










































Use of Urology-Based Clinical Practice  
Guidelines in International Settings
German Patino,*1,2 Medina Ndoye,*1,3 Hannah S. Thomas,*1,4 Andrew J. Cohen,5 Nnenaya A. Mmonu,1 
Carissa E. Chu,1 Benjamin N. Breyer, 1,6 

*Authors contributed equally

1Department of Urology, University of California San Francisco, United States 2 Hospital San Ignacio, Bogotá, Colombia 3 Hôpital Général de Grand Yoff, Dakar, Senegal 
4 University of Edinburgh School of Medicine, Edinburgh, United  Kingdom5 The Brady Urological Institute at Johns Hopkins, Baltimore, United States  
6 Department of Biostatistics and Epidemiology, University of California San Francisco, United States

Abstract

Objective Clinical practice guidelines (CPGs) serve as frameworks to unify diagnostic criteria and guide clinical 
decision-making. There is a paucity of literature surrounding the uptake of CPGs in urology practice settings 
with varied levels of resources worldwide. This study aims to evaluate reported use of CPGs within the context of 
international urology practice, identify local barriers to uptake, and evaluate the role of stakeholders in the CPG-
development process.

Methods This was an international, multi-center, cross-sectional study. An online survey collecting variables 
pertaining to the use of CPGs was distributed to attending/consultant urologists in Latin America, Africa, and China. 
Statistical analysis was conducted using R software.

Result A total of 249 practicing urologists from 28 countries completed the survey. The majority of participants 
were males, aged 36 to 45, and practiced in a non-academic setting. Ninety-three percent of urologists used CPGs in 
their everyday clinical practice, and 43% believed CPGs were very important to medical decision-making. However, 
barriers such as the lack of adaptability or applicability of CPGs to local settings were mentioned by 29% and 24% 
of participants, respectively. Urologists believed scientific associations (81%), national urology boards (68%), and 
ministries of health (56%), were important stakeholders to consult to foster the development of local CPGs.

Conclusions Globally, CPGs are widely used tools for clinical practice. However, there are concerns about the 
adaptability and applicability of CPGs to settings that may lack the resources to implement their recommendations. 
Efforts should be directed towards incorporating scientific and medical stakeholders into the review and adaptation of 
urology CPGs to suit the unique features of local health care systems.

Key Words Competing Interests Article Information

Urology, CPG, guidelines, global health, 
barriers

None declared. Received on: August 4, 2020 
Accepted on: October 12, 2020

Soc Int Urol J. 2021;2(1):10–17

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mailto:Benjamin.Breyer%40ucsf.edu?subject=SIUJ
http://www.siuj.org


Introduction

With the large volume of clinical research, it is 
cha l leng i ng for prac t it ioners to i ndependent ly 
synthesize and review scientific literature to ascertain 
proper ev idence-based care[1]. Clinica l practice 
guidelines (CPGs) are tools used to identify, evaluate, 
and synthesize recent data and high-quality evidence 
to assist clinicians in providing evidence-based and 
outcome-based medicine[2,3]. Developing CPGs 
mandates multi-professional collaboration through 
systematic, independent, and transparent methods to 
produce appropriate quality criteria. When implemented 
effectively, CPGs have been shown to improve the 
standardization of medical services, raise the quality 
of care, promote patient safety, and achieve optimal 
cost-effectiveness[4]. However, while CPGs are largely 
considered valuable tools to improve processes of care, 
associations between adherence to CPGs and patient-
related outcomes remain variable[5–7].

To guide clinical decision-making in urology, CPGs 
have been developed by major North American and 
European professional urology organizations such 
as the American Urological Association (AUA) and 
European Association of Urology (EAU). In the US, 
approximately 95% of urologists reported using the AUA 
CPGs in regular clinical decision-making[8]. Figures 
are more variable in European cohorts where Italian 
urologists’ adherence to non-oncologic urology CPGs 
ranged from 45% to 88%[9], while Croatian urologists’ 
compliance with EAU recommendations ranged from 
8% to 100%[10]. More specifically, CPG uptake varies 
when consulting for pathology and symptom-specific 
cases such as benign prostatic hyperplasia[11], bladder 
cancer[12] and asymptomatic hematuria[13]. Younger 
age and academic practice settings have been found to be 
associated with greater CPG adherence[8,9].

