence] This is based on low-quality evidence from observational studies showing lack of benefit.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Low-intensity ESWT should be considered investigational for men with ED and not routinely recommended. [Low evidence] This is based on low-quality evidence from observational studies.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Intracavernosal stem cell therapy should be considered investigational for men with ED and not routinely recommended. [Low evidence] This is based on low-quality evidence from observational studies.
[WEAK recommendation, EXPERT OPINION evidence] [Weak recommendation] Platelet-rich plasma therapy should be considered experimental for men with ED and not recommended for routine use. [Expert opinion evidence] This is based on expert consensus due to lack of evidence.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Yes, an in-office test should be performed for men with ED considering IU alprostadil. [Expert opinion] This is based on clinical principles and expert consensus.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] Yes, men with ED should be informed regarding the treatment option of intracavernosal injections, including discussion of benefits and risks. [Low evidence] Based on Grade C evidence from observational studies.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Yes, an in-office injection test should be performed for men with ED considering ICI therapy. [Expert opinion] This is based on clinical principles and expert consensus.
[STRONG recommendation, LOW evidence] [Strong recommendation] Yes, men with ED should be informed regarding the treatment option of penile prosthesis implantation, including discussion of benefits and risks. [Low evidence] Based on Grade C evidence from observational studies.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Yes, men with ED who have decided on penile implantation surgery should be counseled regarding post-operative expectations. [Expert opinion] This is based on clinical principles and expert consensus.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] No, penile prosthetic surgery should not be performed in the presence of systemic, cutaneous, or urinary tract infection. [Expert opinion] This is based on clinical principles and expert consensus.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Penile arterial reconstruction may be considered for young men with ED and focal pelvic/penile arterial occlusion, but only if they have no generalized vascular disease or veno-occlusive dysfunction. [Low evidence] Based on Grade C evidence from observational studies.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] No, penile venous surgery is not recommended for men with ED. [Low evidence] Based on Grade C evidence from observational studies.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Low-intensity extracorporeal shock wave therapy should be considered investigational for men with ED and only used in institutional review board-approved clinical trials. [Low evidence] Based on Grade C evidence from observational studies.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Intracavernosal stem cell therapy should be considered investigational for men with ED and only used in institutional review board-approved clinical trials. [Low evidence] Based on Grade C evidence from observational studies.
[CONDITIONAL recommendation, EXPERT OPINION evidence] [Conditional recommendation] Platelet-rich plasma therapy should be considered experimental for men with ED and should not be offered except in institutional review board-approved research trials. [Expert opinion] Based on expert consensus without direct evidence.
[Strong recommendation] PDE5 inhibitors are recommended for the treatment of erectile dysfunction in the general population due to their similar and proven efficacy across different types. [High evidence] This is based on multiple randomized controlled trials and systematic data analyses showing consistent improvements in erectile function.
[Weak recommendation] Higher doses of PDE5 inhibitors may be considered but are not strongly recommended due to small and non-linear dose-response effects, with minimal additional clinical benefit. [High evidence] This is supported by data from fixed-dose randomized controlled trials.
[Moderate recommendation] Both on-demand and daily dosing of tadalafil are reasonable options for erectile dysfunction, as they produce similar levels of efficacy. [High evidence] This conclusion is based on data from randomized controlled trials comparing different dosing regimens.
[Conditional recommendation] Intracavernosal injections may be considered for erectile dysfunction in selected patients, but clinicians should be aware of common adverse events such as pain and fibrosis. [Low evidence] This is based on data from observational studies and case series.
[Moderate recommendation] Penile prosthesis surgery is recommended for patients with erectile dysfunction who are suitable candidates, as it leads to high patient and partner satisfaction rates. [Moderate evidence] This is supported by data from observational studies and clinical series.
[Weak recommendation] Yes, clinicians should engage in shared decision-making with appropriate patients, proceeding based on patient values and preferences. [Expert opinion evidence] This is based on clinical consensus rather than direct evidence.
[Strong recommendation] Yes, clinicians should use PSA as the first screening test for prostate cancer. [High evidence] This is based on multiple RCTs demonstrating benefit in reducing metastasis and mortality.
[Weak recommendation] Yes, clinicians should repeat the PSA prior to secondary biomarker, imaging, or biopsy for people with a newly elevated PSA. [Expert opinion evidence] This is based on expert consensus due to evidence that PSA may normalize on retesting.
[NO RECOMMENDATION recommendation, VERY LOW evidence] [No recommendation] Currently, there is insufficient evidence to recommend specific management strategies (e.g., repeat MRI, repeat targeted biopsy, in-bore biopsy) or the use of evolving MRI protocols like biparametric MRI and artificial intelligence. Further study is required to determine optimal approaches.
[STRONG recommendation, MODERATE evidence] [Strong recommendation] Efforts should be made by clinicians, payors, and healthcare systems to bridge the gap in access and affordability of diagnostic or imaging modalities. [Moderate evidence] This is based on observational studies showing dramatic disparities.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Clinicians should counsel patients receiving therapy for GSM that long-term treatment and follow-up may be required to manage signs and symptoms. [Expert opinion] This is based on clinical principles and expert consensus.
[Strong recommendation] Moderate hypofractionation should be offered to low-risk prostate cancer patients who reject active surveillance and are receiving EBRT to the prostate with or without seminal vesicles irradiation. [High evidence] Based on multiple RCTs demonstrating similar cancer control and toxicity compared to conventional fractionation.
[Strong recommendation] Moderate hypofractionation should be offered to intermediate-risk prostate cancer patients receiving EBRT to the prostate with or without seminal vesicles irradiation. [High evidence] Based on multiple RCTs showing non-inferior cancer control and comparable toxicity.
[Strong recommendation] Moderate hypofractionation should be offered to high-risk prostate cancer patients receiving EBRT to the prostate without pelvic lymph node irradiation. [High evidence] Based on RCTs demonstrating similar cancer control and toxicity across risk groups.
[Strong recommendation] Moderate hypofractionation should be offered to prostate cancer patients candidates for EBRT regardless of age, comorbidities, anatomy, or urinary function. [High evidence] Based on RCTs indicating no significant impact of these factors on treatment efficacy.
[Strong recommendation] Patients should be advised about the small increased risk of acute gastrointestinal toxicity with moderate hypofractionation, but it has similar risks of acute and late genitourinary and late gastrointestinal toxicity compared to conventional fractionation. [High evidence] Based on RCTs consistently showing these toxicity profiles.
[Conditional recommendation] Schemes of 6000 cGy in 20 fractions of 300 cGy and 7000 cGy in 28 fractions of 250 cGy are suggested, as they are supported by the largest evidence base. [Moderate evidence] Based on clinical trials, but no optimal scheme can be determined due to lack of direct comparisons.
[Conditional recommendation] No moderate hypofractionation scheme is suggested over another for cancer control in specific risk groups, and efficacy does not appear to be affected by age, comorbidity, anatomy, or urinary function. [Moderate evidence] Based on RCT subgroup analyses, but definitive conclusions are limited by lack of direct comparisons.
[Conditional recommendation] Ultra-hypofractionation can be offered as an alternative to conventional fractionation for low-risk prostate cancer patients who reject active surveillance and choose active treatment with EBRT. [Moderate evidence] Based on prospective non-randomized studies showing acceptable outcomes, but limited long-term data.
[Conditional recommendation] Ultra-hypofractionation can be offered as an alternative to conventional fractionation for intermediate-risk prostate cancer patients receiving EBRT, but the task force strongly recommends that these patients be treated as part of a clinical trial or multi-institutional registry. [Low evidence] Based on limited comparative data, with insufficient evidence from randomized trials.
[Conditional recommendation] Ultra-hypofractionation is not suggested for high-risk prostate cancer patients receiving EBRT outside of a clinical trial or multi-institutional registry due to insufficient comparative evidence. [Low evidence] Based on limited data, with no published RCTs comparing ultra-hypofractionation to conventional fractionation in this population.
[Moderate recommendation] Moderate hypofractionated radiotherapy is recommended as it provides similar efficacy to conventional fractionation based on high evidence from multiple randomized controlled trials.
[Moderate recommendation] The basic assessment should include a careful history, physical examination, and laboratory examination to document symptoms and exclude other disorders. [Low evidence] This is based on clinical principle with consensus agreement.
[Moderate recommendation] Baseline voiding symptoms and pain levels should be obtained to measure treatment effects. [Low evidence] Based on clinical principle.
[Conditional recommendation] Cystoscopy and/or urodynamics should be considered when the diagnosis is in doubt, but are not necessary for uncomplicated cases. [Expert Opinion] Based on consensus without direct evidence.
[Conditional recommendation] Cystoscopy should be performed in patients suspected of having Hunner lesions. [Expert Opinion] Based on panel consensus.
[Conditional recommendation] Treatment decisions should involve shared decision-making with patient education, and initial treatment should typically be nonsurgical except for Hunner lesions. [Expert Opinion] Based on consensus.
[Moderate recommendation] Treatment efficacy should be periodically reassessed, and ineffective treatments should be stopped. [Low evidence] Based on clinical principle.
[Moderate recommendation] The IC/BPS diagnosis should be reconsidered if no improvement occurs after multiple treatments. [Low evidence] Based on clinical principle.
[Moderate recommendation] Patients should be educated about bladder function, IC/BPS, treatment options, and the need for multiple trials. [Low evidence] Based on clinical principle.
[Moderate recommendation] Self-care practices and behavioral modifications should be discussed and implemented as feasible. [Low evidence] Based on clinical principle.
[Moderate recommendation] Patients should be encouraged to implement stress management practices. [Low evidence] Based on clinical principle.
[Strong recommendation] Appropriate manual physical therapy should be offered to patients with pelvic floor tenderness, but pelvic floor strengthening exercises should be avoided. [High evidence] Based on Grade A evidence from RCTs.
[Weak recommendation] Clinicians may prescribe pharmacologic pain management agents after counseling. [Low evidence] Based on clinical principle similar to other chronic pain conditions.
[Weak recommendation] Amitriptyline, cimetidine, hydroxyzine, or pentosan polysulfate may be administered as oral medications. [Moderate evidence] Based on Grades B and C evidence with uncertain benefit-risk balance.
[Moderate recommendation] Clinicians should counsel patients on the potential risk for macular damage with pentosan polysulfate. [Low evidence] Based on clinical principle and case reports.
[Weak recommendation] Oral cyclosporine A may be offered to patients with Hunner lesions refractory to other treatments. [Low evidence] Based on Grade C evidence from limited studies.
[Weak recommendation] DMSO, heparin, and/or lidocaine may be administered as intravesical treatments. [Moderate evidence] Based on Grades B and C evidence with uncertain benefit-risk balance.
[Weak recommendation] Cystoscopy under anesthesia with short-duration, low-pressure hydrodistension may be undertaken as a treatment option. [Low evidence] Based on Grade C evidence from observational studies.
[Strong recommendation] If Hunner lesions are present, fulguration and/or injection of triamcinolone should be performed. [Low evidence] Based on Grade C evidence from observational studies with clear benefit.
[Weak recommendation] Intradetrusor onabotulinumtoxin A may be administered if other treatments fail, with acceptance of possible self-catheterization. [Low evidence] Based on Grade C evidence.
[Weak recommendation] A trial of neuromodulation may be performed if other treatments fail; if successful, a permanent device may be implanted. [Low evidence] Based on Grade C evidence.
[Weak recommendation] Major surgery may be undertaken in carefully selected patients when all other therapies fail. [Low evidence] Based on Grade C evidence from limited studies.
[Strong recommendation] Long-term oral antibiotic administration should not be offered. [Moderate evidence] Based on Grade B evidence showing lack of efficacy and risks.
[Strong recommendation] Intravesical instillation of BCG should not be offered outside of investigational studies. [Moderate evidence] Based on Grade B evidence of risks and lack of efficacy.
[Strong recommendation] High-pressure, long-duration hydrodistension should not be offered. [Low evidence] Based on Grade C evidence of risks.
[Strong recommendation] Systemic long-term glucocorticoid administration should not be offered. [Low evidence] Based on Grade C evidence of risks and lack of benefit.
[Conditional recommendation] Major surgery may be undertaken in carefully selected patients with bladder-centric symptoms or end-stage fibrotic bladders after all other therapies fail, based on low-quality evidence from observational studies.
[Strong recommendation] Long-term oral antibiotic administration should not be offered, based on moderate-quality evidence from an RCT and observational studies indicating lack of efficacy and risks.
[Strong recommendation] Intravesical BCG should not be offered outside of investigational studies, based on moderate-quality evidence from RCTs indicating no significant efficacy and serious adverse events.
[Weak recommendation] High-pressure, long-duration hydrodistension should not be offered, based on low-quality evidence from observational studies showing inconsistent benefits and serious adverse events.
[Weak recommendation] Systemic long-term glucocorticoid administration should not be offered, based on low-quality evidence from observational studies showing risks outweigh benefits.
[MODERATE recommendation, MODERATE evidence] [Moderate recommendation] Clinicians should inform patients undergoing localized prostate cancer treatment of all known factors that could affect continence. [Moderate evidence] This is based on Grade B evidence, indicating moderate certainty.
[STRONG recommendation, MODERATE evidence] [Strong recommendation] Clinicians should counsel patients regarding the risk of sexual arousal incontinence and climacturia following localized prostate cancer treatment. [Moderate evidence] This is based on Grade B evidence, indicating moderate certainty.
[STRONG recommendation, HIGH evidence] [Strong recommendation] 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. [High evidence] This is based on Grade A evidence, indicating high certainty.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Prior to radical prostatectomy, clinicians may offer patients pelvic floor muscle exercises or pelvic floor muscle training. [Low evidence] This is based on Grade C evidence, indicating low certainty.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] Clinicians should inform patients undergoing radical prostatectomy or transurethral resection of the prostate after radiation therapy of the high rate of urinary incontinence following these procedures. [Low evidence] This is based on Grade C evidence, indicating low certainty.
[MODERATE recommendation, MODERATE evidence] [Moderate recommendation] In patients who have undergone radical prostatectomy, clinicians should offer pelvic floor muscle exercises or pelvic floor muscle training in the immediate post-operative period. [Moderate evidence] This is based on Grade B evidence, indicating moderate certainty.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] In patients with bothersome stress urinary incontinence after prostate treatment, clinicians may offer surgery as early as six months if incontinence is not improving despite conservative therapy. [Low evidence] This is based on Grade C evidence, indicating low certainty.
[STRONG recommendation, MODERATE evidence] [Strong recommendation] In patients with bothersome stress urinary incontinence after prostate treatment despite conservative therapy, clinicians should offer surgical treatment at one year post-prostate treatment. [Moderate evidence] This is based on Grade B evidence, indicating moderate certainty.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should evaluate patients with incontinence after prostate treatment with history, physical exam, and appropriate diagnostic modalities to categorize type and severity of incontinence and degree of bother. [Expert opinion] This is based on Clinical Principle, indicating expert consensus.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] In patients with urgency urinary incontinence or urgency predominant mixed urinary incontinence, clinicians should offer treatment options per the American Urological Association Overactive Bladder Guideline. [Expert opinion] This is based on Clinical Principle, indicating expert consensus.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Prior to surgical intervention for stress urinary incontinence, clinicians should confirm stress urinary incontinence by history, physical exam, or ancillary testing. [Expert opinion] This is based on Clinical Principle, indicating expert consensus.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should inform patients with incontinence after prostate treatment of management options for their incontinence, including surgical and non-surgical options. [Expert opinion] This is based on Clinical Principle, indicating expert consensus.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] In patients with incontinence after prostate treatment, clinicians should discuss risk, benefits, and expectations of different treatments using the shared decision-making model. [Expert opinion] This is based on Clinical Principle, indicating expert consensus.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Prior to surgical intervention for stress urinary incontinence, clinicians should perform cystourethroscopy to assess for urethral and bladder pathology that may affect outcomes of surgery. [Expert opinion] This is based on Expert Opinion, indicating consensus without direct evidence.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Clinicians may perform urodynamic testing in patients prior to surgical intervention for stress urinary incontinence in cases where it may facilitate diagnosis or counseling. [Low evidence] This is based on Grade C evidence, indicating low certainty.
[MODERATE recommendation, MODERATE evidence] [Moderate recommendation] In patients seeking treatment for incontinence after radical prostatectomy, clinicians should offer pelvic floor muscle exercises or pelvic floor muscle training. [Moderate evidence] This is based on Grade B evidence, indicating moderate certainty.
[STRONG recommendation, MODERATE evidence] [Strong recommendation] Clinicians should discuss the option of artificial urinary sphincter with patients who are experiencing mild to severe stress urinary incontinence after prostate treatment. [Moderate evidence] This is based on Grade B evidence, indicating moderate certainty.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Prior to implantation of artificial urinary sphincter, clinicians should ensure that patients have adequate physical and cognitive abilities to operate the device. [Expert opinion] This is based on Clinical Principle, indicating expert consensus.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] In patients who select artificial urinary sphincter, clinicians should preferentially utilize a single cuff perineal approach. [Low evidence] This is based on Grade C evidence, indicating low certainty.
[MODERATE recommendation, MODERATE evidence] [Moderate recommendation] Clinicians should discuss the option of male slings with patients as treatment options for mild to moderate stress urinary incontinence after prostate treatment. [Moderate evidence] This is based on Grade B evidence, indicating moderate certainty.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] Clinicians should not routinely implant male slings in patients with severe stress incontinence. [Low evidence] This is based on Grade C evidence, indicating low certainty.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Clinicians may offer adjustable balloon devices to non-radiated patients with mild to severe stress urinary incontinence after prostate treatment. [Low evidence] This is based on Grade C evidence, indicating low certainty.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] Clinicians should manage patients with stress urinary incontinence after treatment of benign prostatic hyperplasia the same as patients that have undergone radical prostatectomy. [Low evidence] This is based on Grade C evidence, indicating low certainty.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] In patients with stress urinary incontinence after primary, adjuvant, or salvage radiotherapy who are seeking surgical management, clinicians should offer artificial urinary sphincter over male slings or adjustable balloons. [Low evidence] This is based on Grade C evidence, indicating low certainty.
