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Reaching for the stars – rating the quality of systematic reviews with the Assessment of Multiple Systematic Reviews (AMSTAR) 2

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The number of published systematic reviews and meta‐analyses in the urological literature has dramatically increased in recent years [1]. This is good news given their importance in guiding clinical decision‐making, guideline development and health policy. However, many of these studies are of low quality, raising concerns about the trustworthiness of their results. As with other research studies, it is therefore important for readers to have a framework for determining the quality of a given systematic review. Therefore, in 2017 BJU International launched a scoring system for systematic reviews that provides readers with a summary assessment as to whether established methodological safeguards against bias for systematic reviews have been met [2]. This is based on the Assessment of Multiple Systematic Reviews (AMSTAR), a validated instrument that assesses methodological quality on an 11‐point scale (0–11), with higher scores reflecting greater methodological rigor and all criteria being given the same relative weight [3].

Recently, an updated version of this instrument has become available, offering a better assessment of systematic reviews [4]. The revised instrument (AMSTAR 2) includes 10 of the original domains; it has 16 items in total (compared with 11 in the original), simpler response categories to the original AMSTAR, and provides an overall rating that is largely based on seven critical domains that should all be met. These relate to: (i) documentation of an a priori registered protocol in Prospective Register of Systematic Reviews (PROSPERO) or through Cochrane, (ii) a comprehensive literature search, (iii) explicit justification for excluding studies, (iv) a risk of bias assessment of included studies, (v) appropriate use of meta‐analytical methods, (vi) consideration of risk of bias when interpreting the results of the review, and (vii) assessment of presence and likely impact of publication bias. Other, non‐critical domains include a clear description of the study question in Population, Intervention, Comparison, Outcome (PICO) format, study selection and data extraction in duplicate, and identification of sources of funding of the studies included in the review and the review itself. This results in a four‐tiered rating (high, moderate, low, and critically low) that reflects the confidence that a reader may place in the results. Notably, a high‐quality rating requires no critical weakness and allows for only one non‐critical weakness. More than one non‐critical weakness drops the rating down to moderate, and just one critical weakness (such as lack of an a priori protocol) drops the rating down to low. Any review that has more than one critical weakness will be rated as critically low.

BJU International editors will routinely apply this AMSTAR 2‐based scoring system to screen for methodological quality in order to raise the awareness of this issue and promote reviews of higher quality (Fig. 1)[1]. Needless to say, BJU International is not the place for systematic reviews of sub‐optimal methodological quality in which the readers cannot place their trust. Meanwhile, we also fully understand that methodological rigor is not everything but has to be paired with clinical relevance and newsworthiness. Much has been written about the dramatic redundancy of systematic reviews on the same topic; in certain areas of medicine, the number of systematic reviews exceeds that of eligible studies that these reviews included [5]. Therefore, when systematic reviews already exist, there needs to be a clear rationale for any ‘encore’ performance. BJU International also encourages the development of systematic reviews by author teams that are financially unconflicted and have thoughtfully managed any intellectual conflict of interest.

Figure 1: New BJUI rating system of systematic reviews based on AMSTAR 2. The number of coloured stars in the inner and outer layers of the system represents completeness of an individual critical domain and overall confidence rating of the systematic review, respectively. The number in the middle of the system refers to the summary AMSTAR 2 score based on the overall confidence rating of the systematic review (high: 4, moderate: 3, low: 2, critically low: 1).

Through this initiative, BJU International not only intends to become the premier journal for high‐quality systematic reviews as they relate to urology, but also to move the field forward, reducing redundancy and waste. As we embrace the higher standards of AMSTAR 2, we present the first review to be scored using this method in this issue [6] and we encourage all systematic review authors to accept this challenge and reach with us for the stars.

References

  1. Han JL, Gandhi S, Bockoven CG, Narayan VM, Dahm P. The landscape of systematic reviews in urology (1998 to 2015): an assessment of methodological quality. BJU Int 2017; 119: 638–49
  2. Dahm P. Raising the bar for systematic reviews with Assessment of Multiple Systematic Reviews (AMSTAR). BJU Int 2017; 119: 193
  3. Shea BJ, Grimshaw JM, Wells GA et al. Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol 2007; 7: 10

 

About the authors:

Dr Philipp Dahm is Professor of Urology and Vice Chair of Veterans Affairs at the University of Minnesota. He also serves as Director of Research and Education for Surgical Services at the Minneapolis Veterans Administration Medical Center (@EBMUrology).