The uptake of CPGs has not been extensively measured 
within urology settings of varied resource-levels. It has 
been hypothesized that CPGs may be valuable tools in 
low- and middle-income countries (LMICs), where 
resource constraints limit the development of CPGs 
suitable to local sociocultural and economic contexts. 
Cited barriers to CPG implementation in LMICs include 
inadequate facilities for clinical practice advised by 
CPGs and comprehensibility of information within 
CPGs[14]. Multidisciplinary literature has found that 
CPG implementation in LMICs is often best achieved 

when coupled with educational programming and 
adaptation by local experts[15,16].

Through an online survey, this study aimed to 
evaluate clinical decision-making factors and reported 
use of urology CPGs produced by professional urology 
organizations, and national and institutional CPGs. 
Moreover, we sought to understand the key barriers 
to individual providers’ use of such CPGs. Finally, in 
an attempt to improve CPG development and better 
serve international urology practice, we evaluated the 
importance of key stakeholders.

Methods

Study design and participants
This was a n internat iona l, mu lt i-center cross-
sectional study. An online survey eliciting urologist 
demographics and use of and attitudes towards CPGs 
was disseminated, using means appropriate to the target 
region. In Latin America, the survey was disseminated to 
consultant urologists through the email server of several 
national societies. Similarly, prospective participants 
in China were invited to complete the survey through 
the Chinese Urological Association. In Africa, however, 
participants were more likely to respond if the survey 
was disseminated through local clinicians and contacts 
known to a member of the study team. All participants 
were invited to complete the study through a formalized 
letter from the research team from the University of 
California, San Francisco, which included the survey 
link. In cases of non-response, a follow-up link was 
provided one month later. Eligible participants were 
identified as consultant urologists practicing in an 
international setting. Trainees and residents were not 
recruited.

Study variables

A 17-question survey with consent was built through 
Research Electronic Data Capture (REDCap) and 
offered in English, Spanish, French, and Chinese (Suppl.)
[17]. Demographic variables such as provider age, sex, 
and years of practice were collected. Knowledge about 
daily clinical decision-making, knowledge of CPGs, 
and access to relevant sources of scientific information 
was sought. The 5-point Likert scale was used to elicit 
provider perspectives on the role of CPGs in clinical 
decision-making. Finally, barriers to CPG uptake were 
investigated, along with provider perspectives on key 
stakeholders necessary for future CPG development.

Statistical analysis
Descriptive analyses were conducted using Excel 
Pivot tables. Through R Studio, chi-square tests of 
independence were used to approximate statistical 
significance.

Abbreviations 
AUA   American Urological Association
CPG   Clinical practice guideline
EAU   European Association of Urology

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Ethics
This study was forma lly approved t hrough t he 
Institutional Review Board (IRB) within University of 
California San Francisco (#18-25978). The study was 
classed as minimal risk and received exempt IRB status.

Results

Demographics
A total of 249 participants, representing 28 different 
countries, completed the survey (Table 1). Twenty 
countries were in Africa, 7 in Latin America and 1 
in Asia (China). The majority of participants who 
reported demographic characteristics were men (92.8%, 
192/207) aged 36 to 45 years old (38.6%, 95/246). Most 
participants trained in their home country (70.1%, 
143/204), and reported they were now practicing in a 

non-academic setting (community, national hospital, 
or private practice) (64.9%, 135/208). Seventy-three 
urologists considered themselves to be working in an 
academic environment (35.1%, 73/208). A total of 34.6% 
had practiced for 1 to 5 years (72/208), and 32.2% for 
16 or more years (67/208). Overall, 33.7% of sampled 
urologists were practicing in Latin America (84/249), 
31.3% in Africa (78/249), and 18.5% (46/249) in China.

Baseline factors contributing to clinical 
decision-making and access to CPGs
A total of 43% (107/249) of responding urologists rated 
CPGs to be very important during their decision-
making process, while 25.3% (63/249) greatly valued 
the role of scientific publications. Similarly, experience 
and habits, expert opinion, and medical training were 

TABLE 1. 