[STRONG recommendation, MODERATE evidence] [Strong recommendation] In patients with incontinence after prostate treatment, clinicians should counsel patients that efficacy is low and cure is rare with urethral bulking agents. [Moderate evidence] This is based on Grade B evidence, indicating moderate certainty.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should consider other potential treatments for incontinence after prostate treatment as investigational, and patients should be counseled accordingly. [Expert opinion] This is based on Expert Opinion, indicating consensus without direct evidence.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Clinicians may counsel patients regarding risk factors for artificial urinary sphincter erosion. [Low evidence] This is based on Grade C evidence, indicating low certainty.
[STRONG recommendation, MODERATE evidence] [Strong recommendation] Clinicians should counsel patients that artificial urinary sphincter will likely lose effectiveness over time, and reoperations are common. [Moderate evidence] This is based on Grade B evidence, indicating moderate certainty.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] In patients with persistent or recurrent urinary incontinence after artificial urinary sphincter or sling, clinicians should again perform history, physical examination, and/or other investigations to determine the cause of incontinence. [Expert opinion] This is based on Clinical Principle, indicating expert consensus.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] In patients with persistent or recurrent stress urinary incontinence after sling, clinicians should recommend an artificial urinary sphincter. [Low evidence] This is based on Grade C evidence, indicating low certainty.
[STRONG recommendation, MODERATE evidence] [Strong recommendation] In patients with persistent or recurrent stress urinary incontinence after artificial urinary sphincter, clinicians should discuss artificial urinary sphincter revision with the patient. [Moderate evidence] This is based on Grade B evidence, indicating moderate certainty.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] In patients presenting with infection or erosion of an artificial urinary sphincter or sling, clinicians should perform explantation and reimplantation should be delayed. [Expert opinion] This is based on Clinical Principle, indicating expert consensus.
[CONDITIONAL recommendation, EXPERT OPINION evidence] [Conditional recommendation] After explanting an eroded device, clinicians may manage artificial urinary sphincter urethral cuff erosion intra-operatively with urethral catheter alone, in situ urethroplasty, or anastomotic urethroplasty. [Expert opinion] This is based on Expert Opinion, indicating consensus without direct evidence.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should discuss urinary diversion with patients who are unable to obtain long-term quality of life due to incontinence after prostate treatment. [Expert opinion] This is based on Expert Opinion, indicating consensus without direct evidence.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] In patients with bothersome incontinence during sexual activity, clinicians should offer treatment. [Low evidence] This is based on Grade C evidence, indicating low certainty.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] In patients with stress urinary incontinence following urethral reconstructive surgery, clinicians may offer artificial urinary sphincter and counsel that complication rates are higher. [Low evidence] This is based on Grade C evidence, indicating low certainty.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] In patients with incontinence after prostate treatment and erectile dysfunction, clinicians may offer a concomitant or staged procedure. [Low evidence] This is based on Grade C evidence, indicating low certainty.
[STRONG recommendation, HIGH evidence] [Strong recommendation] Clinicians should use clinical T stage, serum PSA, Grade Group, and tumor volume on biopsy for risk stratification. [High evidence] This recommendation is based on high-quality evidence from well-conducted studies.
[WEAK recommendation, EXPERT OPINION evidence] [Weak recommendation] Clinicians may selectively use tissue-based genomic biomarkers when added risk stratification may alter clinical decision-making. [Expert opinion] This is based on expert consensus without direct evidence.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should not routinely perform abdomino-pelvic CT scan or bone scan in asymptomatic patients with low- or intermediate-risk prostate cancer. [Expert opinion] This is based on expert consensus.
[STRONG recommendation, MODERATE evidence] [Strong recommendation] Clinicians should obtain a bone scan and either pelvic mpMRI or CT scan for patients with high-risk prostate cancer. [Moderate evidence] This recommendation is based on moderate-quality evidence.
[WEAK recommendation, EXPERT OPINION evidence] [Weak recommendation] Clinicians may obtain molecular imaging to evaluate for metastases in patients with prostate cancer at high risk for metastatic disease with negative conventional imaging. [Expert opinion] This is based on expert consensus.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should inform patients about treatment risks and incorporate these with cancer risk, life expectancy, and preferences to facilitate shared decision-making. [Expert opinion] This is based on clinical principle and expert consensus.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should provide an individualized risk estimate of post-treatment prostate cancer recurrence to patients. [Expert opinion] This is based on clinical principle and expert consensus.
[STRONG recommendation, HIGH evidence] [Strong recommendation] For patients with favorable intermediate-risk prostate cancer, clinicians should discuss active surveillance, radiation therapy, and radical prostatectomy. [High evidence] This is based on high-quality evidence from well-conducted studies.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should inform patients with intermediate-risk prostate cancer considering ablation about the lack of high-quality data compared to other treatments. [Expert opinion] This is based on expert consensus.
[STRONG recommendation, HIGH evidence] [Strong recommendation] For patients with unfavorable intermediate- or high-risk prostate cancer and estimated life expectancy greater than 10 years, clinicians should offer a choice between radical prostatectomy or radiation therapy plus ADT. [High evidence] This is based on high-quality evidence from well-conducted studies.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should not recommend whole gland or focal ablation for patients with high-risk prostate cancer outside of a clinical trial. [Expert opinion] This is based on expert consensus.
[WEAK recommendation, EXPERT OPINION evidence] [Weak recommendation] Clinicians may recommend palliative ADT alone for patients with high-risk prostate cancer, local symptoms, and limited life expectancy. [Expert opinion] This is based on expert consensus.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Patients managed with active surveillance should be monitored with serial PSA values and repeat prostate biopsy. [Expert opinion] This is based on expert consensus.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] In patients selecting active surveillance, clinicians should utilize mpMRI to augment risk stratification, but not replace periodic biopsy. [Expert opinion] This is based on expert consensus.
[MODERATE recommendation, MODERATE evidence] [Moderate recommendation] In patients electing radical prostatectomy, nerve-sparing, when oncologically appropriate, should be performed. [Moderate evidence] This is based on moderate-quality evidence from studies with some limitations.
[MODERATE recommendation, MODERATE evidence] [Moderate recommendation] Clinicians should inform patients that pelvic lymphadenectomy provides staging information but does not consistently improve survival outcomes. [Moderate evidence] This is based on moderate-quality evidence.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should use nomograms to select patients for lymphadenectomy, balancing benefits and risks. [Expert opinion] This is based on clinical principle and expert consensus.
[MODERATE recommendation, MODERATE evidence] [Moderate recommendation] Clinicians performing pelvic lymphadenectomy should perform an extended dissection to improve staging accuracy. [Moderate evidence] This is based on moderate-quality evidence.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] Clinicians should complete a radical prostatectomy if suspicious regional nodes are encountered intraoperatively. [Low evidence] This is based on low-quality evidence from studies with limitations.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should risk stratify patients with positive lymph nodes identified at radical prostatectomy based on pathologic variables and postoperative PSA. [Expert opinion] This is based on expert consensus.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Clinicians may offer patients with positive lymph nodes identified at radical prostatectomy and an undetectable postoperative PSA adjuvant therapy or observation. [Low evidence] This is based on low-quality evidence, and the decision depends on patient-specific factors.
[STRONG recommendation, HIGH evidence] [Strong recommendation] Clinicians should not routinely recommend adjuvant radiation therapy after radical prostatectomy. [High evidence] This is based on high-quality evidence from well-conducted studies.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should utilize available techniques like target localization and image-guidance to optimize the therapeutic ratio of EBRT. [Expert opinion] This is based on clinical principle and expert consensus.
[STRONG recommendation, HIGH evidence] [Strong recommendation] Clinicians should utilize dose escalation when EBRT is the primary treatment for patients with prostate cancer. [High evidence] This is based on high-quality evidence from well-conducted studies.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Clinicians may counsel patients that proton therapy is an option, but it has not been shown superior to other modalities. [Low evidence] This is based on low-quality evidence, and the decision should be individualized.
[STRONG recommendation, HIGH evidence] [Strong recommendation] Clinicians should offer moderate hypofractionated EBRT for patients with low- or intermediate-risk prostate cancer who elect EBRT. [High evidence] This is based on high-quality evidence from well-conducted studies.
[CONDITIONAL recommendation, MODERATE evidence] [Conditional recommendation] Clinicians may offer ultra hypofractionated EBRT for patients with low- or intermediate-risk prostate cancer who elect EBRT. [Moderate evidence] This is based on moderate-quality evidence, and the decision should be individualized.
[STRONG recommendation, MODERATE evidence] [Strong recommendation] Clinicians should offer dose-escalated hypofractionated EBRT, LDR seed implant, or HDR implant as equivalent treatments. [Moderate evidence] This is based on moderate-quality evidence from studies.
[STRONG recommendation, MODERATE evidence] [Strong recommendation] Clinicians should not electively radiate pelvic lymph nodes in patients with low- or intermediate-risk prostate cancer electing radiation therapy. [Moderate evidence] This is based on moderate-quality evidence.
[MODERATE recommendation, MODERATE evidence] [Moderate recommendation] Clinicians should not routinely use ADT in patients with low- or favorable intermediate-risk prostate cancer electing radiation therapy. [Moderate evidence] This is based on moderate-quality evidence.
[STRONG recommendation, HIGH evidence] [Strong recommendation] In patients with unfavorable intermediate-risk prostate cancer electing radiation therapy, clinicians should offer the addition of short-course ADT. [High evidence] This is based on high-quality evidence from well-conducted studies.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] Clinicians should offer moderate hypofractionated EBRT for patients with high-risk prostate cancer who are candidates for EBRT. [Low evidence] This is based on low-quality evidence from studies with limitations.
[STRONG recommendation, HIGH evidence] [Strong recommendation] Clinicians should offer dose-escalated hypofractionated EBRT or combined EBRT + brachytherapy with ADT. [High evidence] This is based on high-quality evidence from well-conducted studies.
[CONDITIONAL recommendation, MODERATE evidence] [Conditional recommendation] Clinicians may offer radiation to the pelvic lymph nodes in patients with high-risk prostate cancer electing radiation therapy. [Moderate evidence] This is based on moderate-quality evidence, and the decision should be individualized.
[STRONG recommendation, MODERATE evidence] [Strong recommendation] When treating pelvic lymph nodes with radiation, clinicians should utilize IMRT with doses between 45 Gy to 52 Gy. [Moderate evidence] This is based on moderate-quality evidence.
[STRONG recommendation, HIGH evidence] [Strong recommendation] In patients with high-risk prostate cancer electing radiation therapy, clinicians should recommend the addition of long-course ADT. [High evidence] This is based on high-quality evidence from well-conducted studies.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] When combined ADT and radiation are used, ADT may be initiated neoadjuvantly, concurrently, or adjuvantly. [Low evidence] This is based on low-quality evidence, and the timing should be individualized.
[WEAK recommendation, EXPERT OPINION evidence] [Weak recommendation] Clinicians may use combined androgen suppression, LHRH agonist alone, or LHRH antagonist alone when combining ADT with radiation therapy. [Expert opinion] This is based on expert consensus without direct evidence.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should monitor patients post therapy with PSA and symptom assessment. [Expert opinion] This is based on clinical principle and expert consensus.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should support patients through symptom management and encouraging engagement with resources. [Expert opinion] This is based on clinical principle and expert consensus.
[WEAK recommendation, EXPERT OPINION evidence] [Weak recommendation] Clinicians may use combined androgen suppression, an LHRH agonist alone, or an LHRH antagonist alone, based on expert opinion.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Clinicians should monitor patients with PSA and symptom assessment, based on clinical principles and expert opinion.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Clinicians should support patients through continued symptom management and encouraging engagement with professional or community-based resources, based on clinical principles and expert opinion.
[Moderate recommendation] Yes, clinicians should initiate concurrent assessment of both male and female partners. [Expert opinion] This is based on expert consensus.
[Moderate recommendation] Yes, clinicians should include a reproductive history. [Expert opinion] Based on clinical principle.
[Strong recommendation] Yes, clinicians should include one or more semen analyses. [Moderate evidence] Based on Grade B evidence with moderate certainty.
[Moderate recommendation] Yes, male reproductive experts should evaluate such patients with complete history, physical exam, and directed tests. [Expert opinion] Based on expert consensus.
[Moderate recommendation] Yes, clinicians should evaluate the male partner. [Low evidence] Based on Grade C evidence with low certainty.
[Moderate recommendation] Yes, clinicians should counsel on health risks associated with abnormal sperm production. [Moderate evidence] Based on Grade B evidence with moderate certainty.
[Moderate recommendation] Yes, clinicians should inform patients of relevant, associated health conditions. [Moderate evidence] Based on Grade B evidence.
[Moderate recommendation] Yes, clinicians should advise couples with advanced paternal age (≥40) of increased risk of adverse health outcomes for offspring. [Expert opinion] Based on expert consensus.
[Conditional recommendation] Clinicians may discuss risk factors and counsel that data are limited. [Low evidence] Based on Grade C evidence with low certainty.
[Moderate recommendation] Yes, clinicians should use semen analysis results to guide management, with multiple abnormalities being most significant. [Expert opinion] Based on expert consensus.
[Moderate recommendation] Clinicians should recommend renal ultrasonography for patients with vasal agenesis to evaluate for renal abnormalities. [Expert opinion] This is based on expert consensus.
[Strong recommendation] Clinicians should not recommend varicocelectomy for males with non-palpable varicoceles detected solely by imaging. [Low evidence] This is supported by low-quality evidence.
[Moderate recommendation] Clinicians should inform couples of the absence of definitive evidence supporting varicocele repair prior to surgical sperm retrieval with ART. [Expert opinion] This is based on expert consensus.
[Moderate recommendation] Clinicians should perform a microdissection testicular sperm extraction (micro-TESE) for males with non-obstructive azoospermia undergoing sperm retrieval. [Low evidence] This is supported by low-quality evidence.
[Conditional recommendation] Intracytoplasmic sperm injection (ICSI) may be performed with fresh or cryopreserved sperm in males undergoing surgical sperm retrieval. [Low evidence] This is based on low-quality evidence and depends on lab preferences and patient factors.
[Conditional recommendation] Clinicians may extract sperm from either the testis or the epididymis in males with azoospermia due to obstruction undergoing surgical sperm retrieval. [Low evidence] This is based on low-quality evidence showing similar outcomes.
[Conditional recommendation] Clinicians may consider the utilization of testicular sperm in nonazoospermic males with an elevated sperm DNA Fragmentation Index. [Expert opinion] This is based on clinical principles and expert consensus.
[Conditional recommendation] For males with aspermia, clinicians may perform surgical sperm extraction or induced ejaculation (e.g., sympathomimetics, vibratory stimulation, electroejaculation) depending on the patient’s condition and clinician’s experience. [Expert opinion] This is based on expert consensus.
[Conditional recommendation] Clinicians may treat infertility associated with retrograde ejaculation with sympathomimetics, induced ejaculation, or surgical sperm retrieval. [Expert opinion] This is based on expert consensus and depends on severity and response to therapy.
[Moderate recommendation] Clinicians should counsel couples desiring conception after vasectomy that surgical reconstruction, surgical sperm retrieval, or both are viable options. [Low evidence] This is supported by low-quality evidence.
[Moderate recommendation] Clinicians should counsel males with vasal or epididymal obstructive azoospermia that microsurgical reconstruction may be successful in returning sperm to the ejaculate. [Expert opinion] This is based on expert consensus.
[Conditional recommendation] For infertile males with ejaculatory duct obstruction, clinicians may consider transurethral resection of ejaculatory ducts (TURED) and/or surgical sperm extraction. [Expert opinion] This is based on expert consensus and shared decision-making.
[Conditional recommendation] Clinicians may manage male infertility with assisted reproductive technologies (ART). [Expert opinion] This is based on expert consensus and depends on individual patient characteristics.
[Conditional recommendation] Clinicians may advise infertile couples with a low total motile sperm count that IUI success rates may be reduced, and ART (IVF with ICSI) may be considered. [Expert opinion] This is based on expert consensus.
[Moderate recommendation] In a patient presenting with hypogonadotropic hypogonadism, clinicians should evaluate to determine the etiology and treat based on diagnosis. [Expert opinion] This is based on clinical principles and expert consensus.
[Conditional recommendation] Clinicians may use aromatase inhibitors, hCG, SERMs, or a combination for infertile males with low serum testosterone. [Low evidence] This is based on low-quality evidence and should be individualized.
[Strong recommendation] For males interested in current or future fertility, clinicians should not prescribe exogenous testosterone therapy. [Expert opinion] This is based on clinical principles due to its inhibitory effects on spermatogenesis.
[Moderate recommendation] For infertile males with hyperprolactinemia, clinicians should evaluate for the etiology and treat accordingly. [Expert opinion] This is based on expert consensus.
[Moderate recommendation] Clinicians should inform males with idiopathic infertility that the use of selective estrogen receptor modulators (SERMs) has limited benefits compared to assisted reproductive technologies. [Expert opinion] This is based on expert consensus.
[Moderate recommendation] Clinicians should counsel patients that the benefits of supplements (e.g., antioxidants, vitamins) are of questionable clinical utility in treating male infertility, and data are inadequate for specific recommendations. [Moderate evidence] This is supported by moderate-quality evidence.
[Conditional recommendation] For males with idiopathic infertility, clinicians may consider treatment using a follicle-stimulating hormone (FSH) analogue to improve sperm concentration, pregnancy rate, and live birth rate. [Moderate evidence] This is based on moderate-quality evidence.
[Conditional recommendation] In patients with non-obstructive azoospermia (NOA), clinicians may inform them of the limited data supporting pharmacologic manipulation with SERMs, AIs, and gonadotropins prior to surgery. [Low evidence] This is based on low-quality evidence.
[Moderate recommendation] Clinicians should discuss the effects of gonadotoxic therapies and other cancer treatments on sperm production with patients prior to commencement of therapy. [Low evidence] This is supported by low-quality evidence but is clinically important.
