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Guideline Summary
Guideline Title
Guidelines on robotic- and single-site surgery in urology.
Bibliographic Source(s)
Merseburger AS, Nagele U, Herrmann TRW, Traxer O, Kyriaziazis I, Liatsikos EN. Guidelines on robotic- and single-site surgery in urology. Arnhem (The Netherlands): European Association of Urology (EAU); 2013 Mar. 38 p. [206 references]
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Any urological disease or condition requiring single-site or robotic surgery (e.g., renal cancer, prostate cancer, vaginal vault prolapse)

Guideline Category
Management
Technology Assessment
Treatment
Clinical Specialty
Internal Medicine
Nephrology
Obstetrics and Gynecology
Oncology
Surgery
Urology
Intended Users
Physicians
Guideline Objective(s)

To evaluate the current literature and the level of evidence of keyhole and robotic-assisted surgery in urological procedures

Target Population

Patients undergoing robotic-assisted and single-site surgery in urology

Interventions and Practices Considered
  1. Robotic partial nephrectomy (RPN)
  2. Laparoscopic partial nephrectomy (LPN)
  3. Robotic radical nephrectomy (RRN)
  4. Reconstructive renal surgery
  5. Laparoendoscopic single site (LESS) surgery
  6. Single-incision triangulated umbilical surgery (SITUS)
  7. Robot-assisted radical prostatectomy (RARP)
  8. Open retropubic partial prostatectomy (ORP)
  9. Laparoscopic radical prostatectomy (LRP)
  10. Robotic-assisted pelvic lymph node (LN) dissection (PLND)
  11. Robotic colpopexy
  12. Open radical cystectomy (ORC)
  13. Robotic-assisted laparoscopic sacrocolpopexy (RALS)

Note: Other procedures discussed include laparoscopic pyeloplasty (LPP), laparoscopic radical nephrectomy (LRN), robotic-assisted laparoscopic radical prostatectomy (RALP), robot-assisted radical cystectomy (RARC), and robot-assisted laparoscopic pyeloplasty (RLPP).

Major Outcomes Considered
  • Survival rate
  • Positive surgical margin rate
  • Change in renal function
  • Length of hospital stay
  • Operating time
  • Mean blood loss/transfusion rate
  • Conversion rate
  • Potency and continence rate
  • Number of lymph nodes removed
  • Complication rate

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

General Search Strategy

A structured literature search is performed for all guidelines but this search is limited to randomised controlled trials and meta-analyses, covering at least the past three years, or up until the date of the latest text update if this exceeds the three-year period. Other excellent sources to include are other high-level evidence, Cochrane review and available high-quality guidelines produced by other expert groups or organizations. If there are no high-level data available, the only option is to include lower-level data. The choice of literature is guided by the expertise and knowledge of the Guidelines Working Group.

Specific Strategy for This Guideline

Literature Search

Searches were carried out in the Cochrane Library Database of Systematic Reviews, the Cochrane Library of Controlled Clinical Trials, Medline, and EMBASE on the Dialog-Datastar platform. The controlled terminology of the respective databases was used and both MeSH and EMTREE were analysed for relevant entry terms.

Inclusion Criteria

Case reports, congress proceedings, editorials, reviews and letters to the editor were not included. Publications reporting from the same institution and cohort were limited to the most recent or largest study. An online systematic review of the literature, according to Cochrane recommendations, was performed in July 2012 and identified data from 1990 to 2012. Manuscripts in languages other than English were included if data were extractable; these manuscripts were selected for inclusion in analysis using the criteria mentioned above.