Demographics of study participants

Participants
Africa
n (%)

Latin America
n (%)

China
n (%)

Totals 
n (%)

P -Value

Age
25–35 
36–45 
46–55 
56–65 
≥ 66 

28 (26.4)
51 (48.1)
15 (14.2)
9 (8.5)

3 (2.83)

30 (31.6)
29 (30.5)
15 (15.8)
15 (15.8) 

6 (6.3

12 (26)
15 (33)
16 (35)

2 (4)
0 (0)

70 (28.5)
95 (38.6)
46 (18.7)
26 (10.6)
9 (3.7)

0.0058

Gender
Male 

Female 
72 (86.7)
11 (13.3)

72 (86.7)
11 (13.3)

44 (97)
1 (3)

192 (92.8)
15 (7.2)

0.023

Place of training
Home country 

Other countries
 36 (45.6)
43 (54.4)

62 (77.5)
18 (22.5)

45 (100)
0 (0)

143 (70.1)
61 (29.9)

<0.001

Years of practice
1–5 
6–10 
11–15 
≥ 16 

38 (48.1)
17 (21.5)
11 (13.9)
13 (16.5)

25 (29.8)
19 (22.6)

8 (9.5)
32 (38)

9 (20)
3 (6)

11 (24)
22 (48)

72 (34.6)
39 (18.8)
30 (14.4)
67 (32.2)

<0.001

Type of practice
Academic

Community hospital
National hospital
Private practice

53 (67.1)
2 (2.5)

16 (20.3)
8 (10.1)

8 (9.5)
24 (28.6)
26 (31)
26 (31)

12 (26)
0 (0)

32 (71)
1 (3)

73 (35.1)
26 (12.5)
74 (35.6)
35 (16.8)

 <0.001

Respondents were in the following countries. In Africa: Algeria, Liberia, Nigeria, Zambia, Senegal, Kenya, Mali, Niger, Madagascar, Gabon, Togo, Ivory 
Coast, Cameroon, Mauritania, Burkina Faso, Guinea, Morocco, Benin, Republic of the Congo, and Democratic Republic of the Congo. In Latin America: 
Brazil, Bolivia, Uruguay, Paraguay, Colombia, Argentina, Mexico. In Asia: China.

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considered to be very important by 20.5% (51/249), 
13.7% (34/249), and 23.7% (59/249) of participants, 
respectively. In terms of relevant scientific resources, 
30.5% (76/249) of participants greatly valued meta-
analyses for consultation during medical decision-
making, while 25.7% (64/249) emphasized randomized 
control trials. Ten percent (24/249) of participants 
believed systematic reviews were important to consider, 
along with case reports (6%, 15/249), and case series 
(5.2%, 13/249).

The majority of participants confirmed they were able 
to access the internet from their home (69.5%, 173/249), 
mobile phone (73.5%, 183/249), or local hospital (61.4%, 
153/249). Some participants reported difficulty accessing 
CPGs through institutional (26.5%, 66/249) or personal 
memberships (23.7%, 59/249). Less than half felt CPGs 
were easily accessible through open access options 
(38.2%, 95/249).

Use of urology CPGs in international settings
Overall, 92.6% (225/243) of urologists reported using 
some form of CPGs in their daily clinical practice 
(Table 2). Of those who used CPGs, the majority were 
based at either a national hospital (30.5%, 69/226) or 

an academic center (28.8%, 65/226). In Africa, 87.4% 
(90/103) of urologists who responded used CPGs in daily 
practice, along with 96.8% (92/95) in Latin America 
and 95.6% (43/45) in China. The most commonly used 
CPGs were those from the EAU, as most clinicians 
reported using them “always” or “frequently” (63.9%, 
159/249) (Table 3). Both CPGs produced by the AUA 
and the clinician’s national urology association were 
used mostly “frequently” or “sometimes,” capturing 80% 
(199/249) and 58% (144/249) of clinicians, respectively, 
in these categories. In comparison, respondents 
indicated that they used the joint consultations released 
by the Société Internationale d ’Urologie and the 
International Consultation on Urologic Diseases “never” 
or “sometimes” (70.7%, 176/249), closely followed by 
guidelines published by the clinician’s local institution 
(57%, 142/249). Of participating clinicians, 51% 
(127/249), reported sometimes consulting “Other” CPG 
sources as well. 

Reported barriers to CPG use
Among participants, the principal cited barrier to the 
use of CPGs in everyday practice was the perceived 
lack of adaptability of the existing CPGs (29.2%, 

TABLE 2. 