[Moderate recommendation] Clinicians should inform patients undergoing chemotherapy and/or radiation therapy to avoid initiating a pregnancy for at least 12 months after completion of treatment. [Expert opinion] This is based on expert consensus to reduce genetic risks.
[Moderate recommendation] Clinicians should encourage males to bank sperm, preferably multiple specimens, prior to gonadotoxic therapy or cancer treatment that may affect fertility. [Expert opinion] This is based on expert consensus for fertility preservation.
[Conditional recommendation] Clinicians may inform patients that a semen analysis should be performed at least 12 months (preferably 24 months) after completion of gonadotoxic therapies. [Low evidence] This is based on low-quality evidence showing recovery patterns.
[Moderate recommendation] Clinicians should inform patients undergoing a retroperitoneal lymph node dissection (RPLND) of the risk of aspermia or retrograde ejaculation. [Expert opinion] This is based on clinical principles for informed consent.
[Moderate recommendation] Clinicians should obtain a post-orgasmic urinalysis for males with aspermia after retroperitoneal lymph node dissection and reduced volume ejaculate who are interested in fertility. [Expert opinion] This is based on clinical principles to differentiate between retrograde ejaculation and failure of emission.
[Strong recommendation] Clinicians should inform males seeking paternity who are persistently azoospermic after gonadotoxic therapies that microdissection testicular sperm extraction (micro-TESE) is a treatment option. [Moderate evidence] This is supported by moderate-quality evidence showing sperm retrieval rates.
[Strong recommendation] Pituitary imaging is recommended for the evaluation of hyperprolactinemia. [Low evidence] This recommendation is based on observational studies.
[Strong recommendation] Testicular sperm is recommended over ejaculated sperm for ICSI in infertile males with high sperm DNA damage to improve pregnancy rates. [Low evidence] This is based on individual studies.
[STRONG recommendation, LOW evidence] [Strong recommendation] Microhematuria should be defined as >3 red blood cells per high-power field on microscopic evaluation of a single, properly collected urine specimen. [Low evidence] This is based on observational studies with low certainty.
[STRONG recommendation, LOW evidence] [Strong recommendation] Microhematuria should not be defined by positive dipstick testing alone; a positive dipstick should prompt microscopic evaluation. [Low evidence] Based on observational studies with low certainty.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Clinicians should perform a history, physical examination including blood pressure, and serum creatinine to assess risk factors. [Expert opinion] This is based on clinical principles and expert consensus.
[STRONG recommendation, LOW evidence] [Strong recommendation] They should undergo the same evaluation as patients not on these agents. [Low evidence] Based on observational studies with low certainty.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Clinicians should perform appropriate physical examination and tests to identify such etiologies. [Expert opinion] This is based on clinical principles and expert consensus.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Repeat urinalysis after resolution; if microhematuria persists or etiology unclear, perform risk-based urologic evaluation. [Expert opinion] Based on clinical principles and expert consensus.
[STRONG recommendation, LOW evidence] [Strong recommendation] Obtain a urinalysis with microscopic evaluation after treatment to ensure resolution of hematuria. [Low evidence] Based on observational studies with low certainty.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Yes, refer for nephrological evaluation, but still perform risk-based urologic evaluation. [Expert opinion] Based on clinical principles and expert consensus.
[STRONG recommendation, LOW evidence] [Strong recommendation] Categorize as low/negligible-, intermediate-, or high-risk based on tables. [Low evidence] Based on observational studies with low certainty.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] Obtain repeat urinalysis within six months instead of immediate cystoscopy or imaging. [Low evidence] Based on observational studies with low certainty.
[STRONG recommendation, LOW evidence] [Strong recommendation] Reclassify as intermediate- or high-risk and perform risk-based evaluation accordingly. [Low evidence] Based on observational studies with low certainty.
[STRONG recommendation, LOW evidence] [Strong recommendation] Recommend cystoscopy and renal ultrasound. [Low evidence] Based on observational studies with low certainty.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] In appropriately counseled patients, clinicians may offer urine cytology or tumor markers to decide on cystoscopy, but renal and bladder ultrasound should still be performed. [Low evidence] Based on observational studies with low certainty.
[STRONG recommendation, LOW evidence] [Strong recommendation] Obtain repeat urinalysis within 12 months; if persistent microhematuria, undergo cystoscopy. [Low evidence] Based on observational studies with low certainty.
[STRONG recommendation, LOW evidence] [Strong recommendation] Perform cystoscopy and axial upper tract imaging. [Low evidence] Based on observational studies with low certainty.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] Perform multiphasic CT urography. [Low evidence] Based on observational studies with low certainty.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] May utilize MR urography. [Low evidence] Based on observational studies with low certainty.
[CONDITIONAL recommendation, EXPERT OPINION evidence] [Conditional recommendation] May utilize retrograde pyelography with non-contrast imaging or renal ultrasound. [Expert opinion] Based on expert consensus.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] Perform white light cystoscopy. [Low evidence] Based on observational studies with low certainty.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Clinicians may perform additional imaging. [Low evidence] Based on observational studies with low certainty.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Yes, perform upper tract imaging regardless of risk category. [Expert opinion] Based on expert consensus.
[STRONG recommendation, LOW evidence] [Strong recommendation] No, they should not be routinely used. [Low evidence] Based on observational studies with low certainty.
[STRONG recommendation, LOW evidence] [Strong recommendation] No, they should not be routinely used. [Low evidence] Based on observational studies with low certainty.
[CONDITIONAL recommendation, EXPERT OPINION evidence] [Conditional recommendation] May obtain urine cytology for equivocal cystoscopic findings or persistent microhematuria with irritative symptoms. [Expert opinion] Based on expert consensus.
[STRONG recommendation, LOW evidence] [Strong recommendation] Engage in shared decision-making about repeating urinalysis. [Low evidence] Based on observational studies with low certainty.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Yes, clinicians may discontinue further evaluation. [Low evidence] Based on observational studies with low certainty.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Engage in shared decision-making about additional evaluation. [Expert opinion] Based on expert consensus.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] Yes, initiate further evaluation for gross hematuria, increased microhematuria, or new symptoms. [Low evidence] Based on observational studies with low certainty.
[STRONG recommendation] A full history and physical exam, including an exam under anesthesia, should be performed at the time of TURBT. [EXPERT OPINION evidence] This is based on clinical consensus.
[STRONG recommendation] Clinicians should perform a complete staging evaluation with chest imaging, cross-sectional abdominal/pelvic imaging with contrast if possible, and laboratory tests including a comprehensive metabolic panel. [EXPERT OPINION evidence] This is based on clinical consensus.
[STRONG recommendation] An experienced genitourinary pathologist should review the pathology when variant histology is suspected or muscle invasion is equivocal. [EXPERT OPINION evidence] This is based on clinical consensus.
[STRONG recommendation] Curative treatment options should be discussed using a multidisciplinary approach, considering patient comorbidities and tumor characteristics. [EXPERT OPINION evidence] This is based on clinical consensus.
[STRONG recommendation] Clinicians should counsel patients regarding complications and quality of life implications of treatment. [EXPERT OPINION evidence] This is based on clinical consensus.
[STRONG recommendation] Yes, clinicians should offer cisplatin-based NAC to eligible radical cystectomy patients prior to cystectomy using a multidisciplinary approach. [MODERATE evidence] This is based on grade B evidence from randomized trials.
[STRONG recommendation] No, clinicians should not prescribe carboplatin-based NAC for clinically resectable stage cT2-T4aN0 bladder cancer; ineligible patients should proceed to definitive therapy or clinical trial. [EXPERT OPINION evidence] This is based on expert consensus.
[STRONG recommendation] Radical cystectomy should be performed as soon as possible after completion and recovery from NAC, ideally within 12 weeks unless medically inadvisable. [EXPERT OPINION evidence] This is based on expert consensus.
[MODERATE recommendation] Patients without prior NAC and with pT3-4/N+ disease should be offered adjuvant cisplatin-based chemotherapy or immunotherapy; those with prior cisplatin and pT2-4/N+ should be offered adjuvant immunotherapy. [LOW evidence] This is based on grade C evidence from limited studies.
[STRONG recommendation] Yes, clinicians should offer radical cystectomy with bilateral pelvic lymphadenectomy to surgically eligible patients. [MODERATE evidence] This is based on grade B evidence from studies.
[STRONG recommendation] In males, remove the bladder, prostate, and seminal vesicles; in females, remove the bladder and consider adjacent organs based on disease characteristics, with organ sparing considered individually. [EXPERT OPINION evidence] This is based on clinical consensus.
[MODERATE recommendation] Yes, clinicians should discuss and consider sexual function preserving procedures for patients with organ-confined disease and no involvement of bladder neck, urethra, or prostate. [LOW evidence] This is based on grade C evidence from limited studies.
[STRONG recommendation] All options—ileal conduit, continent cutaneous, and orthotopic neobladder—should be discussed with patients. [EXPERT OPINION evidence] This is based on clinical consensus.
[STRONG recommendation] Clinicians must verify a negative urethral margin in patients receiving an orthotopic urinary diversion. [EXPERT OPINION evidence] This is based on clinical consensus.
[STRONG recommendation] Yes, clinicians should attempt to optimize patient performance status in the perioperative setting. [EXPERT OPINION evidence] This is based on expert consensus.
[STRONG recommendation] Yes, perioperative pharmacologic thromboembolic prophylaxis should be given. [MODERATE evidence] This is based on grade B evidence from studies.
[STRONG recommendation] Yes, µ-opioid antagonist therapy should be used unless contraindicated. [MODERATE evidence] This is based on grade B evidence from randomized trials.
[STRONG recommendation] Yes, patients should receive detailed teaching regarding care of urinary diversion prior to discharge. [EXPERT OPINION evidence] This is based on clinical consensus.
[STRONG recommendation] Yes, clinicians must perform a bilateral pelvic lymphadenectomy at the time of any surgery with curative intent. [MODERATE evidence] This is based on grade B evidence.
[STRONG recommendation] Clinicians should remove, at a minimum, the external and internal iliac and obturator lymph nodes. [EXPERT OPINION evidence] This is based on clinical consensus.
[STRONG recommendation] Yes, clinicians should offer bladder preserving therapy to patients who desire bladder retention or have comorbidities making cystectomy unsuitable, when clinically appropriate. [EXPERT OPINION evidence] This is based on clinical consensus.
[MODERATE recommendation] No, they should not undergo partial cystectomy or maximal TURBT as primary curative therapy. [LOW evidence] This is based on grade C evidence.
[STRONG recommendation] No, clinicians should not offer radiation therapy alone as a curative treatment. [LOW evidence] This is based on grade C evidence.
[STRONG recommendation] Clinicians should offer maximal TURBT followed by chemotherapy combined with EBRT, with planned cystoscopic surveillance. [MODERATE evidence] This is based on grade B evidence.
[STRONG recommendation] Yes, radiation sensitizing chemotherapy should be included when using multimodal therapy with curative intent. [MODERATE evidence] This is based on grade B evidence.
[STRONG recommendation] Clinicians should perform regular surveillance with CT scans, cystoscopy, and urine cytology. [LOW evidence] This is based on grade C evidence.
[STRONG recommendation] Yes, clinicians should offer radical cystectomy with bilateral pelvic lymphadenectomy to medically fit patients. [LOW evidence] This is based on grade C evidence.
[MODERATE recommendation] Clinicians may offer either local measures (e.g., TURBT with intravesical therapy) or radical cystectomy with lymphadenectomy. [LOW evidence] This is based on grade C evidence.
[STRONG recommendation] Clinicians should obtain chest and cross-sectional abdominal/pelvic imaging at 6-12 month intervals for 2-3 years, then may continue annually. [EXPERT OPINION evidence] This is based on expert consensus.
[STRONG recommendation] Patients should undergo laboratory assessment at three to six month intervals for two to three years, then annually. [EXPERT OPINION evidence] This is based on expert consensus.
[STRONG recommendation] Yes, clinicians should monitor the urethral remnant for recurrence in patients with a retained urethra. [EXPERT OPINION evidence] This is based on expert consensus.
[STRONG recommendation] Yes, clinicians should discuss coping and recommend participation in support groups or individual counseling. [EXPERT OPINION evidence] This is based on expert consensus.
[STRONG recommendation] Yes, clinicians should encourage smoking cessation, exercise, and a healthy diet. [EXPERT OPINION evidence] This is based on expert consensus.
[STRONG recommendation] Clinicians should consider unique clinical characteristics that may require divergence from standard management. [EXPERT OPINION evidence] This is based on expert consensus.
[Strong recommendation] Clinicians should discuss coping with diagnosis and treatment and recommend considering support groups or individual counseling. [Expert opinion] This is based on expert consensus.
[Strong recommendation] Clinicians should encourage patients to adopt healthy lifestyle habits, such as smoking cessation, exercise, and a healthy diet. [Expert opinion] This recommendation is based on expert consensus.
[Conditional recommendation] Clinicians should consider unique clinical characteristics that may require divergence from standard approaches. [Expert opinion] This is based on expert consensus.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] A clinician should perform a thorough cystoscopic examination of the entire urethra and bladder to evaluate and document tumor characteristics. [Expert opinion] This is based on clinical principle and expert consensus.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] A clinician should perform complete visual resection of bladder tumors when technically feasible. [Expert opinion] This is based on clinical principle and expert consensus.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] A clinician should perform upper urinary tract imaging as part of the initial evaluation. [Expert opinion] This is based on clinical principle and expert consensus.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] A clinician should consider prostatic urethral biopsies, upper tract imaging, and enhanced cystoscopic techniques. [Expert opinion] This is based on expert consensus.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] A clinician should assign a clinical stage and classify the patient as low-, intermediate-, or high-risk. [Low evidence] Based on Grade C evidence, including observational studies.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] An experienced genitourinary pathologist should review the pathology for variant histologies or LVI. [Low evidence] Based on Grade C evidence.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] A clinician should perform a restaging TURBT within four to six weeks. [Expert opinion] This is based on expert consensus.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] A clinician should consider offering initial radical cystectomy. [Expert opinion] This is based on expert consensus due to high upstaging risk.
[STRONG recommendation, MODERATE evidence] [Strong recommendation] A clinician should not use urinary biomarkers in place of cystoscopic evaluation. [Moderate evidence] Based on Grade B evidence from studies comparing biomarkers to cystoscopy.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] A clinician should not routinely use urinary biomarkers or cytology. [Expert opinion] This is based on expert consensus.
[CONDITIONAL recommendation, EXPERT OPINION evidence] [Conditional recommendation] A clinician may use biomarkers to assess BCG response or adjudicate equivocal cytology. [Expert opinion] This is based on expert consensus.
[STRONG recommendation, MODERATE evidence] [Strong recommendation] A clinician should perform repeat resection or endoscopic treatment of remaining tumor. [Moderate evidence] Based on Grade B evidence.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] A clinician should consider performing repeat TURBT within six weeks. [Low evidence] Based on Grade C evidence.
[STRONG recommendation, MODERATE evidence] [Strong recommendation] A clinician should perform repeat TURBT to include muscularis propria within six weeks. [Moderate evidence] Based on Grade B evidence.
[MODERATE recommendation, MODERATE evidence] [Moderate recommendation] A clinician should consider administering single postoperative intravesical chemotherapy within 24 hours for low- or intermediate-risk patients, but should not use it if perforation or extensive resection is suspected. [Moderate evidence] Based on Grade B evidence.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] A clinician should not administer induction intravesical therapy in low-risk patients. [Low evidence] Based on Grade C evidence.
[MODERATE recommendation, MODERATE evidence] [Moderate recommendation] A clinician should consider administering a six-week course of induction intravesical chemotherapy or immunotherapy. [Moderate evidence] Based on Grade B evidence.
[STRONG recommendation, MODERATE evidence] [Strong recommendation] A clinician should administer a six-week induction course of BCG. [Moderate evidence] Based on Grade B evidence.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] A clinician may utilize maintenance therapy. [Low evidence] Based on Grade C evidence.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] A clinician should consider maintenance BCG for one year, as tolerated. [Low evidence] Based on Grade C evidence.
[MODERATE recommendation, MODERATE evidence] [Moderate recommendation] A clinician should continue maintenance BCG for three years, as tolerated. [Moderate evidence] Based on Grade B evidence.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] A clinician should consider performing prostatic urethral biopsy and upper tract evaluation. [Low evidence] Based on Grade C evidence.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] A clinician should offer a second course of BCG. [Low evidence] Based on Grade C evidence.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] A clinician should offer radical cystectomy. [Low evidence] Based on Grade C evidence.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] A clinician should not prescribe additional BCG to patients intolerant or with early recurrence after adequate BCG therapy. [Low evidence] Based on Grade C evidence.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] A clinician may recommend clinical trial enrollment, alternative intravesical therapies, or systemic immunotherapy for CIS. [Low evidence] Based on Grade C evidence.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] A clinician should not perform radical cystectomy until bladder-sparing modalities have failed. [Expert opinion] This is based on clinical principle and expert consensus.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] A clinician should consider offering initial radical cystectomy for persistent high-grade T1 disease with adverse features. [Low evidence] Based on Grade C evidence.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] A clinician should offer radical cystectomy. [Low evidence] Based on Grade C evidence.
[MODERATE recommendation, MODERATE evidence] [Moderate recommendation] A clinician should offer BLC at TURBT to increase detection and decrease recurrence. [Moderate evidence] Based on Grade B evidence.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] A clinician may consider use of NBI to increase detection and decrease recurrence. [Low evidence] Based on Grade C evidence.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] A clinician should perform the first surveillance cystoscopy within three to four months. [Expert opinion] This is based on expert consensus.
[Conditional recommendation] Clinicians may consider using narrow-band imaging to increase detection and decrease recurrence in patients with NMIBC, based on low-quality evidence.
[Moderate recommendation] The first surveillance cystoscopy should be performed within three to four months after initial evaluation and treatment, based on expert opinion.
[Moderate recommendation] Routine surveillance upper tract imaging should not be performed in asymptomatic low-risk NMIBC patients, based on expert opinion.