 

Dr Jae Hung Jung is from the Department of Urology, Wonju College of Medicine, Yonsei University, Korea.

 

 

 

Guideline of guidelines: Asymptomatic Microscopic Haematuria

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Abstract

The aim of the present study was to review major organizational guidelines on the evaluation and management of asymptomatic microscopic haematuria (AMH). We reviewed the haematuria guidelines from: the American Urological Association; the consensus statement by the Canadian Urological Association, Canadian Urologic Oncology Group and Bladder Cancer Canada; the American College of Physicians; the Joint Consensus Statement of the Renal Association and British Association of Urological Surgeons; and the National Institute for Health and Care Excellence. All guidelines reviewed recommend evaluation for AMH in the absence of potential benign aetiologies, with the evaluation including cystoscopy and upper urinary tract imaging. Existing guidelines vary in their definition of AMH (role of urine dipstick vs urine microscopy), the age threshold for recommending evaluation, and the optimal imaging method (computed tomography vs ultrasonography). Of the reviewed guidelines, none recommended the use of urine cytology or urine markers during the initial AMH evaluation. Patients should have ongoing follow-up after a negative initial AMH evaluation. Significant variation exists among current guidelines for AMH with respect to who should be evaluated and in what manner. Given the patient and health system implications of balancing appropriately focused and effective diagnostic evaluation, AMH represents a valuable future research opportunity.

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Article of the Week: Muscolofascial Reconstruction after RP

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Every Week the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video from Dr. Francesco Alessandro Mistretta, discussing his paper.

If you only have time to read one article this week, it should be this one.

Posterior musculofascial reconstruction after radical prostatectomy: an updated systematic review and a meta-analysis

 

Angelica A.C. Grasso*, Francesco A. Mistretta*, Marco Sandri†, Gabriele Cozzi*, Elisa De Lorenzis*, Marco Rosso*, Giancarlo Albo*, Franco Palmisano*, Alex Mottrie‡, Alexander Haese§, Markus Graefen§, Rafael Coelho, Vipul R. Patel¶ and Bernardo Rocco*

 

*Department of Urology, Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, University of Milan, Milan, Italy, †DMS StatLab, Data Methods and Systems Statistical Laboratory, University of Brescia, Brescia, Italy, ‡OLV Robotic Surgery Institute, Aalst, Belgium, §Martini Clinic Prostate Cancer Center, University Clinic Eppendorf, Hamburg, Germany, and Global Robotics Institute, Florida Hospital-Celebration Health Celebration, University of Central Florida School of Medicine, Orlando, FL, USA

 

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To evaluate the influence of posterior musculofascial plate reconstruction (PR) on early return of continence after radical prostatectomy (RP); an updated systematic review of the literature. A systematic review of the literature was performed in June 2015, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and searching Medline, Embase, Scopus and Web of Science databases. We searched the terms posterior reconstruction prostatectomy, double layer anastomosis prostatectomy across the ‘Title’ and ‘Abstract’ fields of the records, with the following limits: humans, gender (male), and language (English). The authors reviewed the records to identify studies comparing cohorts of patients who underwent RP with or without restoration of the posterior aspect of the rhabdosphincter. A meta-analysis of the risk ratios estimated using data from the selected studies was performed. In all, 21 studies were identified, including three randomised controlled trials. The overall analysis of comparative studies showed that PR improved early continence recovery at 3–7, 30, and 90 days after catheter removal, while the continence rate at 180 days was statistically but not clinically affected. Statistically significantly lower anastomotic leakage rates were described after PR. There were no significant differences for positive surgical margins rates or for complications such as acute urinary retention and bladder neck stricture. The analysis confirms the benefits at 30 days after catheter removal already discussed in the review published in 2012, but also shows a significant advantage in terms of urinary continence recovery in the first 90 days. A multicentre prospective randomised controlled trial is currently being conducted in several institutions around the world to better assess the effectiveness of PR in facilitating an earlier recovery of postoperative urinary continence.