Literature Search for Robotic-Assisted Radical Prostatectomy

A comprehensive PubMed search was conducted on publications related to the robot-assisted radical prostatectomy (RARP). No time frame was used. Key words included 'robot assisted radical prostatectomy' or "robotic prostatectomy" and one of the following: 'oncological outcome', 'continence' and 'potency'. Additional relevant literature was retrieved from references outlined by the initially harvested manuscripts. Literature was limited to human studies only and manuscripts published in English. Due to the wide extent of the robotic prostatectomy literature (more than 1,300 articles), review was restricted to comparative studies and meta-analyses that compared robot-assisted with open and conventional laparoscopic approaches. Review manuscripts were also excluded.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Level of Evidence

Level Type of Evidence
1a Evidence obtained from meta-analysis of randomised trials
1b Evidence obtained from at least one randomised trial
2a Evidence obtained from one well-designed controlled study without randomisation
2b Evidence obtained from at least one other type of well-designed quasi-experimental study
3 Evidence obtained from well-designed non-experimental studies, such as comparative studies, correlation studies and case reports
4 Evidence obtained from expert committee reports or opinions or clinical experience of respected authorities
Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

References in the text have been assessed according to their level of scientific evidence (see the "Rating Scheme for the Strength of the Evidence" field), according to the Oxford Centre for Evidence-based Medicine Levels of Evidence.

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

General Methods Used to Formulate the Recommendations

  • The first step in the European Association of Urology (EAU) guidelines procedure is to define the main topic.
  • The second step is to establish a working group. The working groups comprise about 4 to 8 members, from several countries. Most of the working group members are academic urologists with a special interest in the topic. Specialists from other medical fields are included as full members of the working groups as needed. In general, general practitioners or patient representatives are not part of the working groups. Each member is appointed for a four-year period, renewable once. A chairman leads each group.
  • The third step is to collect and evaluate the underlying evidence from the published literature.
  • The fourth step is to structure and present the information. All main recommendations are summarised in boxes and the strength of the recommendation is clearly marked in three grades (A–C), depending on the evidence source upon which the recommendation is based. Every possible effort is made to make the linkage between the level of evidence and grade of recommendation as transparent as possible.

Specific Methods Used for This Guideline

The panel members are surgeons with particular expertise in performing the procedures discussed in this document. All have been trained in traditional open and laparoscopic surgical approaches. Robotic assisted surgery is performed as a routine procedure by 2 expert panel members on a daily basis.

Guideline recommendations have been graded (see the "Rating Scheme for the Strength of the Recommendations" field) according to the Oxford Centre for Evidence-based Medicine Levels of Evidence. Grading aims to provide transparency between the underlying evidence and the recommendation given.

It should be noted that when recommendations are graded, the link between the level of evidence (LE) and grade of recommendation (GR) is not directly linear. Availability of randomised controlled trials (RCTs) may not necessarily translate into a grade A recommendation where there are methodological limitations or disparity in published results.

Alternatively, absence of high level of evidence does not necessarily preclude a grade A recommendation, if there is overwhelming clinical experience and consensus. There may be exceptional situations where corroborating studies cannot be performed, perhaps for ethical or other reasons and in this case unequivocal recommendations are considered helpful. Whenever this occurs, it is indicated in the text as "upgraded based on panel consensus". The quality of the underlying scientific evidence – although a very important factor – has to be balanced against benefits and burdens, values and preferences, and costs when a grade is assigned.

Rating Scheme for the Strength of the Recommendations

Grade of Recommendations

Grade Nature of Recommendations
A Based on clinical studies of good quality and consistency addressing the specific recommendations and including at least one randomised trial
B Based on well-conducted clinical studies, but without randomised clinical trials
C Made despite the absence of directly applicable clinical studies of good quality
Cost Analysis

The rapid adoption of robot-assisted surgery for prostate cancer and other diseases has called into question whether the benefits of this technology justify the cost, as there is no clear evidence demonstrating superior clinical outcomes of these techniques over traditional surgical approaches (i.e., open or laparoscopy). There are only few, small, single-centre studies on comparative costs of robot-assisted radical cystectomy (RARC) vs. open radical cystectomy (ORC). Similar to other diseases, RARC has been estimated to be more costly than ORC (i.e., approximately US $1600 difference per case in direct costs). A population-based study found that the inpatient cost difference exceeded the US $1600 figure.