[Conditional recommendation] In patients with low-grade Ta disease and sub-centimeter papillary tumors, clinicians may consider in-office fulguration as an alternative to resection under anesthesia, based on expert opinion.
[Moderate recommendation] For intermediate-risk NMIBC patients with a negative first surveillance cystoscopy, subsequent cystoscopy with cytology should be performed every 3-6 months for 2 years, then every 6-12 months for years 3-4, and annually thereafter, based on expert opinion.
[Moderate recommendation] For high-risk NMIBC patients with a negative first surveillance cystoscopy, subsequent cystoscopy with cytology should be performed every 3-4 months for 2 years, then every 6 months for years 3-4, and annually thereafter, based on expert opinion.
[STRONG recommendation] Clinicians should obtain a medical history with comprehensive bladder assessment, conduct a physical examination, and perform a urinalysis to exclude microhematuria and infection. [EXPERT OPINION evidence] This is based on clinical principle and consensus.
[WEAK recommendation] Clinicians may offer telemedicine for initial evaluation, noting that physical exam is omitted and urinalysis should be obtained locally. [EXPERT OPINION evidence] This is based on expert opinion.
[CONDITIONAL recommendation] Clinicians may obtain a post-void residual to exclude incomplete emptying, particularly in patients with voiding or emptying symptoms. [EXPERT OPINION evidence] This is based on clinical principle.
[WEAK recommendation] Clinicians may obtain symptom questionnaires or voiding diaries to aid diagnosis, exclude other disorders, assess bother, or evaluate treatment response. [EXPERT OPINION evidence] This is based on clinical principle.
[STRONG recommendation] Clinicians should not routinely perform urodynamics, cystoscopy, or urinary tract imaging in the initial evaluation of OAB patients. [EXPERT OPINION evidence] This is based on clinical principle.
[CONDITIONAL recommendation] Clinicians may perform advanced testing when diagnostic uncertainty exists. [EXPERT OPINION evidence] This is based on clinical principle.
[STRONG recommendation] Clinicians should assess for comorbid conditions that may contribute to OAB symptoms and educate patients on managing these conditions. [EXPERT OPINION evidence] This is based on expert opinion.
[WEAK recommendation] Clinicians may use telemedicine for follow-up visits with OAB patients. [EXPERT OPINION evidence] This is based on expert opinion.
[STRONG recommendation] Clinicians should engage in shared decision-making with OAB patients, considering their values and preferences. [EXPERT OPINION evidence] This is based on clinical principle.
[STRONG recommendation] Clinicians should discuss incontinence management strategies, such as pads or barrier creams, with all patients who have urgency urinary incontinence. [EXPERT OPINION evidence] This is based on expert opinion.
[STRONG recommendation] Clinicians should offer bladder training to all patients with OAB. [HIGH evidence] This is based on multiple randomized controlled trials with consistent results.
[WEAK recommendation] Clinicians may offer select non-invasive therapies to all patients with OAB. [EXPERT OPINION evidence] This is based on clinical principle.
[WEAK recommendation] In patients with OAB not responding to monotherapy, clinicians may combine behavioral, non-invasive, pharmacologic, or minimally invasive therapies. [EXPERT OPINION evidence] This is based on expert opinion.
[STRONG recommendation] Clinicians should counsel patients that there is insufficient evidence to support the use of nutraceuticals, vitamins, supplements, or herbal remedies in OAB treatment. [EXPERT OPINION evidence] This is based on expert opinion.
[STRONG recommendation] Clinicians should offer antimuscarinic medications or beta-3 agonists to patients with OAB to improve urinary urgency, frequency, and incontinence. [HIGH evidence] This is based on multiple randomized controlled trials with consistent results.
[STRONG recommendation] Clinicians should counsel patients on side effects of all oral OAB medication options and choose treatment based on side effect profiles in shared decision-making. [EXPERT OPINION evidence] This is based on clinical principle.
[STRONG recommendation] Clinicians should discuss the potential risk for dementia and cognitive impairment with patients taking antimuscarinic medications for OAB. [EXPERT OPINION evidence] This is based on clinical principle.
[STRONG recommendation] Clinicians should use antimuscarinic medications with extreme caution in OAB patients who have narrow-angle glaucoma, impaired gastric emptying, or a history of urinary retention. [EXPERT OPINION evidence] This is based on clinical principle.
[STRONG recommendation] Clinicians should assess patients with OAB who have initiated pharmacotherapy for efficacy and side effects. [EXPERT OPINION evidence] This is based on expert opinion.
[WEAK recommendation] In such patients, clinicians may offer a different medication in the same or different class to improve tolerability or efficacy. [EXPERT OPINION evidence] This is based on clinical principle.
[CONDITIONAL recommendation] In patients with OAB not improving with monotherapy, clinicians may offer combination therapy with a medication from a different class. [MODERATE evidence] This is based on single randomized controlled trials or strong observational studies.
[WEAK recommendation] Clinicians may offer minimally invasive procedures to OAB patients who are unable or unwilling to undergo behavioral, non-invasive, or pharmacologic therapies. [EXPERT OPINION evidence] This is based on clinical principle.
[WEAK recommendation] Clinicians may offer minimally invasive therapies to OAB patients without requiring trials of behavioral, non-invasive, or pharmacologic management, in shared decision-making. [EXPERT OPINION evidence] This is based on expert opinion.
[MODERATE recommendation] Clinicians should offer sacral neuromodulation, percutaneous tibial nerve stimulation, and/or intradetrusor botulinum toxin injection to such patients. [HIGH evidence] This is based on multiple randomized controlled trials with consistent results.
[STRONG recommendation] Clinicians should measure post-void residual in OAB patients prior to intradetrusor botulinum toxin injection. [EXPERT OPINION evidence] This is based on clinical principle.
[STRONG recommendation] Clinicians should obtain a post-void residual in OAB patients whose symptoms have not adequately improved or have worsened after intradetrusor botulinum toxin injection. [EXPERT OPINION evidence] This is based on clinical principle.
[STRONG recommendation] Clinicians should discontinue oral medications in OAB patients who have an appropriate response to a minimally invasive procedure but restart pharmacotherapy if efficacy is not maintained. [EXPERT OPINION evidence] This is based on expert opinion.
[WEAK recommendation] Clinicians may perform urodynamics in OAB patients who do not adequately respond to pharmacotherapy or minimally invasive therapies to evaluate bladder function and exclude other disorders. [EXPERT OPINION evidence] This is based on clinical principle.
[WEAK recommendation] Clinicians may offer bladder augmentation cystoplasty or urinary diversion in severely impacted OAB patients who have not responded to all other therapies. [EXPERT OPINION evidence] This is based on expert opinion.
[STRONG recommendation] Clinicians should only recommend chronic indwelling urethral or suprapubic catheters to OAB patients when therapies are contraindicated, ineffective, or no longer desired, in shared decision-making due to risks. [EXPERT OPINION evidence] This is based on expert opinion.
[WEAK recommendation] Clinicians may offer initial management with non-invasive therapies, pharmacotherapy, or minimally invasive therapies to patients with BPH and bothersome OAB, in shared decision-making. [EXPERT OPINION evidence] This is based on expert opinion.
[CONDITIONAL recommendation] Clinicians may offer monotherapy with antimuscarinic medications or beta-3 agonists, or combination therapy with an alpha blocker and an antimuscarinic or beta-3 agonist, to patients with BPH and OAB. [MODERATE evidence] This is based on single randomized controlled trials or strong observational studies.
[Conditional recommendation] Clinicians may offer minimally invasive procedures to such patients. [Expert opinion] This is based on clinical principle and expert consensus.
[Conditional recommendation] Clinicians may offer minimally invasive therapies without requiring prior trials of other therapies, based on shared decision-making. [Expert opinion] This recommendation is based on expert opinion.
[Moderate recommendation] Clinicians should offer sacral neuromodulation, percutaneous tibial nerve stimulation, and/or intradetrusor botulinum toxin injection. [High evidence] This is based on high-quality evidence (Grade A).
[Moderate recommendation] Clinicians should measure post-void residual prior to intradetrusor botulinum toxin therapy. [Expert opinion] This is based on clinical principle and expert consensus.
[Moderate recommendation] Clinicians should obtain a post-void residual in such patients. [Expert opinion] This is based on clinical principle and expert consensus.
[Conditional recommendation] Clinicians may perform urodynamics in such patients to evaluate bladder function and exclude other disorders. [Expert opinion] This is based on clinical principle and expert consensus.
[Conditional recommendation] Clinicians may offer bladder augmentation cystoplasty or urinary diversion to severely impacted patients with OAB who have not responded to all other therapeutic options. [Expert opinion] This is based on expert opinion.
[Moderate recommendation] Clinicians should only recommend chronic indwelling urethral or suprapubic catheters when OAB therapies are contraindicated, ineffective, or no longer desired by the patient, and always in the context of shared decision-making due to risk of harm. [Expert opinion] This is based on expert opinion.
[Conditional recommendation] Clinicians may offer initial management with non-invasive therapies, pharmacotherapy, or minimally invasive therapies, based on shared decision-making. [Expert opinion] This is based on expert opinion.
[Conditional recommendation] Clinicians should offer monotherapy with antimuscarinic medications or beta-3 agonists, or combination therapy with an alpha blocker and an antimuscarinic medication or beta-3 agonist. [Moderate evidence] This is based on moderate-quality evidence (Grade B).
[Strong recommendation] Clinicians should conduct a diagnostic process including a careful history and physical exam of the genitalia. [Expert opinion] This is based on a Clinical Principle, reflecting consensus on necessary clinical evaluation.
[Strong recommendation] Clinicians should only evaluate and treat Peyronie's disease if they have the experience and diagnostic tools to appropriately manage the condition. [Expert opinion] This is based on expert consensus.
[Strong recommendation] Clinicians should discuss available treatment options and their benefits and risks/burdens with patients. [Expert opinion] This is based on a Clinical Principle reflecting standard care consensus.
[Weak recommendation] Clinicians may offer oral non-steroidal anti-inflammatory medications for pain management in active Peyronie's disease. [Expert opinion] This is based on expert consensus due to insufficient evidence.
[Moderate recommendation] Clinicians should not offer oral therapy with vitamin E, tamoxifen, procarbazine, omega-3 fatty acids, or vitamin E with L-carnitine. [Moderate to low evidence] This is based on evidence strength Grade B for some therapies (moderate certainty) and Grade C for others (low certainty).
[Moderate recommendation] Clinicians should not offer electromotive therapy with verapamil. [Low evidence] This is based on evidence strength Grade C, indicating low certainty from limited studies.
[Moderate recommendation] Clinicians may administer intralesional collagenase clostridium histolyticum with modeling for curvature reduction in stable disease with curvature 30-90° and intact erectile function. [Moderate evidence] Based on evidence strength Grade B from RCTs like IMPRESS I/II.
[Moderate recommendation] Clinicians may administer intralesional interferon α-2b. [Low evidence] Based on evidence strength Grade C, from a single RCT and observational studies with low certainty.
[Conditional recommendation] Clinicians may offer intralesional verapamil, but the evidence is weak and benefits/risks are unclear. [Low evidence] Based on evidence strength Grade C from conflicting RCTs and observational studies.
[Strong recommendation] Clinicians should counsel patients about potential adverse events (e.g., penile bruising, dizziness, nausea, injection site pain) prior to starting intralesional verapamil. [Expert opinion] This is based on a Clinical Principle.
[Moderate recommendation] Clinicians should not use extracorporeal shock wave therapy for reducing penile curvature or plaque size. [Moderate evidence] Based on evidence strength Grade B from RCTs showing no reliable improvement.
[Conditional recommendation] Clinicians may offer extracorporeal shock wave therapy to improve penile pain, considering the natural history of pain resolution and potential adverse events. [Moderate evidence] Based on evidence strength Grade B from RCTs showing pain reduction.
[Strong recommendation] Clinicians should assess patients as surgical candidates based on the presence of stable disease. [Expert opinion] This is based on a Clinical Principle that surgery is appropriate only after symptoms have stabilized.
[Moderate recommendation] Clinicians may offer tunical plication surgery to patients with adequate rigidity to improve penile curvature. [Low evidence] Based on evidence strength Grade C from observational studies.
[Moderate recommendation] Clinicians may offer plaque incision or excision and/or grafting to patients with adequate rigidity to improve penile curvature. [Low evidence] Based on evidence strength Grade C from observational studies.
[Moderate recommendation] Clinicians may offer penile prosthesis surgery to patients with erectile dysfunction and/or deformity preventing coitus despite other therapies. [Low evidence] Based on evidence strength Grade C from observational studies.
[Moderate recommendation] Clinicians may perform adjunctive intra-operative procedures (e.g., modeling, plication, incision/grafting) if significant deformity persists after prosthesis insertion. [Low evidence] Based on evidence strength Grade C from observational studies.
[Strong recommendation] Clinicians should use inflatable penile prosthesis for patients undergoing prosthetic surgery for Peyronie's disease. [Expert opinion] This is based on expert consensus regarding fewer adverse events and better modeling capability.
[Strong recommendation] Validated measures of both objective and subjective outcomes must be used. [Expert opinion evidence] This is based on guideline panel consensus to ensure reliable assessment.
[Weak recommendation] Pain may be measured using visual analog scales. [Moderate evidence] This is based on validation studies showing reliable documentation.
[Moderate recommendation] Patients should be queried regarding distress during baseline evaluation and follow-up. [Expert opinion evidence] This is based on panel emphasis to address subjective components of the disease.
[Strong recommendation] Objective outcomes must be documented to inform patients about actual changes in curvature and dimensions. [Low evidence] This is supported by observational studies showing discrepancies between patient perceptions and objective measures.
[MODERATE recommendation, Expert Opinion evidence] [Moderate recommendation] Clinicians should perform a comprehensive history and physical examination, including the genitalia and perineum. [Expert opinion] This is based on clinical principles and expert consensus.
[MODERATE recommendation, Expert Opinion evidence] [Moderate recommendation] Clinicians should obtain a corporal blood gas at the initial presentation of priapism. [Expert opinion] This is based on clinical principles.
[WEAK recommendation, Expert Opinion evidence] [Weak recommendation] Clinicians may utilize penile duplex Doppler ultrasound when the diagnosis is indeterminate. [Expert opinion] This is based on expert consensus.
[MODERATE recommendation, Expert Opinion evidence] [Moderate recommendation] Clinicians should order additional diagnostic testing for etiology but not delay definitive treatment. [Expert opinion] This is based on expert consensus.
[MODERATE recommendation, Expert Opinion evidence] [Moderate recommendation] Conservative therapies are unlikely to succeed and should not delay definitive treatments. [Expert opinion] This is based on expert consensus.
[MODERATE recommendation, Moderate evidence] [Moderate recommendation] Clinicians should counsel all patients about the chance of erectile dysfunction. [Moderate evidence] Based on Grade B evidence.
[MODERATE recommendation, Moderate evidence] [Moderate recommendation] Clinicians should counsel that the likelihood of erectile function recovery is low. [Moderate evidence] Based on Grade B evidence.
[MODERATE recommendation, Low evidence] [Moderate recommendation] Clinicians should use intracavernosal phenylephrine and corporal aspiration, with or without irrigation, before operative interventions. [Low evidence] Based on Grade C evidence.
[MODERATE recommendation, Expert Opinion evidence] [Moderate recommendation] Clinicians should monitor blood pressure and heart rate. [Expert opinion] This is a clinical principle.
[MODERATE recommendation, Low evidence] [Moderate recommendation] Clinicians should perform a distal corporoglanular shunt, with or without tunneling. [Low evidence] Based on Grade C evidence.
[MODERATE recommendation, Low evidence] [Moderate recommendation] Clinicians should consider corporal tunneling. [Low evidence] Based on Grade C evidence.
[MODERATE recommendation, Low evidence] [Moderate recommendation] Clinicians should counsel that there is inadequate evidence to quantify the benefit of proximal shunts. [Low evidence] Based on Grade C evidence.
[MODERATE recommendation, Low evidence] [Moderate recommendation] Clinicians should perform corporal blood gas or color duplex Doppler ultrasound. [Low evidence] Based on Grade C evidence.
[WEAK recommendation, Expert Opinion evidence] [Weak recommendation] Clinicians may consider placement of a penile prosthesis in untreated priapism >36 hours or refractory cases. [Expert opinion] This is based on expert consensus.
[MODERATE recommendation, Low evidence] [Moderate recommendation] Clinicians should discuss risks and benefits of early versus delayed placement. [Low evidence] Based on Grade C evidence.
[CONDITIONAL recommendation, Low evidence] [Conditional recommendation] Clinicians should inform that optimal prevention strategies are unknown. [Low evidence] Based on Grade C evidence.
[STRONG recommendation, Moderate evidence] [Strong recommendation] Clinicians should inform that hormonal regulators may impair fertility and sexual function. [Moderate evidence] Based on Grade B evidence.
[MODERATE recommendation, Expert Opinion evidence] [Moderate recommendation] Clinicians should not delay standard priapism management for disease-specific interventions. [Expert opinion] This is based on expert consensus.
[MODERATE recommendation, Expert Opinion evidence] [Moderate recommendation] Clinicians should not use exchange transfusion as primary treatment. [Expert opinion] This is based on expert consensus.
[MODERATE recommendation, Expert Opinion evidence] [Moderate recommendation] Clinicians should administer intracavernosal phenylephrine as initial treatment. [Expert opinion] This is based on expert consensus.
[MODERATE recommendation, Low evidence] [Moderate recommendation] Clinicians should utilize intracavernosal phenylephrine if conservative management fails. [Low evidence] Based on Grade C evidence.
[MODERATE recommendation, Expert Opinion evidence] [Moderate recommendation] Clinicians should instruct patients to return if erection lasts >4 hours. [Expert opinion] This is based on expert consensus.
[MODERATE recommendation, Expert Opinion evidence] [Moderate recommendation] Clinicians should counsel that it is not an emergency and offer observation. [Expert opinion] This is based on expert consensus.