 

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Editorial: The Jury on Posterior Muscolofascial Reconstruction is still out

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In their systematic review and meta-analysis, Grasso et al. [1] address the question of whether posterior muscolofascial reconstruction (PMR), the so-called Rocco stitch, positively affects urinary continence after radical prostatectomy. The relevance of the question to this structured form of inquiry is that individual studies to date have been inconclusive. We recognize Sir Archie Cochrane, who gave his name to the Cochrane Collaboration that pioneered the methods for conducting systematic reviews, for emphasizing the critical importance of looking at the entire body of evidence in a structured manner when seeking to answer a clinical question [2]. In the present study, which included both randomized controlled trials (RCTs) and observational studies of variable methodological quality, a favourable impact of PMR across all postoperative time points (3–7 days, 30 days, 3 and 6 months) was observed. The effect was most pronounced early on at the time of catheter removal, when the patients undergoing PMR were nearly twice as likely as the control group (risk ratio 1.9; 95% CI 1.3–2.9) to be continent, thereby suggesting a major benefit of this approach. It should be noted, however, that this analysis was dominated by the observational studies, particularly retrospective observational studies, which offer the least degree of methodological rigor.

Even more important, therefore, than the act of pooling across studies is the rating of the quality of evidence for the body of evidence on an outcome-specific basis. Based on the GRADE approach, which has become the most widely endorsed framework for rating the quality of evidence, we would initially place a high and low level of confidence in a body of evidence drawn from RCTs and observational studies, respectively [3]. As a result, one might plan a separate analysis of those two groups of studies first, and only move to pool them if their results were similar. In this case, the results from the RCTs and observational studies were different, with prospective and retrospective studies reporting larger, probably exaggerated effect sizes; however, it is also understood that other aspects such as study limitation (risk of bias), inconsistency, impression, indirectness and risk publication bias may lower our confidence in the effect estimates from RCTs [4]. Focusing on the body of evidence from RCTs alone (Table 1) we have ‘moderate’ confidence that PMR may not improve early continence at the time of catheter removal. Similarly, the few RCTs that contributed to the assessment of continence at later timepoints do not provide evidence that continence is affected favourably, although our confidence for those outcomes is only ‘low’ or ‘very low’, suggesting that future trials may change these estimates of effect. Meanwhile, it should be noted that none of the RCTs appeared to provide information on the potential downsides of PMR, such as rates of urinary retention or bladder neck contracture. As a result, enough uncertainty remains to state that the jury on PMR is still out; this is consistent with the authors’ call for a future high-quality trial, which is reportedly ongoing. While PMR is already widely used by open and robot-assisted prostatectomy surgeons around the globe, this example sheds light on current evidentiary standards of surgical innovation. Following the IDEAL recommendations, it would be much preferred if the urological community committed to well designed trials for novel surgical approaches and device-dependent interventions up front, before moving to widespread dissemination [5].

JulEOTW2

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Philipp Dahm
Department of Urology, Minneapolis VA Health Care System, Urology Section 112D and University of Minnesota, Minneapolis, MN, USA

 

References

 

1 Grasso AAC, Mistretta FA, Sandri M et al. Posterior musculofascial reconstruction after radical prostatectomy: an updated systematic review and a meta-analysis. BJU Int 2016; 118: 20–34.

 

2 Hajebrahimi S, Dahm P, Buckingham J. Evidence-based urology in practice: the cochrane library. BJU Int 2009; 104: 1048–9

 

3 Canfield SE, Dahm P. Rating the quality of evidence and the strength of recommendations using GRADE. World J Urol 2011; 29: 311–7

 

4 Guyatt GH, Oxman AD, Vist GE et al. GRADE: what is “quality of evidence” and why is it important to clinicians? BMJ 2008; 336: 995–8

 

5 McCulloch P. The IDEAL recommendations and urological innovation. World J Urol 2011; 29: 331–6

 