However, RARC has been reported to result in potentially less perioperative complications and a shorter length of stay than ORC, thereby possibly lowering hospital costs. When perioperative complication costs were included in the cost-comparison analysis of RARC and ORC, one study found that RARC was indeed cheaper than ORC (83 vs. 103 consecutive cases, respectively). The generalisability of these single-institution analyses is limited as the data are from high-volume, tertiary care centres with significant robotic experience. The cost issue therefore remains unsettled.

Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation

Formal blinded peer review was performed prior to publication.

The Appraisal of Guidelines for Research and Evaluation (AGREE) instrument was used to analyse and assess a range of specific attributes contributing to the validity of a specific clinical guideline.

The AGREE instrument, to be used by two to four appraisers, was developed by the AGREE collaboration (www.agreetrust.org External Web Site Policy) using referenced sources for the evaluation of specific guidelines (see the "Availability of Companion Documents" field for further methodology information).

Recommendations

Major Recommendations

Note from the European Association of Urology (EAU) and the National Guideline Clearinghouse (NGC): The following recommendations were current as of March 2013. However, because EAU updates their guidelines frequently, users may wish to consult the EAU Web site External Web Site Policy for the most current version available.

Levels of evidence (1–4) and grades of recommendation (A–C) are defined at the end of the "Major Recommendations" field.

Renal Robotics – Radical Nephrectomy, Reconstructive, and Pyeloplasty

Conclusions and Recommendations on Robotic Partial Nephrectomy (RPN) and Laparoscopic Partial Nephrectomy (LPN)

Conclusions on RPN and LPN

  • Conclusive long-term data are not available.
  • RPN and robotic radical nephrectomy (RRN) are technically feasible.
  • No comparable long-term data on oncological, safety, and functional outcomes are available. However, based on short-term data and panel expertise, no significant differences are expected (Level of evidence: 4).
  • In ablative surgery, robotics will produce no better outcomes compared to laparoscopy.
  • Possible benefit in reconstructive surgery, i.e., partial nephrectomy/pyeloplasty

Recommendations

  • Use laparoscopy for simple or radical nephrectomy (Grade of recommendation: C).
  • Use robotic-assisted or laparoscopic surgery for partial or reconstructive renal surgery if technically feasible (Grade of recommendation: C).
  • Use of minimal invasive techniques should not compromise nephron-sparing surgery in ≤pT1b (Grade of recommendation: C).

Laparoendoscopic Single Site (LESS) Kidney – Radical Nephrectomy, Partial Nephrectomy, Nephroureterectomy, Pyeloplasty, and (Partial) Adrenalectomy

Conclusions and Recommendations

Conclusions

  • LESS surgical procedures of the upper urinary tract are technically feasible but demanding (Level of evidence: 3).
  • Long-term oncological data are not yet available.
  • No proven or documented benefits over laparoscopic approach.
  • Cosmesis is a reported advantage (Level of evidence: 4).

Recommendations

  • LESS surgery should be favoured in cases where cosmesis is of paramount importance (Grade of Recommendation: A).
  • Only experienced laparoscopic surgeons should embark on this technique (Grade of Recommendation: A).

LESS Partial Nephrectomy

Recommendations

  • LESS surgery or single-incision triangulated umbilical surgery (SITUS) partial nephrectomy for renal cell cancer can provide an alternative surgical approach in experienced hands if all the factors involved in choosing open or laparoscopic partial nephrectomy are considered, especially with regard to warm ischaemia time (WIT) and organ sparing. Currently, LESS or SITUS practical nephrectomy are only advised as part of a clinical study (Level of evidence: 2a, 3b; Grade of recommendation: B).
  • Open or conventional laparoscopic partial nephrectomy is mandatory for patients with tumours smaller than 4 cm (Level of evidence: 1b; Grade of recommendation: A).

Robotic-assisted Radical Prostatectomy (RARP)

Conclusions and Recommendations on Robotic Radical Prostatectomy

Conclusions

  • RARP for localised prostate cancer is now a well-established surgical approach offering similar positive surgical margin rates with open retropubic radical prostatectomy (ORP) and laparoscopic radical prostatectomy (LRP) (Level of evidence: 2a).
  • Long-term prostate-specific antigen (PSA)-free survival of patients treated with RARP as documented for up to 5 years is comparable with other radical prostatectomy approaches (Level of evidence: 3b).
  • In the absence of Level 1a data and very limited long-term data, a firm conclusion regarding the oncological superiority of the technique over other techniques cannot be drawn (Level of evidence: 2a).