[WEAK recommendation, Expert Opinion evidence] [Weak recommendation] Clinicians should consider penile duplex ultrasound for fistula assessment. [Expert opinion] This is based on expert consensus.
[MODERATE recommendation, Low evidence] [Moderate recommendation] Clinicians should offer embolization as first-line therapy. [Low evidence] Based on Grade C evidence.
[MODERATE recommendation, Low evidence] [Moderate recommendation] Patients should be informed about risks of ED, recurrence, and failure. [Low evidence] Based on Grade C evidence.
[MODERATE recommendation, Low evidence] [Moderate recommendation] Clinicians should offer repeat embolization over surgical ligation. [Low evidence] Based on Grade C evidence.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should instruct patients to return to the office or Emergency Department if an erection lasts longer than 4 hours. [Expert opinion] Based on expert consensus.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should counsel patients that non-ischemic priapism is not an emergency and offer an initial period of observation. [Expert opinion] Based on expert consensus.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should consider penile duplex ultrasound to assess fistula location and size in patients with non-ischemic priapism. [Expert opinion] Based on expert consensus.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] Clinicians should offer embolization as first-line therapy for patients with persistent non-ischemic priapism who wish to be treated after a trial of observation. [Low evidence] Based on small series and observational studies.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] Patients should be informed that embolization carries risks of erectile dysfunction, recurrence, and failure to correct non-ischemic priapism. [Low evidence] Based on limited studies.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] Clinicians should offer repeat embolization over surgical ligation for patients who have failed an initial embolization attempt. [Low evidence] Based on limited comparative data.
[Strong recommendation] Offer multiparametric MRI and report results using a 5-point Likert scale. [High evidence] Based on good evidence from clinical trials, including a large UK study.
[Strong recommendation] Do not routinely offer isotope bone scans. [Moderate evidence] Based on committee assessment and alignment with current practice.
[Conditional recommendation] Offer active surveillance as first-line; consider radical prostatectomy or radiotherapy if active surveillance is not suitable. [High evidence] Based on the UK ProtecT trial showing benefits and risks.
[Weak recommendation] Discuss docetaxel chemotherapy as an option, explaining benefits and harms for shared decision-making. [High evidence] Based on a large UK randomised trial showing delay in disease progression but unclear survival benefit.
[Strong recommendation] Offer docetaxel chemotherapy, starting within 12 weeks of androgen deprivation therapy, using six cycles at 75 mg/m2. [High evidence] Based on good evidence from RCTs demonstrating improved survival.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Clinicians should obtain high-quality, multiphase, cross-sectional abdominal imaging to characterize and stage the renal mass, including assessment of tumor complexity, enhancement, and fat presence. [Expert opinion evidence] Based on clinical principle and consensus.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Clinicians should obtain a comprehensive metabolic panel, complete blood count, urinalysis, and chest imaging for metastatic evaluation. [Expert opinion evidence] Based on clinical principle and consensus.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Clinicians should assign CKD stage based on GFR and proteinuria. [Expert opinion evidence] Based on expert opinion and consensus.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] A urologist should lead counseling and consider all management strategies, with multidisciplinary involvement when needed. [Expert opinion evidence] Based on expert opinion and consensus.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Clinicians should provide counseling on tumor biology, patient-specific risk assessment (sex, tumor size/complexity, histology, imaging), and review low oncologic risk of cT1a tumors. [Expert opinion evidence] Based on clinical principle and consensus.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Clinicians must review treatment morbidities and the importance of age, comorbidities/frailty, and life expectancy. [Expert opinion evidence] Based on clinical principle and consensus.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Clinicians should review risks of progressive CKD, need for renal replacement therapy, and long-term survival. [Expert opinion evidence] Based on clinical principle and consensus.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should consider referral to nephrology for patients at high risk of CKD progression, such as those with eGFR <45 mL/min/1.73m2, proteinuria, or expected eGFR <30 mL/min/1.73m2 post-intervention. [Expert opinion evidence] Based on expert opinion and consensus.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Clinicians should recommend genetic counseling for patients ≤46 years, with multifocal/bilateral masses, or suggestive personal/family history or pathology. [Expert opinion evidence] Based on expert opinion and consensus.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] Patients should be counseled on the rationale, predictive values, risks, and non-diagnostic rates of RMB. [Low evidence] Based on Grade C evidence from observational studies or limited data.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should consider RMB when a mass is suspected to be hematologic, metastatic, inflammatory, or infectious. [Expert opinion evidence] Based on clinical principle and consensus.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] RMB should be obtained on a utility-based approach when it may influence management, but is not required for young/healthy patients unwilling to accept uncertainties or older/frail patients managed conservatively. [Expert opinion evidence] Based on expert opinion and consensus.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] Multiple core biopsies should be performed and are preferred over FNA. [Low evidence] Based on Grade C evidence from observational studies or limited data.
[MODERATE recommendation, MODERATE evidence] [Moderate recommendation] Clinicians should prioritize partial nephrectomy (PN) for cT1a renal masses, as it minimizes CKD risk and has favorable oncologic outcomes. [Moderate evidence] Based on Grade B evidence from RCTs with some limitations or strong observational studies.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] Clinicians should prioritize nephron-sparing approaches for patients with solitary kidney, bilateral tumors, familial RCC, preexisting CKD, or proteinuria. [Low evidence] Based on Grade C evidence from observational studies or limited data.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] Nephron-sparing approaches should be considered for young patients, those with multifocal masses, or comorbidities like hypertension, diabetes, urolithiasis, or obesity. [Low evidence] Based on Grade C evidence from observational studies or limited data.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Clinicians should prioritize nephron mass preservation and avoid prolonged warm ischemia. [Expert opinion evidence] Based on expert opinion and consensus.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Clinicians should prioritize negative surgical margins, determine parenchyma removal based on surgeon discretion, and consider tumor enucleation in familial RCC, multifocal disease, or severe CKD. [Expert opinion evidence] Based on expert opinion and consensus.
[MODERATE recommendation, MODERATE evidence] [Moderate recommendation] Clinicians should consider RN when increased oncologic potential is suggested by tumor size, RMB, or imaging. [Moderate evidence] Based on Grade B evidence from RCTs with some limitations or strong observational studies.
[Moderate recommendation] RN should be considered for patients with solid or Bosniak 3/4 complex cystic renal masses when increased oncologic potential is suggested by tumor size, renal mass biopsy (if obtained), or imaging. [Moderate evidence] Based on observational studies.
[Moderate recommendation] Lymph node dissection should be performed for staging purposes in patients with clinically concerning regional lymphadenopathy. [Expert opinion] Based on consensus.
[Moderate recommendation] Adrenalectomy should be performed if imaging or intraoperative findings suggest metastasis or direct invasion of the adrenal gland. [Expert opinion] Based on clinical principles.
[Moderate recommendation] A minimally invasive approach should be considered when it does not compromise oncologic, functional, and perioperative outcomes. [Expert opinion] Based on consensus.
[Moderate recommendation] Referral to medical oncology should be considered when there is concern for metastasis or incompletely resected disease, and patients with high-risk or locally advanced resected cancers should be counselled about adjuvant therapy and clinical trials. [Expert opinion] Based on clinical principles.
[Moderate recommendation] TA should be considered as an alternate approach for cT1a solid renal masses <3 cm, with percutaneous technique preferred to minimize morbidity. [Low evidence] Based on observational studies.
[Conditional recommendation] Both RFA and cryoablation may be offered as options, depending on patient preference and clinical factors. [Low evidence] Based on observational studies.
[Moderate recommendation] RMB should be performed prior to or at the time of ablation to provide pathologic diagnosis and guide surveillance. [Expert opinion] Based on consensus.
[Strong recommendation] Counseling should include information on the increased likelihood of tumor persistence or local recurrence compared to surgical excision, with the option of repeat ablation if needed. [Moderate evidence] Based on observational studies.
[Conditional recommendation] AS may be elected for solid renal masses <2 cm or predominantly cystic complex masses, with potential for delayed intervention. [Low evidence] Based on observational studies.
[Moderate recommendation] AS/expectant management should be prioritized when intervention risks or competing risks of death outweigh oncologic benefits, with periodic surveillance based on shared decision-making. [Expert opinion] Based on clinical principles.
[Moderate recommendation] For patients preferring AS with equivocal risk/benefit, consider RMB for risk stratification and repeat imaging in 3-6 months, with surveillance based on growth rate and shared decision-making. [Expert opinion] Based on consensus.
[Moderate recommendation] Intervention should be recommended when oncologic benefits outweigh risks and competing mortality; if AS is pursued, encourage RMB for risk stratification and recommend close surveillance. [Low evidence] Based on observational studies.
[Moderate recommendation] Discuss stage, grade, histology, recurrence risks, and sequelae; for benign masses, occasional evaluation and testing are sufficient without routine imaging. [Expert opinion] Based on consensus.
[Moderate recommendation] Periodic medical history, physical exam, laboratory studies, and imaging should be performed to detect recurrence and sequelae. [Expert opinion] Based on clinical principles.
[Moderate recommendation] Periodic testing of serum creatinine, eGFR, and urinalysis should be performed; other labs may be obtained based on clinician discretion or suspicion of advanced disease. [Expert opinion] Based on consensus.
[Moderate recommendation] Referral to nephrology should be made for patients with progressive renal insufficiency or proteinuria. [Expert opinion] Based on consensus.
[Moderate recommendation] Bone scans should only be performed if clinical symptoms, elevated alkaline phosphatase, or radiographic findings suggest bony neoplasms. [Low evidence] Based on observational studies.
[Strong recommendation] Prompt MRI or CT scanning of the brain and/or spine should be performed for patients with acute neurological signs or symptoms. [High evidence] Based on multiple RCTs or strong studies.
[Moderate recommendation] Site-specific imaging can be ordered based on clinical symptoms; PET scans should not be routine but may be considered selectively. [Low evidence] Based on observational studies.
[Moderate recommendation] Evaluate extent of disease and refer to medical oncology; consider surgical or ablative therapies for isolated or oligo-metastatic disease. [Expert opinion] Based on consensus.
[Moderate recommendation] Perform metastatic evaluation with imaging; involve a urologist and consider surgical or ablative therapies if isolated. [Expert opinion] Based on consensus.
[Moderate recommendation] Classify patients into risk groups for follow-up based on surgical pathology. [Expert opinion] Based on consensus.
[Moderate recommendation] Abdominal imaging according to Table 1 should be performed, with contrast-enhanced CT or MRI preferred. [Low evidence] Based on observational studies.
[Moderate recommendation] Chest imaging according to Table 1 should be performed, with CXR for low/intermediate risk and CT preferred for high/very high risk. [Low evidence] Based on observational studies.
[Moderate recommendation] Pre- and post-contrast abdominal imaging within 6 months should be performed, with subsequent follow-up per IR protocol. [Expert opinion] Based on consensus.
[Strong recommendation] Complex tumors on nephrometry should be the first targets for percutaneous renal biopsies in small renal masses. [Low evidence] This is based on observational clinical studies.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Yes, clinicians should obtain a complete patient history and perform a pelvic examination in women presenting with rUTIs. [Expert opinion] This is based on clinical principles and expert consensus.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] Yes, clinicians should obtain urinalysis, urine culture, and sensitivity with each symptomatic acute cystitis episode prior to initiating treatment in patients with rUTIs. [Low evidence] This is based on evidence with low certainty.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should document evidence of inflammation (pyuria) and the presence of uropathogenic bacteria in association with symptomatic episodes to diagnose rUTI. [Expert opinion] This is based on clinical principles.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Yes, clinicians should obtain repeat urine studies when an initial urine specimen is suspect for contamination, with consideration for obtaining a catheterized specimen. [Expert opinion] This is based on clinical principles.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] No, cystoscopy and upper tract imaging should not be routinely obtained in the index patient presenting with rUTI. [Expert opinion] This is based on expert consensus.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Yes, clinicians may offer patient-initiated treatment (self-start treatment) to select rUTI patients with acute episodes while awaiting urine cultures. [Low evidence] This is based on evidence with low certainty.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] No, clinicians should omit surveillance urine testing, including urine culture, in asymptomatic patients with rUTIs. [Low evidence] This is based on evidence with low certainty.
[STRONG recommendation, MODERATE evidence] [Strong recommendation] No, clinicians should not treat asymptomatic bacteriuria (ASB) in patients. [Moderate evidence] This is based on evidence with moderate certainty.
[STRONG recommendation, MODERATE evidence] [Strong recommendation] Clinicians should use first-line therapy (i.e., nitrofurantoin, trimethoprim-sulfamethoxazole [TMP-SMX], fosfomycin) dependent on the local antibiogram for the treatment of symptomatic UTIs in women. [Moderate evidence] This is based on evidence with moderate certainty.
[MODERATE recommendation, MODERATE evidence] [Moderate recommendation] Clinicians should treat rUTI patients experiencing acute cystitis episodes with as short a duration of antibiotics as reasonable, generally no longer than seven days. [Moderate evidence] This is based on evidence with moderate certainty.
[WEAK recommendation, EXPERT OPINION evidence] [Weak recommendation] Clinicians may treat with culture-directed parenteral antibiotics for as short a course as reasonable, generally no longer than seven days. [Expert opinion] This is based on expert consensus.
[CONDITIONAL recommendation, MODERATE evidence] [Conditional recommendation] Following discussion of risks, benefits, and alternatives, clinicians may prescribe antibiotic prophylaxis to decrease the risk of future UTIs in women of all ages previously diagnosed with UTIs. [Moderate evidence] This is based on evidence with moderate certainty.
[MODERATE recommendation, MODERATE evidence] [Moderate recommendation] Yes, clinicians should offer cranberry as an option for prophylaxis for women with rUTIs. [Moderate evidence] This is based on evidence with moderate certainty.
[MODERATE recommendation, MODERATE evidence] [Moderate recommendation] Clinicians should inform patients with rUTIs that D-mannose alone for prophylaxis may not be effective in UTI prevention. [Moderate evidence] This is based on evidence with moderate certainty.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Yes, clinicians may offer methenamine hippurate for prophylaxis for women with rUTIs. [Low evidence] This is based on evidence with low certainty.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] When women with rUTIs have a water intake below 1.5 L/day (50 oz), clinicians may offer increased water intake for prophylaxis. [Low evidence] This is based on evidence with low certainty.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] No, clinicians should not perform a post-treatment test of cure urinalysis or urine culture in asymptomatic patients. [Expert opinion] This is based on expert consensus.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Yes, clinicians should repeat urine cultures to guide further management when UTI symptoms persist following antimicrobial therapy. [Expert opinion] This is based on expert consensus.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should evaluate for alternative causes to patient symptoms. [Expert opinion] This is based on expert consensus.
[MODERATE recommendation, MODERATE evidence] [Moderate recommendation] Yes, in perimenopausal and postmenopausal women with rUTIs, clinicians should recommend vaginal estrogen therapy to reduce the risk of future UTIs if there is no contraindication. [Moderate evidence] This is based on evidence with moderate certainty.
[Moderate recommendation] Clinicians should omit surveillance urine testing, including urine culture, in asymptomatic patients with rUTIs. [Low evidence] This is based on observational studies or expert consensus indicating lack of benefit and potential harm from overtreatment.
[Strong recommendation] Clinicians should not treat ASB in patients. [Moderate evidence] Based on randomized controlled trials demonstrating no clinical benefit and clear harm from antibiotic use.
[Strong recommendation] Clinicians should use first-line therapy (nitrofurantoin, TMP-SMX, or fosfomycin) based on the local antibiogram for symptomatic UTIs in women. [Moderate evidence] Supported by systematic reviews and randomized controlled trials demonstrating effectiveness and low resistance.
[Moderate recommendation] Clinicians should treat with as short a duration of antibiotics as reasonable, generally no longer than seven days, for acute cystitis in rUTI patients. [Moderate evidence] Based on systematic reviews indicating similar efficacy with shorter courses and reduced adverse events.
[Conditional recommendation] Clinicians may treat with culture-directed parenteral antibiotics for as short a course as reasonable, generally no longer than seven days, in rUTI patients with resistant cultures. [Expert opinion] Based on panel consensus due to insufficient direct evidence.
[Conditional recommendation] Following discussion of risks, benefits, and alternatives, clinicians may prescribe antibiotic prophylaxis to decrease future UTI risk in women of all ages with prior UTIs. [Moderate evidence] Based on randomized controlled trials showing reduced recurrence but increased adverse events.
[Moderate recommendation] Clinicians should offer cranberry as an option for prophylaxis in women with rUTIs. [Moderate evidence] Supported by randomized controlled trials showing reduced recurrence with minimal harm.
[Moderate recommendation] Clinicians should inform patients with rUTIs that D-mannose alone for prophylaxis may not be effective. [Moderate evidence] Based on a high-quality randomized controlled trial showing no benefit compared to placebo.
[Conditional recommendation] Clinicians may offer methenamine hippurate for prophylaxis in women with rUTIs. [Low evidence] Based on limited studies, such as a non-inferiority trial, showing potential benefit compared to antibiotics.
[Conditional recommendation] When women with rUTIs have water intake below 1.5 L/day, clinicians may offer increased water intake for prophylaxis. [Low evidence] Based on a single trial demonstrating reduced recurrence with higher fluid intake.
[Strong recommendation] Clinicians should not perform post-treatment test of cure urinalysis or urine culture in asymptomatic patients. [Expert opinion] Based on panel consensus to prevent overtreatment, extrapolated from asymptomatic bacteriuria data.
[Moderate recommendation] Clinicians should repeat urine cultures to guide further management when UTI symptoms persist following antimicrobial therapy. [Expert opinion] Based on panel consensus to ensure appropriate treatment and avoid misdiagnosis.
[Moderate recommendation] For patients with persistent UTI symptoms after microbiological cure, clinicians should evaluate for alternative causes. [Expert opinion] Based on panel consensus to identify conditions like overactive bladder or pelvic floor disorders.
[Moderate recommendation] In perimenopausal and postmenopausal women with rUTIs, clinicians should recommend vaginal estrogen therapy to reduce future UTI risk if no contraindications exist. [Moderate evidence] Supported by randomized controlled trials showing decreased recurrence with minimal systemic absorption.