Video: Posterior Muscolofascial Reconstruction after RP

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Posterior musculofascial reconstruction after radical prostatectomy: an updated systematic review and a meta-analysis

Angelica A.C. Grasso*, Francesco A. Mistretta*, Marco Sandri†, Gabriele Cozzi*, Elisa De Lorenzis*, Marco Rosso*, Giancarlo Albo*, Franco Palmisano*, Alex Mottrie‡, Alexander Haese§, Markus Graefen§, Rafael Coelho, Vipul R. Patel¶ and Bernardo Rocco*

 

*Department of Urology, Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, University of Milan, Milan, Italy, †DMS StatLab, Data Methods and Systems Statistical Laboratory, University of Brescia, Brescia, Italy, ‡OLV Robotic Surgery Institute, Aalst, Belgium, §Martini Clinic Prostate Cancer Center, University Clinic Eppendorf, Hamburg, Germany, and Global Robotics Institute, Florida Hospital-Celebration Health Celebration, University of Central Florida School of Medicine, Orlando, FL, USA

 

Read the full article
To evaluate the influence of posterior musculofascial plate reconstruction (PR) on early return of continence after radical prostatectomy (RP); an updated systematic review of the literature. A systematic review of the literature was performed in June 2015, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and searching Medline, Embase, Scopus and Web of Science databases. We searched the terms posterior reconstruction prostatectomy, double layer anastomosis prostatectomy across the ‘Title’ and ‘Abstract’ fields of the records, with the following limits: humans, gender (male), and language (English). The authors reviewed the records to identify studies comparing cohorts of patients who underwent RP with or without restoration of the posterior aspect of the rhabdosphincter. A meta-analysis of the risk ratios estimated using data from the selected studies was performed. In all, 21 studies were identified, including three randomised controlled trials. The overall analysis of comparative studies showed that PR improved early continence recovery at 3–7, 30, and 90 days after catheter removal, while the continence rate at 180 days was statistically but not clinically affected. Statistically significantly lower anastomotic leakage rates were described after PR. There were no significant differences for positive surgical margins rates or for complications such as acute urinary retention and bladder neck stricture. The analysis confirms the benefits at 30 days after catheter removal already discussed in the review published in 2012, but also shows a significant advantage in terms of urinary continence recovery in the first 90 days. A multicentre prospective randomised controlled trial is currently being conducted in several institutions around the world to better assess the effectiveness of PR in facilitating an earlier recovery of postoperative urinary continence.

 

Read more articles of the week

 

Article of the month: Targeting the androgen receptor

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Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying video of a lecture from Professor David Neal, filmed at the Society of Academic Research and Surgery: 2013 Annual Meeting.

If you only have time to read one article this week, it should be this one

The transcriptional programme of the androgen receptor (AR) in prostate cancer

Alastair D. Lamb, Charlie E. Massie and David E. Neal

Cambridge University Department of Urology, Addenbrooke’s Hospital and Cancer Research UK (CRUK) Cambridge Institute, Cambridge, UK

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ABSTRACT

• The androgen receptor (AR) is essential for normal prostate and prostate cancer cell growth.

• AR transcriptional activity is almost always maintained even in hormone relapsed prostate cancer (HRPC) in the absence of normal levels of circulating testosterone.

• Current molecular techniques, such as chromatin-immunoprecipitation sequencing (ChIP-seq), have permitted identification of direct AR-binding sites in cell lines and human tissue with a distinct coordinate network evident in HRPC.

• The effectiveness of novel agents, such as abiraterone acetate (suppresses adrenal androgens) or enzalutamide (MDV3100, potent AR antagonist), in treating advanced prostate cancer underlines the on-going critical role of the AR throughout all stages of the disease.

• Persistent AR activity in advanced disease regulates cell cycle activity, steroid biosynthesis and anabolic metabolism in conjunction with regulatory co-factors, such as the E2F family, c-Myc and signal transducer and activator of transcription (STAT) transcription factors. Further treatment approaches must target these other factors.

LINK TO VIDEO

Lecture filmed at the Society of Academic Research and Surgery: 2013 Annual Meeting. Video available from The Royal Society of Medicine https://www.rsmvideos.com/videoPlayer/?vid=340

 

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