Recommendation

  • Robotic surgery does not improve oncological outcomes in comparison to ORP and LRP; surgical expertise is the crucial factor. Use of the robot is not recommended to improve surgical outcomes (Grade of recommendation: A).

RARP and Urinary Continence

Conclusions and Recommendations on RARP and Incontinence

Conclusions

  • RARP for localised prostate cancer is a surgical approach offering high continence rates, at least comparable with ORP and LRP (Level of evidence: 2a).
  • Experienced robotic surgeons achieve good early continence results (Level of evidence: 3b).
  • There is a trend towards faster recovery of continence after RARP in comparison to ORP and LRP (Level of evidence: 3b).

Recommendation

  • To achieve better early continence results, the use of robotic technique is recommended* (Grade of Recommendation: C).

*The expert panel would like to stress that a well-done laparoscopy or open procedure would produce similar results.

RARP and Potency

Conclusions and Recommendations on RARP and Potency

Conclusions

  • Potency assessment after radical prostatectomy has many limitations, which partly explains the wide variation in potency outcomes among different studies (Level of evidence: 2a).
  • RARP is not inferior to ORP and LRP for potency rates (Level of evidence: 2a).
  • There is a trend towards faster recovery of potency after robotic-assisted laparoscopic radical prostatectomy (RALP) in comparison to ORP and LRP (Level of evidence: 2a-3b).

Recommendations

  • To achieve better early potency results, the use of laparoscopy or robotic techniques are recommended* (Grade of recommendation: C).
  • To achieve better early potency results, a cautery-free (i.e., athermal) technique during neurovascular bundle dissection is recommended (Grade of recommendation: A).

*The expert panel would like to stress that a well-done ORP or LRP, compared to RARP would produce similar results.

Robotic-assisted Pelvic Lymph Node Dissection (PLND) at the Time of Radical Prostatectomy

Conclusions and Recommendations on Root-assisted PLND

Conclusions

  • The reported number of lymph nodes removed in laparoscopic and robotic series is lower than in open surgical series (Level of evidence: 2a).
  • However, the same extent of lymphadenectomy can be safely performed by all techniques of radical prostatectomy including RARP.

Recommendation

  • RARP, LRP, and ORP achieve similar perioperative and oncological PLND outcomes so either technique can be used in lymphadenectomy (Grade of recommendation: A).

Robotic-assisted Laparoscopic Sacrocolpopexy (RALS)

Conclusion and Recommendation on RALS

Conclusion

  • RALS is safe and effective in restoring vaginal vault prolapse with durability evidenced up to 24 months (Level of evidence: 2b).

Recommendation

  • Laparoscopic and robotic colpopexy should be considered standard treatment options for the restoration of apical vaginal vault defects (Grade of recommendation: A).

Robotic-assisted and LESS Cystectomy

  • Due to the lack of data available, the authors cannot recommend this approach, outside of properly designed clinical trials.

Conclusions on Robotic-assisted Radical Cystectomy (RARC)

Conclusions

  • RARC is a feasible and safe approach with comparable perioperative and long-term complications to open radical cystectomy (ORC) (Level of evidence: 1b).
  • RARC can yield the same extent of lymphadenectomy than ORC (Level of evidence: 1b).
  • Initial RARC series had a high rate of positive soft tissue surgical margins. Experienced surgeons, however, can achieve similar margin rates, irrespective of the technique used (Level of evidence: 1b).
  • Short- and intermediate-term survival data from retrospective series suggest that the oncological efficacy of RARC is not inferior to that of ORC (Level of evidence: 3).
  • Urinary diversion can safely be performed extracorporeally or intracorporeally (Level of evidence: 3).