[Strong recommendation] Yes, clinicians should inform patients that salvage radiation is more effective when given at lower PSA levels. [Moderate evidence] This is based on Grade B evidence.
[Moderate recommendation] Clinicians should provide salvage radiation when the PSA is ≤0.5 ng/mL. [Moderate evidence] This is based on Grade B evidence.
[Conditional recommendation] Clinicians may offer salvage radiation when PSA values are <0.2 ng/mL for patients at high risk for clinical progression. [Low evidence] This is based on Grade C evidence.
[Moderate recommendation] Yes, clinicians should inform patients about the risks of salvage radiation and use a shared decision-making approach. [Expert opinion] This is based on clinical principle and consensus.
[Moderate recommendation] Yes, clinicians should use prognostic factors like PSADT, Grade Group, etc., to counsel patients about risk of clinical progression. [Moderate evidence] This is based on Grade B evidence.
[Weak recommendation] Clinicians may obtain ultrasensitive PSA in patients at high risk of recurrence where salvage RT is considered. [Expert opinion] This is based on expert consensus.
[Moderate recommendation] Yes, clinicians should confirm a rising trend in PSA before proceeding with therapy. [Expert opinion] This is based on expert consensus.
[Conditional recommendation] Clinicians may obtain PSMA-PET instead of or after negative conventional imaging for further evaluation. [Low evidence] This is based on Grade C evidence.
[Moderate recommendation] Yes, clinicians should perform next generation molecular PET imaging. [Low evidence] This is based on Grade C evidence.
[Moderate recommendation] Yes, clinicians should incorporate treatment of positive pelvic nodal findings in the radiation plan. [Low evidence] This is based on Grade C evidence.
[Conditional recommendation] Clinicians may obtain a pelvic MRI in addition to PET/CT for evaluation of local recurrence. [Low evidence] This is based on Grade C evidence.
[Moderate recommendation] No, clinicians should not withhold salvage prostate bed RT even with a negative PET/CT. [Expert opinion] This is based on expert consensus.
[Moderate recommendation] Yes, clinicians should offer ADT in addition to salvage RT for patients with high-risk features. [Moderate evidence] This is based on Grade B evidence from randomized trials.
[Conditional recommendation] Clinicians may offer radiation alone for patients without high-risk features. [Low evidence] This is based on Grade C evidence.
[Moderate recommendation] Yes, clinicians should discuss treatment side effects and comorbidities using a shared decision-making approach. [Expert opinion] This is based on clinical principle.
[Moderate recommendation] Yes, clinicians should include ADT rather than treating with RT alone for pN1 disease. [Expert opinion] This is based on clinical principle and supporting studies.
[Moderate recommendation] Clinicians should provide a minimum of four to six months of hormonal therapy. [Expert opinion] This is based on clinical principle and trial data.
[Weak recommendation] Clinicians may extend ADT to 18 to 24 months for patients with high-risk features. [Expert opinion] This is based on expert consensus.
[Conditional recommendation] Clinicians may use expanded radiation fields that include the regional lymph nodes. [Moderate evidence] This is based on Grade B evidence from the NRG/RTOG 0534 trial.
[Moderate recommendation] Yes, clinicians should discuss that including treatment of regional lymph nodes may increase the risk of side effects. [High evidence] This is based on Grade A evidence.
[Strong recommendation] No, clinicians should not recommend the addition of docetaxel. [Moderate evidence] This is based on Grade B evidence from trials showing no benefit and increased toxicity.
[Moderate recommendation] No, clinicians should recommend intensified AR suppression only within a clinical trial setting for pN0 patients. [Expert opinion] This is based on clinical principle and ongoing research.
[Moderate recommendation] Yes, clinicians should perform a prostate biopsy to evaluate for local recurrence. [Expert opinion] This is based on clinical principle.
[Moderate recommendation] Clinicians should offer radical prostatectomy, cryoablation, high-intensity focused ultrasound, or reirradiation as part of a shared decision-making approach. [Low evidence] This is based on Grade C evidence.
[Moderate recommendation] Clinicians should offer whole gland treatment by radical prostatectomy or radiation therapy. [Expert Opinion evidence] Based on expert consensus without direct high-quality evidence.
[Moderate recommendation] Clinicians should offer androgen deprivation therapy (ADT) plus salvage radiation therapy to the prostate bed and pelvic lymph nodes. [Expert Opinion evidence] Based on panel consensus.
[Moderate recommendation] Clinicians should offer salvage pelvic nodal radiation therapy plus androgen deprivation therapy. [Expert Opinion evidence] Based on panel consensus due to limited data.
[Conditional recommendation] Clinicians may offer salvage pelvic lymphadenectomy, but patients must be counseled on uncertain benefits. [Low evidence] Based on limited observational data (Grade C).
[Conditional recommendation] Clinicians may perform SABR MDT, but must weigh toxicity risks against potential benefits. [Low evidence] Based on phase 2 trials and observational data (Grade C).
[Weak recommendation] Clinicians may omit salvage radiotherapy to the prostate bed and should discuss uncertain systemic therapy options. [Expert Opinion evidence] Based on expert consensus due to limited data.
[MODERATE recommendation] Clinicians should include history, physical examination, objective demonstration of SUI, assessment of post-void residual, and urinalysis. [EXPERT OPINION evidence] Based on clinical principles and consensus.
[WEAK recommendation] Clinicians should perform additional evaluations in patients with conditions like inability to diagnose, neurogenic lower urinary tract dysfunction, etc. [EXPERT OPINION evidence] Based on expert consensus.
[WEAK recommendation] Clinicians may perform additional evaluations in patients with conditions like concomitant overactive bladder or prior surgery. [EXPERT OPINION evidence] Based on expert consensus.
[MODERATE recommendation] Clinicians should not perform cystoscopy in index patients unless there is a concern for urinary tract abnormalities. [EXPERT OPINION evidence] Based on clinical principles.
[CONDITIONAL recommendation] Clinicians may omit urodynamic testing for index patients when SUI is clearly demonstrated. [MODERATE evidence] Based on Grade B evidence from studies like the VALUE trial.
[WEAK recommendation] Clinicians may perform urodynamic testing in non-index patients. [EXPERT OPINION evidence] Based on expert consensus.
[WEAK recommendation] The degree of bother should be considered in patients' decisions for SUI therapy. [EXPERT OPINION evidence] Based on expert consensus.
[MODERATE recommendation] Clinicians should counsel patients regarding the availability of observation, pelvic floor muscle training, non-surgical options, and surgical intervention. [EXPERT OPINION evidence] Based on clinical principles.
[MODERATE recommendation] Clinicians should counsel patients on potential complications specific to the treatment options. [EXPERT OPINION evidence] Based on clinical principles.
[STRONG recommendation] Clinicians must discuss the specific risks and benefits of mesh and alternatives to a mesh sling. [EXPERT OPINION evidence] Based on clinical principles.
[WEAK recommendation] Clinicians may offer continence pessary, vaginal inserts, and pelvic floor muscle exercises with or without biofeedback. [EXPERT OPINION evidence] Based on expert consensus.
[STRONG recommendation] Clinicians should counsel index patients regarding the efficacy and safety of options like midurethral slings, autologous fascia pubovaginal sling, Burch colposuspension, and bulking agents. [HIGH evidence] Based on Grade A evidence from multiple RCTs.
[CONDITIONAL recommendation] Clinicians may offer retropubic, transobturator, or single-incision slings to index patients. [MODERATE evidence] Based on Grade A evidence for retropubic/transobturator and Grade B for single-incision slings.
[MODERATE recommendation] Clinicians should not place a mesh sling if the urethra is inadvertently injured. [EXPERT OPINION evidence] Based on clinical principles to avoid complications.
[WEAK recommendation] Clinicians should not offer stem cell therapy for stress incontinence outside of investigative protocols. [EXPERT OPINION evidence] Based on expert consensus due to insufficient data.
[WEAK recommendation] Clinicians may offer pubovaginal slings, retropubic midurethral slings, urethral bulking agents, or adjustable retropubic midurethral slings. [EXPERT OPINION evidence] Based on expert consensus.
[MODERATE recommendation] Clinicians should not utilize synthetic midurethral slings in patients undergoing concomitant urethral diverticulectomy, fistula repair, or mesh excision. [EXPERT OPINION evidence] Based on clinical principles to prevent complications.
[WEAK recommendation] Clinicians should strongly consider avoiding mesh in patients at risk for poor wound healing, such as after radiation therapy. [EXPERT OPINION evidence] Based on expert consensus.
[CONDITIONAL recommendation] Clinicians may perform any incontinence procedure, such as midurethral sling, pubovaginal sling, or Burch colposuspension, during concomitant pelvic prolapse repair. [LOW evidence] Based on Grade C evidence from studies like CARE and OPUS trials.
[WEAK recommendation] Clinicians may offer surgical treatment for SUI in patients with neurogenic bladder after evaluation and counseling. [EXPERT OPINION evidence] Based on expert consensus.
[WEAK recommendation] Clinicians may offer synthetic midurethral slings to populations like those planning to bear children, with diabetes, obesity, or geriatric patients after evaluation and counseling. [EXPERT OPINION evidence] Based on expert consensus.
[WEAK recommendation] Clinicians may offer an obstructing pubovaginal sling or bladder neck closure with urinary drainage after counseling. [EXPERT OPINION evidence] Based on expert consensus.
[WEAK recommendation] Clinicians should communicate with patients early postoperatively to assess for problems and see them if needed. [EXPERT OPINION evidence] Based on expert consensus.
[WEAK recommendation] Patients should be seen and examined within six months post-operatively, with additional follow-up for unfavorable outcomes. [EXPERT OPINION evidence] Based on expert consensus.
[STRONG recommendation, MODERATE evidence] [Strong recommendation] The decision should involve shared decision-making after reviewing risks and benefits, based on [Moderate evidence] from RCTs and systematic reviews.
[WEAK recommendation, EXPERT OPINION evidence] [Weak recommendation] Surgical treatment may be offered after appropriate evaluation and counseling, based on [Expert opinion].
[WEAK recommendation, EXPERT OPINION evidence] [Weak recommendation] Synthetic midurethral slings may be offered to these populations after evaluation and counseling, based on [Expert opinion].
[WEAK recommendation, EXPERT OPINION evidence] [Weak recommendation] An obstructing pubovaginal sling or bladder neck closure with urinary drainage may be offered after counseling, based on [Expert opinion].
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Clinicians should communicate early postoperatively to assess issues, and if present, patients should be seen and examined, based on [Expert opinion].
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Patients should be seen and examined within six months post-operatively, with additional follow-up if needed, based on [Expert opinion].
[Strong recommendation based on expert opinion] Clinicians should obtain a medical history, perform a physical examination, and obtain laboratory studies appropriate to procedural risk and patient comorbidities.
[Strong recommendation based on expert opinion] Yes, clinicians should obtain a urinalysis and/or urine culture prior to surgical intervention.
[Strong recommendation based on expert opinion] No, clinicians should not proceed with definitive stone surgery in patients with untreated bacteriuria/funguria.
[Conditional recommendation with low evidence] Clinicians may obtain cross-sectional imaging to guide surgical treatment selection, depending on patient circumstances.
[Moderate recommendation with low evidence] Yes, clinicians should obtain a CT prior to PCNL for surgical planning.
[Strong recommendation based on expert opinion] Yes, clinicians should assess differential renal function if there is suspicion of clinically relevant loss in the involved kidney.
[Strong recommendation with high evidence] Yes, clinicians should offer MET with alpha-adrenergic blockers for approximately 30 days to facilitate stone passage.
[Conditional recommendation with moderate evidence] Clinicians may offer MET with alpha-adrenergic blockers for approximately 30 days, but benefits are less clear compared to distal stones.
[Conditional recommendation with moderate evidence] Clinicians may offer URS or SWL, depending on patient factors and shared decision-making.
[CONDITIONAL recommendation, MODERATE evidence] [Conditional recommendation] Clinicians may offer standard or mini-PCNL for adult patients undergoing PCNL for kidney stones up to 3 cm in size. [Moderate evidence] Based on Grade B evidence.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] Clinicians should inform patients that mini-PCNL has comparable stone-free rates to standard PCNL with fewer complications, less pain, shorter hospital stay, but longer operative time. [Low evidence] Based on Grade C evidence.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Clinicians may perform PCNL in adult patients without discontinuing daily low dose aspirin. [Low evidence] Based on Grade C evidence.
[CONDITIONAL recommendation, HIGH evidence] [Conditional recommendation] Clinicians may administer systemic TXA at the time of PCNL to reduce blood loss in adult patients with no contraindications. [High evidence] Based on Grade A evidence.
[CONDITIONAL recommendation, MODERATE evidence] [Conditional recommendation] Clinicians may utilize either prone or supine positioning for adult patients undergoing PCNL. [Moderate evidence] Based on Grade B evidence.
[CONDITIONAL recommendation, MODERATE evidence] [Conditional recommendation] Clinicians may utilize intraoperative US, fluoroscopy, or combination image guidance for access during PCNL in adult patients. [Moderate evidence] Based on Grade B evidence.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Clinicians may utilize a suction sheath during mini-PCNL in adult patients to improve stone-free rates and reduce secondary procedures, when available. [Low evidence] Based on Grade C evidence.
[CONDITIONAL recommendation, HIGH evidence] [Conditional recommendation] Clinicians may omit nephrostomy tube placement after PCNL in adult patients, regardless of ureteral stent placement. [High evidence] Based on Grade A evidence.
[CONDITIONAL recommendation, EXPERT OPINION evidence] [Conditional recommendation] Clinicians may obtain a CT in the immediate/early post-operative period after PCNL to assess stone-free status and need for secondary procedures. [Expert opinion] Based on expert consensus.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Clinicians should minimize ionizing radiation during surgical stone procedures using radiation-reducing techniques in adult and pediatric patients. [Expert opinion] Based on expert consensus.
[STRONG recommendation, MODERATE evidence] [Strong recommendation] Clinicians should inform adult and pediatric patients that URS is associated with a higher stone-free rate than SWL for kidney and ureteral stones. [Moderate evidence] Based on Grade B evidence.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Clinicians may perform laparoscopic/robotic pyelolithotomy or ureterolithotomy in adult patients when endoscopic or percutaneous treatments are unavailable, unsuccessful, or limited by patient factors. [Low evidence] Based on Grade C evidence.
[CONDITIONAL recommendation, MODERATE evidence] [Conditional recommendation] Clinicians may omit pre-operative prophylactic antibiotics for adult patients undergoing SWL for kidney or ureteral stones. [Moderate evidence] Based on Grade B evidence.
[MODERATE recommendation, MODERATE evidence] [Moderate recommendation] Clinicians should administer pre-operative prophylactic antibiotics for adult patients undergoing URS and PCNL for kidney or ureteral stones. [Moderate evidence] Based on Grade B evidence.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Clinicians should obtain a complete blood count, basic metabolic panel, urinalysis, and urine culture for adult and pediatric patients with obstructing stones and suspected infection. [Expert opinion] Based on expert consensus.
[STRONG recommendation, LOW evidence] [Strong recommendation] Clinicians should initiate urgent renal drainage for adult patients with obstructing kidney and/or ureteral stones and suspected infection. [Low evidence] Based on Grade C evidence.
[CONDITIONAL recommendation, HIGH evidence] [Conditional recommendation] Clinicians may drain the collecting system with either a nephrostomy tube or ureteral stent for adult patients with obstructing kidney and/or ureteral stones and suspected infection. [High evidence] Based on Grade A evidence.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Clinicians should obtain a urine sample from the collecting system for culture, when possible, during urgent drainage for adult and pediatric patients with obstructing stones and suspected infection. [Expert opinion] Based on expert consensus.
[MODERATE recommendation, MODERATE evidence] [Moderate recommendation] Clinicians should offer concurrent URS removal of secondary, asymptomatic non-obstructing kidney stones <6 mm during the same surgical session for adult patients undergoing URS or PCNL for a primary stone. [Moderate evidence] Based on Grade B evidence.
[CONDITIONAL recommendation, MODERATE evidence] [Conditional recommendation] Clinicians may offer bilateral same-session stone treatment for adult patients with bilateral kidney and/or ureteral stones. [Moderate evidence] Based on Grade B evidence.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Clinicians should place a ureteral stent for adult and pediatric patients undergoing bilateral stone surgery or surgery in a functionally solitary kidney. [Expert opinion] Based on expert consensus.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Clinicians should not place a ureteral stent with the intention of improving stone-free rate for adult patients undergoing SWL for kidney and/or ureteral stones. [Expert opinion] Based on clinical principle.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] Clinicians should employ a slow shockwave strategy (e.g., 60 shocks per minute) to optimize stone clearance and minimize complications for adult and pediatric patients undergoing SWL. [Low evidence] Based on Grade C evidence.
[STRONG recommendation, MODERATE evidence] [Strong recommendation] Clinicians should prescribe post-operative alpha-adrenergic blockers to improve stone-free rates and reduce post-operative pain for adult patients undergoing SWL. [Moderate evidence] Based on Grade B evidence.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Clinicians may perform URS for adult patients with kidney and/or ureteral stones who have uncorrected bleeding diatheses or require continued AC/AP therapy. [Low evidence] Based on Grade C evidence.
[CONDITIONAL recommendation, EXPERT OPINION evidence] [Conditional recommendation] Clinicians may offer primary URS without prior stent placement for adult patients with kidney and/or ureteral stones. [Expert opinion] Based on expert consensus.
[CONDITIONAL recommendation, MODERATE evidence] [Conditional recommendation] Clinicians may use a UAS for adult patients undergoing URS for kidney and/or ureteral stones. [Moderate evidence] Based on Grade B evidence.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Clinicians may choose a flexible and navigable suction UAS for adult patients undergoing URS with a UAS for kidney and/or ureteral stones. [Low evidence] Based on Grade C evidence.