Reported use of CPGs across international settings of practice and participant beliefs regarding individual 
stakeholders’ responsibility in the development of CPGs

Participants
Africa
n (%)

Latin America
n (%)

China
n (%)

Totals
n (%)

P -Value

Use of CPG
Yes
No 

90 (87.4) 
13 (12.6)

92 (96.8) 
3 (3.2)

43 (95.6) 
2 (4.0)

225 (92.6) 
18 (7.4)

0.0279

Type of stakeholder

Scientific 
association

81 (76.4) 85 (89.5) 34 (75) 200 (81.3) 0.0331

Ministry of health 55 (51.9) 63 (66.3) 19 (42) 137 (55.7) 0.0160

Board of urology 73 (68.9) 69 (72.6) 26 (57) 168 (68.3) 0.2081

Non-profit 
organization, n (%)

15 (14.2) 11 (11.6) 5 (10) 31 (12.6) 0.8138

Pharmaceutical 
industry

20 (18.9) 5 (5.3) 2 (4) 27 (11) 0.0026

Health care provider 44 (41.5) 31 (32.6) 5 (10) 80 (32.5)  0.0013

Insurance company 8 (7.5) 9 (9.5) 1 (2) 18 (7.3) 0.3039

Proportions equate to the number of participants who indicated “Yes” to the importance of this stakeholder in the CPG-development process.

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35/120) (Figure  1). Secondarily, participants felt that 
international CPGs were not applicable to their country 
(24.2%, 29/120) or relevant for the health and/or 
financial status of their patients (16.7%, 20/120). Open 
responses from a few participants reported barriers such 
as cost, time, expertise, and equipment limitations.

Stakeholder responsibility for the 
development of urology CPGs
Overall, scientif ic associations, national urolog y 
boards, and ministries of health were believed to be 
important stakeholders for local CPG development, by 
81.3% (200/246), 68.3% (168/246), and 55.7% (137/246) 
of participants, respectively (Table 2). Seen as less 
important to the CPG-development process were 
insurance companies (7.3%, 18/246) and members of the 
pharmaceutical industry (11%, 27/246).

Discussion
This study affirmed that CPGs for urology are widely 
used in many countries. Urologists who reported uptake 
of CPGs are primarily based in national hospitals or 
academic centers, and consult the EAU, AUA, and 
the CPGs of their own national urology associations. 
Ongoing barriers to CPG use in international urology 
practices relate to the lack of adaptability and relevant, 
everyday application. In creating CPGs that better serve 
urologists in resource-variable countries, participants 
believe that scientific associations, ministries of health, 
and national urology associations should be involved as 
key stakeholders.

To our knowledge, this study is the first assessment 
of CPG use among urologists in resource-variable 

settings. CPGs are effective tools for crafting evidence-
based clinical environments, with the avoidance of 
inappropriate treatment[4]. However, recommendations 
that are clinically effective may not necessarily reflect the 
realities of local constraints; therefore, cost-effectiveness 
must be considered as well[18]. The World Health 
Organization affirms that CPGs must have explicit aims 
and ultimately be targeted to the users themselves[19]. 
Accredited CPGs are a valuable tool for urologists 
worldwide, although lack of resources often limits their 
proper implementation and therefore their usefulness. 
This study sur veyed a broad range of urologists 
operating in health care systems of varied capacities 
around the world. In Latin America, recent studies have 
noted increased use of the GRADE criteria for CPG 
development; however, there is a paucity of guidelines 
for relevant, regional pathology[20]. Similarly, in China, 
where traditional remedies represent 40% of health care 
provision, complementary medicine principles may be 
integrated into the framework of medical CPGs[21,22]. 
Finally, at least one study of CPGs across Africa has 
indicated that standards of evidence are distinctly 
different, signaling the need for greater regional cross-
collaboration to produce high-quality recommendations 
[23]. These examples suggest that despite the similar 
reported use of urology CPGs in Latin America, Africa, 
and China, these results do not necessarily ref lect 
generalizable knowledge within each distinct region.

Ninety-three percent of urologists reported consulted 
international CPGs during daily clinical decision-
making; however, they may not derive the full benefits 
or the same benefits as urologists in high-resource 
countries, because the CPGs may lack applicability 

Lack of 
adaptability

International 
not applicable 

Patient 
condition

Not 
easy

Language 
barriers Other

0

        5

10

15

20

25

30

35

N
um

be
r o

f p
ar

tic
ip

an
ts

Reported barriers to uptake of clinical practice Guidelines

A52 FIG1

FIGURE 1. 