Definitions:

Level of Evidence

Level Type of Evidence
1a Evidence obtained from meta-analysis of randomised trials
1b Evidence obtained from at least one randomised trial
2a Evidence obtained from one well-designed controlled study without randomisation
2b Evidence obtained from at least one other type of well-designed quasi-experimental study
3 Evidence obtained from well-designed non-experimental studies, such as comparative studies, correlation studies and case reports
4 Evidence obtained from expert committee reports or opinions or clinical experience of respected authorities

Grade of Recommendations

Grade Nature of Recommendations
A Based on clinical studies of good quality and consistency addressing the specific recommendations and including at least one randomised trial
B Based on well-conducted clinical studies, but without randomised clinical trials
C Made despite the absence of directly applicable clinical studies of good quality
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Except for a few procedures for which more mature data exist, recommendations are generally based on the panel's review of low-level evidence and expert opinion.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate use of robotic- and single-site surgery in urology

Potential Harms
  • As with all technical equipment, malfunctions may occur during robotic surgery; conversion to open procedure may be necessary in that case.
  • Robotic radical nephrectomy (RRN). The reported complication rate of RRN in experienced hands is 18%, which is similar to the reported rate for laparoscopic radical nephrectomy. A longer operative time for RRN is reported, mainly due to the learning curve, robot dock time, and port placement. In the largest single centre series to date, which consists of 400 patients undergoing RPN, there were a total of 11 intraoperative complications (2.7%). There were 61 cases (15.3%) of postoperative complications, which were mainly low grade (grades 3 and 4 in 3.2%).
  • Robotic partial nephrectomy (RPN). In one study, the mean blood loss was higher in RPN cohort compared to the laparoscopic partial nephrectomy (LPN) group. Conversion rate was significantly lower (1%) in the RPN group compared to the LPN cohort.
  • Laparoendoscopic single-site surgery (LESS). In one study, LESS was associated with a higher complication rate than in major conventional laparoscopic series. An 18-institution multinational series with 1,076 patients reported a total of 3.3% of intraoperative complications (1.7% vascular, 0.5% bowel, 0.2% splenic, and diaphragmatic injuries) and 9.5% postoperative complications. Postoperative complications were 3.3% Dindo-Clavien grade 1, 3.8% grade 2, 1.9% grade 3, and 0.4% grade 4. An additional port was used in 23% of all cases. Conversion rate was 20.8% (1% to open surgery) and the overall transfusion rate was 6.1%.
  • Robot-assisted radical prostatectomy (RARP). RARP for localised prostate cancer has similar positive surgical margin rates with open retropubic radical prostatectomy (ORP) and laparoscopic radical prostatectomy (LRP). RARP reveals a trend towards better potency and continence outcomes compared to LRP.
  • Robot-assisted radical cystectomy (RARC). Taken together, complication rates of RARC in the literature range from 20% to 91%. Risk factors associated with major complications after RARC are age >65 years, estimated perioperative blood loss >500 mL and intraoperative intravenous fluid >5,000 mL. The cumulative data supports the finding that the perioperative and long-term safety of RARC is at least not inferior to that of ORC. However, the long-term oncological safety of RARC is still under debate.

Qualifying Statements

Qualifying Statements
  • There is still an on-going learning curve with robotic surgery. It was therefore difficult to draw strong conclusions from the data currently available for analysis. There is a lack of multicentre, randomised, controlled studies producing conclusive evidence supporting open vs. laparoscopic surgery. In the absence of high-quality data, the expert panel came to the conclusion that providing guidance on the use of robotic-assisted surgery may even be more important. Except for a few procedures for which more mature data exist, recommendations are therefore generally based on the panel's review of low-level evidence and expert opinion.
  • This document will not address economic evidence for robotic surgery in a systematic fashion. Resource limitations made it impossible for the panel to perform a comparative cost analysis (laparoscopic vs. robot-assisted surgery). Doing so within a European-wide setting is not possible because national health policies determine the costs of clinical care.
  • The aim of clinical guidelines is to help clinicians to make informed decisions about their patients. However, adherence to a guideline does not guarantee a successful outcome. Ultimately, healthcare professionals must make their own treatment decisions about care on a case-by-case basis, after consultation with their patients, using their clinical judgment, knowledge, and expertise. A guideline is not intended to take the place of physician judgment in diagnosing and treatment of an individual patient.
  • Guidelines may not be complete or accurate. The European Association of Urology (EAU) and their Guidelines Office, and members of their boards, officers and employees disclaim all liability for the accuracy or completeness of a guideline, and disclaim all warranties, express or implied to their incorrect use.
  • Guidelines users always are urged to seek out newer information that might impact the diagnostic and treatment recommendations contained within a guideline.
  • Due to their unique nature – as international guidelines, the EAU Guidelines are not embedded within one distinct healthcare setting – variations in clinical settings, resources, or common patient characteristics, are not accounted for.