[CONDITIONAL recommendation, HIGH evidence] [Conditional recommendation] Clinicians may use either a single-use or reusable flexible ureteroscope for adult patients undergoing URS for kidney and/or ureteral stones. [High evidence] Based on Grade A evidence.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Clinicians may utilize either a holmium:YAG or thulium fiber laser for lithotripsy during URS in adult patients for kidney and/or ureteral stones. [Low evidence] Based on Grade C evidence.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Clinicians should utilize laser settings with the lowest total power that will accomplish clinical stone ablation for adult and pediatric patients undergoing URS with laser lithotripsy. [Expert opinion] Based on expert consensus.
[CONDITIONAL recommendation, MODERATE evidence] [Conditional recommendation] Clinicians may utilize a strategy of fragmenting and basketing or dusting for laser lithotripsy during URS in adult and pediatric patients for kidney and/or ureteral stones. [Moderate evidence] Based on Grade B evidence.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Clinicians may omit post-operative ureteral stent placement following uncomplicated URS for adult patients with kidney and/or ureteral stones. [Low evidence] Based on Grade C evidence.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Clinicians should obtain stone for analysis when possible for adult and pediatric patients undergoing surgical intervention for kidney and/or ureteral stones. [Expert opinion] Based on clinical principle.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] Clinicians should utilize a multi-modal, non-opioid analgesic regimen and minimize use of opioids for post-operative pain management in adult patients undergoing surgical intervention for kidney and/or ureteral stones. [Low evidence] Based on Grade C evidence.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Clinicians should order follow-up imaging to assess residual stone burden and identify hydronephrosis or other complications for adult and pediatric patients undergoing surgical intervention for kidney and/or ureteral stones. [Expert opinion] Based on expert consensus.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] Clinicians should offer secondary endoscopic removal of residual fragments and engage in shared decision-making for adult and pediatric patients with residual stones after surgical intervention, considering benefits and risks. [Low evidence] Based on Grade C evidence.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Clinicians should utilize US as first-line imaging for pregnant patients with suspected symptomatic kidney and/or ureteral stones; if needed, non-contrast MRI or CT are appropriate alternatives. [Expert opinion] Based on expert consensus.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Clinicians should coordinate pharmacologic and/or surgical intervention with the obstetrician for pregnant patients with symptomatic kidney and/or ureteral stones. [Expert opinion] Based on clinical principle.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Clinicians should offer observation with a trial of stone passage for pregnant patients with kidney and/or ureteral stones and well controlled symptoms. [Expert opinion] Based on clinical principle.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Clinicians may offer URS for pregnant patients with ureteral stones when trial of passage is unsuccessful or not feasible; alternatively, placement of a ureteral stent or nephrostomy tube with frequent changes may be offered. [Low evidence] Based on Grade C evidence.
[MODERATE recommendation, MODERATE evidence] [Moderate recommendation] Ureteral stenting is preferred over nephrostomy tubes due to lower associated risks of urinary tract infections, inpatient hospitalization, emergency department visits, and preterm birth. [Moderate evidence] This is based on large retrospective cohort studies with propensity score matching.
[WEAK recommendation, HIGH evidence] [Weak recommendation] Medical expulsive therapy may be considered to reduce the rate of surgical intervention in patients with ureteral stones, but its overall benefit-risk balance is uncertain. [High evidence] This is supported by a meta-analysis of multiple randomized controlled trials.
[MODERATE recommendation, HIGH evidence] [Moderate recommendation based on high evidence] Tamsulosin is probably effective for facilitating the expulsion of distal ureteral stones, supported by multiple randomized controlled trials.
[CONDITIONAL recommendation, MODERATE evidence] [Conditional recommendation based on moderate evidence] Ureteroscopy may be considered safe for pregnant patients with urolithiasis, depending on individual circumstances, as supported by a systematic review and meta-analysis.
[WEAK recommendation, MODERATE evidence] [Weak recommendation based on moderate evidence] Either ureteroscopic lithotripsy or extracorporeal shock wave lithotripsy may be considered for proximal ureteral stones, as evidence from randomized trials shows comparable efficacy, but optimal choice depends on individual patient and stone characteristics.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] A solid mass in the testis should be managed as a malignant neoplasm until proven otherwise, based on [Expert opinion] clinical principle.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] Serum tumor markers (AFP, hCG, and LDH) should be drawn and measured prior to any treatment, including orchiectomy, based on [Low evidence] Grade C evidence.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] Patients should be counseled about risks of hypogonadism and infertility and offered sperm banking when appropriate, based on [Low evidence] Grade C evidence and [Expert opinion] clinical principle for specific subgroups.
[STRONG recommendation, MODERATE evidence] [Strong recommendation] Scrotal ultrasound with Doppler should be obtained in patients with a unilateral or bilateral scrotal mass suspicious for neoplasm, based on [Moderate evidence] Grade B evidence.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] Testicular microlithiasis in the absence of solid mass and risk factors does not confer increased cancer risk and does not require further evaluation, based on [Low evidence] Grade C evidence.
[Strong recommendation] Clinicians should recommend risk-appropriate, multi-agent chemotherapy for these patients, based on moderate evidence.
[Moderate recommendation] Surveillance is recommended, with RPLND or one cycle of BEP chemotherapy as alternatives for selected patients, based on moderate evidence.
[Strong recommendation] Clinicians should recommend surveillance, RPLND, or one/two cycles of BEP chemotherapy based on shared decision-making, based on moderate evidence.
[Strong recommendation] Patients should undergo RPLND, based on expert opinion.
[Moderate recommendation] RPLND or chemotherapy should be recommended, based on moderate evidence.
[Moderate recommendation] Risk-appropriate, multi-agent chemotherapy should be recommended, based on moderate evidence.
[Conditional recommendation] RPLND may be offered as an alternative to chemotherapy for select patients, based on low evidence.
[Moderate recommendation] Referral to an experienced surgeon at a high-volume center should be considered, based on low evidence.
[Weak recommendation] Minimally-invasive RPLND may be offered by experienced surgeons, based on expert opinion and limited evidence.
[Moderate recommendation] Primary RPLND should be performed with curative intent and adherence to anatomical principles, based on moderate evidence.
[Moderate recommendation] Surveillance or adjuvant chemotherapy should be recommended, based on moderate evidence.
[Strong recommendation] History/physical and abdominal imaging every 6 months for 2 years, then 6-12 months for years 3-5, with chest imaging and markers as needed, based on moderate evidence.
[Moderate recommendation] Physical exam and serum tumor markers at specified intervals, based on low evidence.
[Moderate recommendation] Radiologic assessment at specified intervals, based on moderate evidence.
[Strong recommendation] Shorter imaging intervals should be used for men at higher risk of relapse, based on expert opinion.
[Moderate recommendation] Full restaging and treatment based on TNM-s status should be performed, based on low evidence.
[Moderate recommendation] Patients should be informed of the ≤1% risk of late relapse after 5 years, based on moderate evidence.
[Weak recommendation] Annual serologic and radiographic assessment may be performed as indicated, based on expert opinion (clinical principle).
[Strong recommendation] Patients should be referred to survivorship clinics for long-term monitoring, based on expert opinion.
[Moderate recommendation] A total testosterone level below 300 ng/dL is recommended as a cut-off for diagnosing low testosterone. [Moderate evidence] This is based on moderate certainty evidence.
[Strong recommendation] The diagnosis should be made only after two total testosterone measurements taken on separate early morning occasions. [High evidence] This is based on high certainty evidence.
[Moderate recommendation] The diagnosis requires both low total testosterone levels and associated symptoms/signs. [Moderate evidence] Based on moderate certainty evidence.
[Moderate recommendation] Consider measuring total testosterone in patients with specific histories like anemia, diabetes, etc., even if asymptomatic. [Moderate evidence] Based on moderate certainty evidence.
[Conditional recommendation] Validated questionnaires are not currently recommended for candidate selection or monitoring. [Low evidence] Based on low certainty evidence.
[Strong recommendation] Measure serum luteinizing hormone levels in patients with low testosterone. [High evidence] Based on high certainty evidence.
[Strong recommendation] Measure serum prolactin in patients with low testosterone and low/normal LH levels. [High evidence] Based on high certainty evidence.
[Strong recommendation] Evaluate for endocrine disorders in such patients. [High evidence] Based on high certainty evidence.
[Strong recommendation] Yes, measure serum estradiol in testosterone deficient patients with breast symptoms or gynecomastia before therapy. [Expert opinion] Based on expert consensus.
[Moderate recommendation] Perform a reproductive health evaluation before treatment. [Moderate evidence] Based on moderate certainty evidence.
[Strong recommendation] Measure hemoglobin and hematocrit and inform patients about polycythemia risk before therapy. [High evidence] Based on high certainty evidence.
[Strong recommendation] Yes, measure PSA in men over 40 years old before therapy to exclude prostate cancer. [Expert opinion] Based on clinical principle and consensus.
[Strong recommendation] Inform patients that low testosterone is a risk factor for cardiovascular disease. [Moderate evidence] Based on moderate certainty evidence.
[Moderate recommendation] Inform patients that therapy may improve erectile function, sex drive, anemia, bone density, lean mass, and depressive symptoms. [Moderate evidence] Based on moderate certainty evidence.
[Strong recommendation] Discuss the long-term impact on spermatogenesis with patients interested in future fertility. [High evidence] Based on high certainty evidence.
[Strong recommendation] Inform patients that there is no evidence linking testosterone therapy to prostate cancer development. [Moderate evidence] Based on moderate certainty evidence.
[Strong recommendation] Inform them that there is inadequate evidence to quantify the risk-benefit ratio of therapy. [Expert opinion] Based on expert consensus.
[Moderate recommendation] Counsel patients that it is unclear whether therapy increases or decreases cardiovascular event risk. [Moderate evidence] Based on moderate certainty evidence.
[Conditional recommendation] Yes, counsel all men with testosterone deficiency about lifestyle modifications. [Moderate evidence] Based on moderate certainty evidence.
[Conditional recommendation] Adjust dosing to achieve total testosterone in the middle tertile of the normal range. [Low evidence] Based on low certainty evidence.
[Strong recommendation] No, exogenous testosterone therapy should not be prescribed to men currently trying to conceive. [High evidence] Based on high certainty evidence.
[Strong recommendation] Do not commence therapy for three to six months in such patients. [Expert opinion] Based on expert consensus.
[Moderate recommendation] No, clinicians should not prescribe alkylated oral testosterone. [Moderate evidence] Based on moderate certainty evidence.
[Strong recommendation] Discuss the risk of transference. [High evidence] Based on high certainty evidence.
[Conditional recommendation] Aromatase inhibitors, hCG, SERMs, or combinations may be used. [Low evidence] Based on low certainty evidence.
[Conditional recommendation] Prescribe commercially manufactured products over compounded testosterone when possible. [Low evidence] Based on low certainty evidence.
[Strong recommendation] Measure an initial follow-up total testosterone level after an appropriate interval to ensure target levels are achieved. [Expert opinion] Based on expert consensus.
[Strong recommendation] Measure testosterone levels every 6-12 months while on therapy. [Expert opinion] Based on expert consensus.
[Strong recommendation] Discuss cessation 3-6 months after starting if testosterone normalizes but symptoms don't improve. [Expert opinion] Based on clinical principle.
[Moderate recommendation] Patients should be informed that the evidence is inconclusive for testosterone therapy improving cognitive function, measures of diabetes, energy, fatigue, lipid profiles, and quality of life. [Moderate evidence] Based on Grade B evidence.
[Strong recommendation] The long-term impact of exogenous testosterone on spermatogenesis should be discussed with patients who are interested in future fertility. [High evidence] Based on Grade A evidence.
[Strong recommendation] Clinicians should inform patients of the absence of evidence linking testosterone therapy to the development of prostate cancer. [Moderate evidence] Based on Grade B evidence.
[Conditional recommendation] Patients with testosterone deficiency and a history of prostate cancer should be informed that there is inadequate evidence to quantify the risk-benefit ratio of testosterone therapy. [Expert opinion] Based on expert consensus.
[Conditional recommendation] All men with testosterone deficiency should be counseled regarding lifestyle modifications as a treatment strategy. [Moderate evidence] Based on Grade B evidence.
[Conditional recommendation] Clinicians should adjust testosterone therapy dosing to achieve a total testosterone level in the middle tertile of the normal reference range. [Low evidence] Based on Grade C evidence.
[Strong recommendation] Exogenous testosterone therapy should not be prescribed to men who are currently trying to conceive. [High evidence] Based on Grade A evidence.
[Conditional recommendation] Testosterone therapy should not be commenced for a period of three to six months in patients with a history of cardiovascular events. [Expert opinion] Based on expert consensus.
[Moderate recommendation] Clinicians should not prescribe alkylated oral testosterone. [Moderate evidence] Based on Grade B evidence.
[Strong recommendation] Clinicians should discuss the risk of transference with patients using testosterone gels/creams. [High evidence] Based on Grade A evidence.
[Conditional recommendation] Clinicians may use aromatase inhibitors, human chorionic gonadotropin, selective estrogen receptor modulators, or a combination thereof in men with testosterone deficiency desiring to maintain fertility. [Low evidence] Based on Grade C evidence.
[Conditional recommendation] Commercially manufactured testosterone products should be prescribed rather than compounded testosterone, when possible. [Low evidence] Based on Grade C evidence.
[Conditional recommendation] Clinicians should measure an initial follow-up total testosterone level after an appropriate interval to ensure that target testosterone levels have been achieved. [Expert opinion] Based on expert consensus.
[Conditional recommendation] Testosterone levels should be measured every 6-12 months while on testosterone therapy. [Expert opinion] Based on expert consensus.
[Conditional recommendation] Clinicians should discuss the cessation of testosterone therapy three to six months after commencement in patients who experience normalization of total testosterone levels but fail to achieve symptom or sign improvement. [Expert opinion] Based on clinical principles.
[Strong recommendation] Measure prolactin level. [Expert Opinion] Based on AUA guideline consensus.
[Strong recommendation] Perform a semen analysis. [Expert Opinion] Based on AUA guideline consensus.
[Strong recommendation] Refer to a primary care clinician, internist, or endocrinologist for further evaluation and management. [Expert Opinion] Based on AUA guideline consensus.
[Strong recommendation] Repeat the prolactin level measurement to rule out a spurious elevation. [Expert Opinion] Based on AUA guideline consensus.
[Moderate recommendation] Consider referral to an endocrinologist. [Expert Opinion] Based on AUA guideline consensus.
[Strong recommendation] Refer to an endocrinologist. [Expert Opinion] Based on AUA guideline consensus.
[Moderate recommendation] Consider a period of monitoring, as symptoms may resolve spontaneously. [Expert Opinion] Based on AUA guideline consensus.
[Conditional recommendation] Depending on on-treatment testosterone levels: if in upper normal range, adjust testosterone dose; if low/normal, use aromatase inhibitors (AIs). [Expert Opinion] Based on AUA guideline consensus.
[Strong recommendation] Withhold testosterone therapy until the cause of high Hct is identified and managed. [Expert Opinion] Based on AUA guideline consensus.
[Strong recommendation] Yes, all patients should undergo baseline assessment of hemoglobin and hematocrit prior to initiation of testosterone therapy. [Expert opinion evidence] Based on expert consensus from the AUA guideline.
[Strong recommendation] Testosterone therapy should be withheld until the etiology of the high hematocrit is explained, considering factors like polycythemia vera or lifestyle. [Expert opinion evidence] Based on expert consensus.
[Strong recommendation] Intervention is warranted for hematocrit ≥54% while on testosterone therapy. [Expert opinion evidence] Based on expert consensus.
[Strong recommendation] Dose adjustment should be attempted as first-line management for high on-treatment testosterone levels. [Expert opinion evidence] Based on expert consensus.
[Moderate recommendation] Measuring SHBG and free testosterone levels using a reliable assay like equilibrium dialysis is suggested for men with low-normal on-treatment testosterone levels. [Expert opinion evidence] Based on expert consensus.
[Moderate recommendation] Dose adjustment of testosterone therapy should be considered if SHBG levels are low or free testosterone levels are high. [Expert opinion evidence] Based on expert consensus.
[Strong recommendation] These men should be referred to a hematologist for further evaluation. [Expert opinion evidence] Based on expert consensus.
[Strong recommendation] A pituitary MRI is warranted in men with sustained elevated prolactin levels, very low total testosterone (<150 ng/dL), and unexplained failure to produce LH/FSH. [Expert opinion evidence] Based on expert consensus.
[Conditional recommendation] Clinicians may decide to refer patients to an endocrinologist before ordering an MRI or order the MRI first and refer only for abnormalities, depending on their experience and patient factors. [Expert opinion evidence] Based on expert consensus.
[Conditional recommendation] For clinicians experienced in managing prolactinomas, bromocriptine or cabergoline may be prescribed without endocrinology input. [Expert opinion evidence] Based on expert consensus.
[Moderate recommendation] Consideration of a baseline DEXA scan is warranted, particularly in middle-aged or older men with severe testosterone deficiency or a history of low trauma bone fracture. [Expert opinion evidence] Based on expert consensus.
[Strong recommendation] Patients with osteoporosis should be referred to an endocrinologist. [Expert opinion evidence] Based on expert consensus.
[Moderate recommendation] A karyotype should be considered in men with unexplained hypergonadotropic hypogonadism. [Expert opinion evidence] Based on expert consensus.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Clinicians should assess medical, relational, and sexual history, and perform a focused physical exam for patients with premature ejaculation. [Expert opinion] Based on clinical principle.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Clinicians may use validated instruments to aid in the diagnosis of premature ejaculation. [Low evidence] Based on evidence grade C.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Clinicians should not use additional tests to evaluate patients with lifelong premature ejaculation. [Low evidence] Based on evidence grade C.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Clinicians may perform additional tests as clinically indicated for the evaluation of patients with acquired premature ejaculation. [Low evidence] Based on evidence grade C.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Clinicians should inform patients that ejaculatory latency is not affected by being circumcised. [Low evidence] Based on evidence grade C.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] Clinicians should consider referring men with premature ejaculation to a mental health professional with expertise in sexual health. [Low evidence] Based on evidence grade C.
