The authors reply: Korean clinical practice guideline for benign prostatic hyperplasia.

To the editor:

The level of recommendation is an indicator of the grading of recommendation degree in taking into account overall such as the balance of profit and loss and cost-effectiveness or cost-benefit aspects after evaluating the level of evidence. In consideration of clinical usability, it eventually have been proposed to the strength of recommendation, a higher level of evidence generally becomes higher level of recommendation. But it is possible to give higher level of recommendation even if low level of evidence depending on panel consensus in the clinical practice guideline (CPG) [123].

If we had to use the recommendation levels of more than 3 steps, we could show a more definite recommendation level in our CPG. But there were often the "strong" recommendations because of simplifying 2-stage recommendation levels. Also in part of the diagnosis we should face the situation not enough higher level literatures. It should be understood that we could not reduce the level of recommendation to "weak" for low evidence level in the cases were clinically deserved. For example 2015 European Association of Urology guideline gave a higher level of recommendation through a panel consensus even if low level of evidence in the diagnosis part of the male lower urinary tract symptoms guideline [4].

It is well known way to be recognized internationally that guideline was made with the method of GRADE (Grading of Recommendations Assessment, Development and Evaluation) Working Group. We will have a plan to try a change the level of recommendation to be recognized internationally in the Korean Urological Association guidelines.