Reply to Meny Lv, Xufei Luo, and Yaolong Chen’s Letter to the Editor re: Mauro Gacci, Vasileios I. Sakalis, Markos Karavitakis, et al. European Association of Urology Guidelines on Male Urinary Incontinence. Eur Urol. In press. https://doi.org/10.1016/j.eururo.2022.05.012

We would like to thank Dr. Lv and colleagues for their measured feedback on our recent publication [1]. The development and publication of a practical, evidence-based guideline comprising definitions, pathophysiology, diagnostic workup, and treatment options for men with different forms of urinary incontinence will aid clinicians in their daily practice. However, it must be emphasised that clinical guidelines present the best evidence available to the experts. Nevertheless, following guideline recommendations will not necessarily result in the best outcomes. Guidelines are not mandates and do not purport to be a legal standard of care. In order to produce evidence-based high-quality guidelines, it is necessary to have stringent methodological and procedural practices in place to support guidelines panels in their work, while also ensuring that quality control indicators are met. To achieve this, the European Association of Urology (EAU) guidelines office has established a centralised methods committee, the members of which are responsible for the methodological standard of all guidelines produced by the EAU. As remarked in the introduction of the manuscript [1], the publication to which Dr. Lv and colleagues refer is an abridged version of a subsection of the EAU guidelines on the management of non-neurogenic male lower urinary tract symptoms (LUTS) [2]. In light of this fact, the article does not contain detailed evidence on the formation of the guidelines panel, the evidence synthesis process, or the process for translating evidence to recommendations. This information is publicly available on the EAU website. All EAU guidelines panels are formed in a fully transparent manner following a predefined process that is comprehensively described in the EAU Guidelines Development Handbook. The EAU Guidelines Development Handbook, the EAU Patient Handbook, and the conflict of interest (COI) policy are all freely available on the EAU website (https:// bit.ly/3AFKItj). Within the EAU male LUTS guidelines panel we fully acknowledge the need to grow the panel membership to include patient representatives. Information on the discipline/content expertise, geographical location, and COIs of members of the guideline development group can be found under the supporting panel overview page of the EAU website (https://bit.ly/3c8R1LR). We acknowledge that the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system is a transparent framework for making clinical practice recommendations. From 2018 onwards, the EAU guidelines have used a modified GRADE approach for the grading of recommendations [3]. This is a hybrid system used in parallel with the Oxford Centre for Evidence-based Medicine Levels of Evidence [4]. It is the goal of the EAU guidelines office to gradually shift to a ‘‘full’’ GRADE approach across all guidelines. To allow for transparent assessment of how recommendation statements have been developed, a strength rating form is provided for each recommendation within the guidelines and addresses a number of key elements: the overall quality of the evidence that exists for the recommendation; the magnitude of the effect (individual or combined effects); the certainty of the results (precision, consistency, heterogeneity, and other statistical or studyrelated factors); the balance between desirable and undesirable outcomes; the impact of patient values and preferences on the intervention; and the certainty of those patient values and preferences. These key elements are the basis that panels use to define the strength of each recommendation [5]. Panels can provide both ‘‘strong’’ and ‘‘weak’’ recommendations ‘‘for’’ or ‘‘against’’ a point. 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 the nature and variability of patient values and preferences. As reported in the manuscript, the strength rating forms for the Male LUTS guidelines can be found on the EAU website (https://bit.ly/ 3Rwroog), as can the search strategies for the literature review (https://bit.ly/3Ppoq2S). Further information on the evidence assessment methodology for the EAU guidelines can be reviewed in the EAU Guidelines Development Handbook and the EAU Guidelines Systematic Review Handbook. It should be noted that all recommendations underpinned by systematic reviews are subject to ‘‘full’’ GRADE compliance. Indeed, we acknowledge that there is still some way to go until the methodological goals for the EAU guidelines are fully implemented across all guidelines, and our effort will focus on continued improvement of the EAU male LUTS guidelines in line with the standards defined by the Guidelines International Network [6] and using the 23 domains of the AGREE-II assessment tool [7].