[STRONG recommendation, MODERATE evidence] [Strong recommendation] Clinicians should recommend daily selective serotonin reuptake inhibitors (SSRIs), on-demand clomipramine or dapoxetine (where available), and topical penile anesthetics as first-line pharmacotherapy for premature ejaculation. [Moderate evidence] Based on evidence grade B.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Clinicians may consider tramadol for the treatment of premature ejaculation in men who have not responded to first-line pharmacotherapy. [Low evidence] Based on evidence grade C.
[WEAK recommendation, EXPERT OPINION evidence] [Weak recommendation] Clinicians may consider alpha-1 adrenoreceptor antagonists for men with premature ejaculation who have not responded to first-line treatment. [Expert opinion] Based on expert consensus.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Clinicians should treat erectile dysfunction as a comorbidity in patients with premature ejaculation, in accordance with AUA guidelines on erectile dysfunction. [Expert opinion] Based on expert consensus.
[MODERATE recommendation, MODERATE evidence] [Moderate recommendation] Clinicians should advise men with premature ejaculation that a combination of behavioral and pharmacological approaches may be more effective than either modality alone. [Moderate evidence] Based on evidence grade B.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Clinicians should notify patients that there is insufficient evidence to support the use of alternative therapies for the treatment of premature ejaculation. [Expert opinion] Based on expert consensus.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Clinicians should inform patients that surgical management for premature ejaculation should be considered experimental and used only in the context of a clinical trial with ethical approval. [Expert opinion] Based on expert consensus.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Clinicians should assess medical, relational, and sexual history, and perform a focused physical exam for patients with delayed ejaculation. [Expert opinion] Based on clinical principle.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Clinicians may perform additional tests as indicated for the evaluation of delayed ejaculation. [Low evidence] Based on evidence grade C.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should consider referring men diagnosed with lifelong or acquired delayed ejaculation to a mental health professional with expertise in sexual health. [Expert opinion] Based on expert consensus.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Clinicians should recommend to men with delayed ejaculation the modification of sexual positions or practices to increase arousal. [Expert opinion] Based on expert consensus.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Clinicians should suggest the substitution, dose adjustment, or gradual discontinuation of medications that may contribute to delayed ejaculation. [Expert opinion] Based on clinical principle.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Clinicians should inform patients that there is insufficient evidence to evaluate the risk-benefit ratio of oral pharmacotherapy for the management of delayed ejaculation. [Expert opinion] Based on expert consensus.
[WEAK recommendation, EXPERT OPINION evidence] [Weak recommendation] Clinicians may offer treatment to normalize serum testosterone levels in patients with delayed ejaculation and testosterone deficiency. [Expert opinion] Based on expert consensus.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Clinicians should treat men with delayed ejaculation and comorbid erectile dysfunction in accordance with AUA guidelines on erectile dysfunction. [Expert opinion] Based on expert consensus.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Clinicians should notify patients with delayed ejaculation that there are currently no data indicating benefit from invasive non-pharmacological strategies. [Expert opinion] Based on expert consensus.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] Clinicians should consider referring men diagnosed with premature ejaculation to a mental health professional with experience in premature ejaculation. [Low evidence] Based on Grade C evidence from observational studies or limited clinical data.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Clinicians could consider on-demand dosing or tramadol for the treatment of premature ejaculation in men who have failed first-line pharmacotherapy. [Low evidence] Based on Grade C evidence from observational studies or limited clinical trials.
[CONDITIONAL recommendation, EXPERT OPINION evidence] [Conditional recommendation] Clinicians could consider treating men with premature ejaculation who have failed first-line therapy with alpha-1 adrenergic antagonists. [Expert opinion] Based on expert consensus without direct high-quality evidence.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should treat erectile dysfunction as a comorbidity in patients with premature ejaculation, according to the AUA guidelines on erectile dysfunction. [Expert opinion] Based on expert consensus without direct high-quality evidence.
[MODERATE recommendation, MODERATE evidence] [Moderate recommendation] Clinicians should inform men with premature ejaculation that combining behavioral and pharmacological approaches may be more effective than either modality alone. [Moderate evidence] Based on Grade B evidence from randomized controlled trials or systematic reviews.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should inform patients that there is insufficient evidence to support the use of alternative therapies for the treatment of premature ejaculation. [Expert opinion] Based on expert consensus without direct high-quality evidence.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should inform patients that surgical management (including volume-enhancing injections) for premature ejaculation should be considered experimental and only used in the context of an ethics board-approved clinical trial. [Expert opinion] Based on expert consensus without direct high-quality evidence.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should evaluate the medical, relationship, and sexual history, and perform a focused physical exam to assess a patient with delayed ejaculation. [Expert opinion] Based on clinical principles and expert consensus.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Clinicians could use additional tests as clinically indicated for the assessment of delayed ejaculation. [Low evidence] Based on Grade C evidence from observational studies or limited data.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should consider the possibility of referring men diagnosed with lifelong or acquired delayed ejaculation to a mental health professional with experience in sexual health. [Expert opinion] Based on expert consensus without direct high-quality evidence.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should inform men with delayed ejaculation that it may be beneficial to modify positions or sexual practices to increase arousal. [Expert opinion] Based on expert consensus without direct high-quality evidence.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should suggest the substitution, dose adjustment, or discontinuation of medications that may contribute to delayed ejaculation. [Expert opinion] Based on clinical principles and expert consensus.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should inform patients that there is insufficient evidence to assess the risk-benefit of oral pharmacotherapy for the management of delayed ejaculation. [Expert opinion] Based on expert consensus without direct high-quality evidence.
[CONDITIONAL recommendation, EXPERT OPINION evidence] [Conditional recommendation] Clinicians can offer treatment to normalize serum testosterone levels in patients with delayed ejaculation and testosterone deficiency. [Expert opinion] Based on expert consensus without direct high-quality evidence.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should treat men with delayed ejaculation and comorbid erectile dysfunction according to the AUA guidelines on erectile dysfunction. [Expert opinion] Based on expert consensus without direct high-quality evidence.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should inform patients with delayed ejaculation that there are currently no data indicating that invasive, non-pharmacological strategies are beneficial. [Expert opinion] Based on expert consensus without direct high-quality evidence.
[MODERATE recommendation] Yes, clinicians should include urethral stricture in the differential diagnosis for patients presenting with decreased urinary stream, incomplete emptying, dysuria, UTI, or rising PVR. [LOW evidence] Based on low quality evidence.
[WEAK recommendation] Clinicians may use a combination of patient reported measures, uroflowmetry, and ultrasound PVR assessment. [EXPERT OPINION] Based on clinical principle and expert consensus.
[MODERATE recommendation] Clinicians should use urethro-cystoscopy, retrograde urethrography, voiding cystourethrography, or ultrasound urethrography. [LOW evidence] Based on low quality evidence.
[MODERATE recommendation] Yes, clinicians should determine the length and location of the urethral stricture. [EXPERT OPINION] Based on expert consensus.
[WEAK recommendation] Surgeons may utilize urethral endoscopic management or immediate suprapubic cystostomy. [EXPERT OPINION] Based on expert consensus.
[CONDITIONAL recommendation] Surgeons may place a suprapubic cystostomy to promote urethral rest in specific patients. [LOW evidence] Based on low quality evidence.
[CONDITIONAL recommendation] Surgeons may offer urethral dilation, direct visual internal urethrotomy, or urethroplasty. [LOW evidence] Based on low quality evidence.
[CONDITIONAL recommendation] Yes, surgeons may perform either dilation or direct visual internal urethrotomy. [LOW evidence] Based on low quality evidence.
[CONDITIONAL recommendation] Surgeons may safely remove the urethral catheter within 72 hours. [LOW evidence] Based on low quality evidence.
[CONDITIONAL recommendation] Yes, clinicians may recommend self-catheterization to maintain patency. [LOW evidence] Based on low quality evidence.
[MODERATE recommendation] Surgeons should offer urethroplasty instead of repeated endoscopic management. [LOW evidence] Based on low quality evidence.
[CONDITIONAL recommendation] Surgeons may offer urethral dilation or urethrotomy combined with drug-coated balloons for strictures <3cm. [MODERATE evidence] Based on moderate quality evidence.
[MODERATE recommendation] Yes, surgeons should refer patients to experts. [EXPERT OPINION] Based on expert consensus.
[WEAK recommendation] Surgeons may initially treat with dilation or meatotomy. [EXPERT OPINION] Based on clinical principle.
[MODERATE recommendation] Surgeons should offer urethroplasty. [LOW evidence] Based on low quality evidence.
[MODERATE recommendation] Surgeons should offer urethroplasty due to high recurrence with endoscopic treatments. [LOW evidence] Based on low quality evidence.
[MODERATE recommendation] Surgeons should offer urethroplasty as the initial treatment. [LOW evidence] Based on low quality evidence.
[MODERATE recommendation] Surgeons may reconstruct using one-stage or multi-stage techniques with oral mucosal grafts, penile fasciocutaneous flaps, or combinations. [LOW evidence] Based on low quality evidence.
[CONDITIONAL recommendation] Surgeons may offer perineal urethrostomy as a long-term alternative. [LOW evidence] Based on low quality evidence.
[MODERATE recommendation] Yes, surgeons should offer perineal urethrostomy as an alternative in high-risk populations. [EXPERT OPINION] Based on expert consensus.
[MODERATE recommendation] Surgeons should use oral mucosa as the first choice. [EXPERT OPINION] Based on expert consensus.
[STRONG recommendation] Yes, surgeons may use either buccal or lingual mucosal grafts as equivalent alternatives. [HIGH evidence] Based on high quality evidence.
[MODERATE recommendation] Surgeons should not perform substitution urethroplasty with allograft, xenograft, or synthetic materials except in experimental settings. [EXPERT OPINION] Based on expert consensus.
[MODERATE recommendation] No, surgeons should not perform a single stage tubularized graft urethroplasty. [EXPERT OPINION] Based on expert consensus.
[MODERATE recommendation] No, surgeons should not use hair-bearing skin. [EXPERT OPINION] Based on clinical principle.
[MODERATE recommendation] Clinicians should use retrograde urethrography with voiding cystourethrogram and/or retrograde + antegrade cystoscopy. [LOW evidence] Based on low quality evidence.
[MODERATE recommendation] Surgeons should perform delayed urethroplasty instead of delayed endoscopic procedures. [EXPERT OPINION] Based on expert consensus.
[MODERATE recommendation] Definitive reconstruction should be planned only after major injuries stabilize and safe positioning is possible. [EXPERT OPINION] Based on expert consensus.
[MODERATE recommendation] Surgeons may reconstruct using oral mucosal grafts, vaginal flaps, or combinations. [LOW evidence] Based on low quality evidence.
[WEAK recommendation] Surgeons may perform dilation, bladder neck incision, or transurethral resection. [EXPERT OPINION] Based on expert consensus.
[CONDITIONAL recommendation] Surgeons may perform dilation, vesicourethral incision, or transurethral resection. [LOW evidence] Based on low quality evidence.
[CONDITIONAL recommendation] Surgeons may perform robotic or open reconstruction. [LOW evidence] Based on low quality evidence.
[WEAK recommendation] Surgeons may offer urethroplasty as a treatment option. [EXPERT OPINION] Based on expert consensus.
[MODERATE recommendation] Clinicians may perform biopsy for suspected lichen sclerosus and must perform biopsy if urethral cancer is suspected. [EXPERT OPINION] Based on clinical principle.
[STRONG recommendation] No, surgeons should not use genital skin for reconstruction. [MODERATE evidence] Based on moderate quality evidence.
[MODERATE recommendation] Yes, clinicians should monitor patients to identify symptomatic recurrence. [EXPERT OPINION] Based on expert consensus.
[STRONG recommendation, MODERATE evidence] [Strong recommendation] A cystoscopy and cross-sectional imaging with contrast, including delayed images of the collecting system and ureter, should be performed. [Moderate evidence] This is based on Grade B evidence.
[STRONG recommendation, LOW evidence] [Strong recommendation] Diagnostic ureteroscopy with biopsy of lesions and cytologic washing should be performed. [Low evidence] This is based on Grade C evidence.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Lower tract tumors should be managed in the same setting as ureteroscopy. [Expert opinion] This is based on expert consensus.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Use gentle dilation techniques like temporary stenting and limit aggressive techniques such as ureteral access sheaths. [Expert opinion] This is based on expert consensus.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Selective upper tract washing or barbotage for cytology may be attempted, and pyeloureterography performed if good quality imaging is unavailable. [Low evidence] This is based on Grade C evidence.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Ureteroscopic inspection of a radiographically and clinically normal contralateral upper tract should not be performed. [Expert opinion] This is based on expert consensus.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Obtain a personal and family history to identify Lynch Syndrome risk factors and offer referral for genetic counseling. [Expert opinion] This is based on expert consensus.
[STRONG recommendation, MODERATE evidence] [Strong recommendation] Universal histologic testing with IHC or MSI should be performed to identify patients for genetic counseling and germline testing. [Moderate evidence] This is based on Grade B evidence.
[STRONG recommendation, MODERATE evidence] [Strong recommendation] Perform a standardized assessment documenting endoscopic and radiographic features for staging and risk assessment. [Moderate evidence] This is based on Grade B evidence.
[STRONG recommendation, MODERATE evidence] [Strong recommendation] Risk-stratify patients as low- or high-risk for invasive disease based on endoscopic, cytologic, pathologic, and radiographic findings, with further stratification into favorable/unfavorable groups. [Moderate evidence] This is based on Grade B evidence.
[Conditional recommendation] Distal ureterectomy and ureteral reimplantation is the preferred treatment for these patients. [Expert opinion] Based on consensus without direct evidence.
[Strong recommendation] The entire distal ureter including the intramural tunnel and orifice should be excised, and the urinary tract should be closed watertight. [Moderate evidence] Based on observational studies.
[Strong recommendation] A single dose of perioperative intravesical chemotherapy should be administered to eligible patients to reduce bladder recurrence risk. [High evidence] Based on multiple prospective RCTs.
[Conditional recommendation] Clinicians may perform LND at the time of NU or ureterectomy for LR UTUC. [Low evidence] Based on limited observational studies.
[Strong recommendation] Clinicians should perform LND at the time of NU or ureterectomy for HR UTUC. [Moderate evidence] Based on non-randomized studies suggesting oncologic benefit.
[Strong recommendation] Clinicians should offer cisplatin-based NAC to patients with HR UTUC undergoing RNU or ureterectomy, especially if post-operative renal function is compromised. [Moderate evidence] Based on meta-analyses and phase II trials.
[Strong recommendation] Clinicians should offer platinum-based adjuvant chemotherapy to patients with advanced UTUC after RNU or ureterectomy who have not received NAC. [High evidence] Based on the randomized phase III POUT trial.
[Conditional recommendation] Adjuvant nivolumab therapy may be offered to patients with HR UTUC after NAC or those ineligible for cisplatin. [Moderate evidence] Based on the CheckMate 274 RCT.
[Conditional recommendation] RNU or ureterectomy should not be offered as initial therapy for metastatic UTUC. [Expert opinion] Based on consensus due to lack of evidence and potential harms.
[Conditional recommendation] Patients should initially be treated with systemic therapy, and consolidative surgery may be performed if they have a partial or complete response. [Expert opinion] Based on consensus from observational data.
[Moderate recommendation] Intravesical chemotherapy, such as mitomycin C or pirarubicin, is recommended after radical nephroureterectomy to reduce bladder recurrence in patients with UTUC. [High evidence] This is supported by randomized clinical trials including the ODMIT-C and THP trials, and systematic reviews.
[Strong recommendation] Adjuvant chemotherapy is recommended for patients with UTUC after surgery to improve survival outcomes. [High evidence] This is supported by the POUT trial, a phase 3 randomized controlled trial.
[Conditional recommendation] Lymph node dissection may be considered during nephroureterectomy for UTUC, particularly in patients with high-risk features or advanced stages. [Moderate evidence] This is based on meta-analyses and systematic reviews evaluating survival outcomes.
[Moderate recommendation] Neoadjuvant chemotherapy may be considered for patients with high-grade UTUC to potentially improve surgical outcomes and survival. [Moderate evidence] This is supported by systematic reviews, meta-analyses, and phase 2 trials.
[Moderate recommendation] Postoperative surveillance, including regular imaging and cystoscopy, is recommended for patients with UTUC to monitor for recurrence. [Low evidence] This is based on guideline consensus and observational studies.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should provide pre-operative consultation for patients considering vasectomy. [Expert opinion] This is based on clinical principles widely agreed upon by urologists.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Consultation may be accomplished virtually or in person. [Low evidence] Based on Grade C evidence with low certainty.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Clinicians should counsel patients that vasectomy is a safe and effective means of permanent contraception. [Low evidence] Based on Grade C evidence with low certainty.
[CONDITIONAL recommendation, MODERATE evidence] [Conditional recommendation] Clinicians may inform patients that no causal link has been established between vasectomy and prostate cancer. [Moderate evidence] Based on Grade B evidence with moderate certainty.
[WEAK recommendation, EXPERT OPINION evidence] [Weak recommendation] Clinicians may forego peri-procedural antibiotics for patients undergoing vasectomy unless at high risk of infection. [Expert opinion] Based on consensus of experts.
[STRONG recommendation, MODERATE evidence] [Strong recommendation] Surgeons should perform vasectomy with an occlusive technique that combines mucosal cautery and fascial interposition. [Moderate evidence] Based on Grade B evidence with moderate certainty.
[STRONG recommendation, HIGH evidence] [Strong recommendation] Surgeons should not perform vas occlusion using only ligation and excision of a short vas segment. [High evidence] Based on Grade A evidence with high certainty.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] Patients should provide at least one appropriately collected semen sample following vasectomy to confirm occlusive success. [Low evidence] Based on Grade C evidence with low certainty.
[STRONG recommendation, MODERATE evidence] [Strong recommendation] Surgeons should evaluate vasal fluid microscopically at the time of vasectomy reversal as it is the best intraoperative predictor of patency. [Moderate evidence] Based on Grade B evidence with moderate certainty.