Reported barriers to uptake of clinical practice guidelines

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and acceptability in different environments. Existing 
CPGs may remain “Eurocentric,” reflecting the ideals, 
principles, and knowledge of only a segment of urologists 
globally. Therefore, strengthening CPG development 
at the national level may be crucial. Conversely, the 
development of CPGs is costly, time-consuming, 
and laborious and may not be a national priority 
amidst resource-constrained health systems. One 
recommended strategy for CPGs in resource-variable 
settings has been the direct adaptation of existing, 
international CPGs. In South Africa, local practitioners 
were commissioned to revise international CPGs, 
with a view to applicability to South African clinical 
practice[24]. Challenged by factors such as funding and 
human resources, the case analysis spotlighted a gap in 
research knowledge and critical appraisal among team 
members[24]. Additional studies suggest that while 
urologists desire to practice evidence-based urology, 
they may not feel they have the necessary appraisal skills 
to conduct a comprehensive scientific analysis[25]. With 
this in mind, parallel development of research training 
and capacity-building should be considered when 
looking to craft local CPGs.

Finally, equitable access to resources is essential to 
close the loop and deliver CPGs to local practitioners. 
Though this access is not universal, our study found 
that providers are generally able to access the internet 
through various means. In Africa, participants indicated 
that internet access for telemedicine is generally 
available in urban areas, but that access is unreliable 
in rural regions[26]. However, even in the presence of 

internet, access to academic literature is variable. In 
our study, less than half of respondents reported the 
ability to access open access CPGs with ease. Academic 
financial barriers such as rising subscription costs and 
evolving publishing restrictions limit global clinicians’ 
access to sound clinical evidence[27]. In the face of these 
challenges, some hail open access as a potential solution 
to mitigate inequities[27]. Authors from low-resource 
countries may not be able to afford the fees for open 
access publication, so studies that might be particularly 
relevant to practice in the region may be subscription-
only and therefore unavailable[28]. Therefore, while 
promoting and crafting CPGs that are relevant to local 
contexts is crucial, the academic community at large 
must consider how best to support dissemination of this 
knowledge. Core urology organizations such as the EAU 
and AUA make their guidelines available free of charge, 
as models of equitable publishing. However, the majority 
of our respondents who used CPGs worked at large 
national hospitals or academic facilities, highlighting an 
additional, important opportunity to engage providers 
in non-academic settings.

While our study highlights a known gap in the 
literature, it has limitations. Although we were able to 
determine that practitioners appear to be aware of CPGs 
and/or have the desire to use them, our analysis did not 
capture the scale and nuance of their use. An exploration 
of provider perspectives through a mixed-method 
approach might provide a better understanding of the 
integration of CPGs in urology practices in resource- 
variable areas. Moreover, the authors recognize that 

TABLE 3. 

Proportion of Reported Frequency of CPG for Each Type of CPG Stakeholders’ Responsibility in the 
Development of CPGs

International CPG

Reported Frequency of CPG Use

Never
n (%)

Sometimes
n (%)

Frequently
n (%)

Always
n (%)

AUA 8 (3.2) 78 (31.3) 121 (48.6) 15 (6.0)

EAU 4 (1.6) 59 (23.7) 115 (46.2) 44 (17.7)

SIU-ICUD Consultation 66 (26.5) 110 (44.2) 40 (16.1) 4 (1.6)

National Urology Association 44 (17.7) 74 (29.7) 70 (28.1) 30 (12.0)

Local Institution 62 (24.9) 80 (32.1) 56 (22.5) 19 (7.6)

Other 52 (20.9) 127 (51.0) 25 (10.0) 8 (3.2)

AUA: American Urological Association, EAU: European Association of Urology, SIU: Société Internationale d’Urologie, ICUD: International Consultation 
on Urologic Disorders. “Other” refers to other forms of CPGs not captured in the above categories.

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sampled participants may not necessarily represent 
generalizable, continent-level findings. Urologists’ 
perspectives were largely compiled through a non-
probable, convenience sampling method, particularly 
among providers in Africa. The global health literature 
acknowledges this approach as a strategy for collecting 

data from hard-to-reach populations, such as isolated 
urologists operating in regions with limited professional 
contacts[29,30]. Overall, we believe this study is an 
important step towards capturing the practice habits of 
urologists in these situations. 

Conclusions
Among our international cohort of urologists, reported 
rates of CPG use were high, indicating widespread 
awareness of their utility. However, the actual relevance 
and application of North American and European CPGs 
in everyday clinical practice is less clear, highlighting 
barriers to large-scale dissemination and subsequent 
promotion of evidence-based urology practice globally. 
Therefore, the development of locally relevant CPGs, 

either through the creation of new guidelines or the 
modification of existing ones, should be a priority 
for stakeholders in health care systems. An effort to 
promote international cooperation is essential to help 
build, adapt, and implement CPGs congruent with 
the epidemiological and socioeconomic context of a 
country’s needs.

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