Guidelines

Renal Cell Carcinoma

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2. METHODS

2.1. Data identification

For the 2023 Guidelines, new and relevant evidence has been identified, collated and appraised through a structured assessment of the literature. A broad and comprehensive scoping search was performed, which was limited to studies representing high certainty of evidence (i.e., systematic reviews with or without meta-analysis, randomised controlled trials (RCTs), and prospective non-randomised comparative studies only for therapeutic interventions, and systematic reviews and prospective studies with well-defined reference standards for diagnostic accuracy studies) published in the English language. In case no higher level data exists for a particular topic, lower level evidence was considered for inclusion. The search was restricted to articles published between May 28th, 2021 and May 24th, 2022. Databases covered included Medline, EMBASE, and the Cochrane Library. After de-duplication, a total of 1,810 unique records were identified, retrieved and screened for relevance.

A total of 59 new references have been included in the 2023 RCC Guidelines publication. A search strategy is published online: https://uroweb.org/guidelines/renal-cell-carcinoma/publications-appendices.

For each recommendation within the guidelines there is an accompanying online strength rating form which includes the assessment of the benefit to harms ratio and patients‘ preferences for each recommendation. The strength rating forms draws on the guiding principles of the GRADE methodology but do not purport to be GRADE [2,3]. Each strength rating form addresses a number of key elements, namely:

  1. the overall quality of the evidence which exists for the recommendation; references used in this text are graded according to a classification system modified from the Oxford Centre for Evidence-Based Medicine Levels of Evidence [4];
  2. the magnitude of the effect (individual or combined effects);
  3. the certainty of the results (precision, consistency, heterogeneity and other statistical or study-related factors);
  4. the balance between desirable and undesirable outcomes;
  5. the impact of patient values and preferences on the intervention;
  6. the certainty of those patient values and preferences.

These key elements are the basis which panels use to define the strength rating of each recommendation.

The strength of each recommendation is represented by the words ‘strong’ or ‘weak’ [5]. The strength of each recommendation is determined by the balance between desirable and undesirable consequences of alternative management strategies, the quality of the evidence (including certainty of estimates), and nature and variability of patient values and preferences.

Specific chapters were updated by way of systematic reviews, commissioned and undertaken by the Panel, based on prioritised topics or questions. These reviews were performed using standard Cochrane systematic review methodology: https://www.cochranelibrary.com/about/about-cochrane-reviews.

Additional methodology information can be found in the general Methodology section of this print, and online at the EAU website: http://uroweb.org/guidelines/. A list of Associations endorsing the EAU Guidelines can also be viewed online at the above address.

2.2. Review

All publications ensuing from systematic reviews have been peer reviewed. The 2021 print of the RCC Guidelines was peer-reviewed prior to publication.

2.3. Future goals

The RCC Guideline Panel supports the focus on patient-reported outcomes as well as the development of clinical quality indicators. A number of key quality indicators for this patient group have been selected:

  • the proportion of patients undergoing thorax computed tomography (CT) for staging of pulmonary metastasis;
  • proportion of patients with T1aN0M0 tumours undergoing nephron-sparing surgery (NSS) as first treatment;
  • the proportion of patients with metastatic RCC (mRCC) offered systemic therapy;
  • the proportion of patients who undergo minimally invasive or operative treatment as first treatment who die within 30 days.

The Panel have set up a database to investigate current practice in follow-up of RCC patients in a number of European centres. Assessing patterns of recurrence and use of imaging techniques are primary outcomes for this project.

The results of ongoing and new systematic reviews will be included in future updates of the RCC Guidelines:

  • What is the best treatment option for > T2 tumours?
  • Adjuvant targeted therapy for RCC at high risk for recurrence;
  • Systematic review of prevalence of intraperitoneal recurrences following robotic/laparoscopic partial nephrectomy;
  • Systematic review of individual, unit and hospital surgical volume for radical and partial nephrectomy and their impact on outcomes;
  • RECUR database analysis of recurrent disease/follow-up.