Implementation of the Guideline

Description of Implementation Strategy

The European Association of Urology (EAU) Guidelines long version (containing all EAU guidelines) is reprinted annually in one book. Each text is dated. This means that if the latest edition of the book is read, one will know that this is the most updated version available. The same text is also made available on a CD (with hyperlinks to PubMed for most references) and posted on the EAU website Uroweb (http://www.uroweb.org/guidelines/online-guidelines/ External Web Site Policy).

Condensed pocket versions, containing mainly flow-charts and summaries, are also printed annually. All these publications are distributed free of charge to all (more than 17,000) members of the association. Abridged versions of the guidelines are published in European Urology as original papers. Furthermore, many important websites list links to the relevant EAU guidelines sections on the association websites and all, or individual, guidelines have been translated to some 25 languages.

Implementation Tools
Quick Reference Guides/Physician Guides
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Merseburger AS, Nagele U, Herrmann TRW, Traxer O, Kyriaziazis I, Liatsikos EN. Guidelines on robotic- and single-site surgery in urology. Arnhem (The Netherlands): European Association of Urology (EAU); 2013 Mar. 38 p. [206 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2013 Mar
Guideline Developer(s)
European Association of Urology - Medical Specialty Society
Source(s) of Funding

European Association of Urology

Guideline Committee

Urological Technologies Guidelines Working Group

Composition of Group That Authored the Guideline

Working Group Members: A.S. Merseburger (Chair); U. Nagele; T.R.W. Herrmann; O. Traxer; I. Kyriazis; S.F. Shariat; E.N. Liatsikos

Financial Disclosures/Conflicts of Interest

All members of the Urological Technologies guidelines working group have provided disclosure statements of all relationships which they have and which might be perceived to be a potential source of a conflict of interest. This information is publicly accessible and can be viewed online at the EAU Web site (http://www.uroweb.org/guidelines/eau-guidelines-board-and-working-panels/ External Web Site Policy). This guidelines document was developed with the financial support of the European Association of Urology. No external sources of funding and support have been involved. The EAU is a non-profit organisation, and funding is limited to administrative assistance and travel and meeting expenses. No honoraria or other reimbursements have been provided.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the European Association of Urology (EAU) Web site External Web Site Policy.

Print copies: Available from the European Association of Urology, PO Box 30016, NL-6803, AA ARNHEM, The Netherlands.

Availability of Companion Documents

The following are available:

  • The European Association of Urology (EAU) guidelines office manual. Arnhem (The Netherlands): European Association of Urology (EAU); 2012. 35 p. Electronic copies: Available in Portable Document Format (PDF) from the European Association of Urology (EAU) Web site External Web Site Policy.
  • Merseburger AS, Herrmann TR, Shariat SF, Kyriazis I, Nagele U, Traxer O, Liatsikos EN. EAU guidelines on robotic and single-site surgery in urology. Eur Urol. 2013 Aug;64(2):277-91. Electronic copies: Available in PDF from the EAU Web site External Web Site Policy.

Print copies: Available from the European Association of Urology, PO Box 30016, NL-6803, AA ARNHEM, The Netherlands.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on July 25, 2013. The information was verified by the guideline developer on August 20, 2013.

Copyright Statement

This summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Downloads are restricted to one download and print per user, no commercial usage or dissemination by third parties is allowed.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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