INTRODUCTION:Daytime urinary incontinence (DUI) is a prevalent condition in children that can have a negative impact on both their quality of life and their parents' psychosocial wellbeing. Parents play a central role in care and often initiate referrals. Despite this, parental experiences are underexplored. OBJECTIVE:The aim of this study was to explore how parents perceive and manage their child's DUI and the associated healthcare process. STUDY DESIGN:A mixed-methods study was set up. In the qualitative phase, semi-structured interviews were conducted with parents of children aged 4-12 years who had completed treatment for DUI at our outpatient clinic. Based on these interviews, a questionnaire was developed and distributed to all parents of children aged 4-18 years who were treated by a paediatrician or paediatric urologist between January 2016 and August 2019. RESULTS:Saturation was reached after seven interviews, revealing three domains influencing care experience. The questionnaire was completed by 85 respondents (response rate 29.5%). 1. Diagnostics/therapy: Diagnostic procedures were generally well tolerated by children, and voiding diaries were not burdensome for parents. Most parents aimed for complete dryness, 64% felt treatment aligned with their goals and 43% reported achieving their goal. 2. Social context: Most parents (75.3%) were concerned about UI. Family life was affected in 36.5% of cases, and 42.4% felt unable to adequately support their child. 3. Interaction between professional and parent/child: Care was perceived as child-centred by 87.1%, and 78.8% felt stimulated to discuss their own concerns. According to parents, 64.8% of children felt comfortable discussing UI with the care professional. Most parents (85.7%) felt involved in treatment planning. However, when asked about their ability to choose a treatment, 49.4% responded 'neutral' and 22,9% disagreed. The mean overall satisfaction score from parents was 7.5 out of 10 (with 1 being the lowest and 10 the highest possible score). DISCUSSION:While overall satisfaction was high, experiences varied, and less than half of parents achieved their goal at the end of the treatment. Some parents primarily sought guidance rather than complete dryness. A lack of dialogue about goals or treatment options may leave needs (like guidance) unmet and lead to unnecessary care (e.g. treatment for total dryness). CONCLUSION:Parents' experiences overall are positive, but can vary widely, affected by their goals and expectations. These findings highlight the importance of discussing expectations to improve outcomes and reduce healthcare use.

This study aimed to evaluate the quality of currently available guidelines on non-neurogenic daytime urinary incontinence (DUI) in children and compare their content regarding the assessment of a child with DUI. We conducted a systematic search for guidelines on non-neurogenic DUI in children. A multidisciplinary team assessed the quality using the Appraisal of Guidelines for Research and Evaluation II (AGREE) instrument, which contains 23 items organized into six domains. Besides, each member evaluated if they would recommend using the guidelines. We extracted diagnostic recommendations from all guidelines for a descriptive comparison. Eight guidelines were included. Overall quality scores ranged from 2.6 to 5.8 on a 7-point scale, (1 for lowest and 7 for highest quality). Three guidelines were rated as good, four as moderate, and one as low quality. The AGREE-II domain Clarity and Presentation received high scores across all guidelines, while Rigour of Development and Applicability received the lowest scores. Recommendations for diagnostics were generally similar, with variations observed in guidelines targeting primary and secondary healthcare. This study is the first to assess the quality of guidelines on non-neurogenic DUI in children. The quality varies, only two out of eight guidelines were recommended by the review team without adjustments. Guideline developers could improve the quality of their guidelines by using tools like AGREE II. Clinicians should consider the findings of our study when selecting a guideline to use in their daily practice. As this is a review, no clinical trial registration was conducted. The review protocol has been registered in PROSPERO (CRD42021149059).

AIMS:This study aimed to compare the recommendations on therapy from currently available guidelines on non-neurogenic daytime urinary incontinence (DUI) in children. METHODS:We conducted a systematic search for guidelines on non-neurogenic DUI in children. We extracted the therapy recommendations from all the guidelines for a descriptive comparison. RESULTS:Eight guidelines were included. All guidelines advise urotherapy as the first step of treatment in children with DUI. They all agree on the importance of addressing co-existing bowel dysfunction and urinary tract infections. Neuromodulation was recommended as an early treatment modality in three guidelines, while the others reserve it for special cases (n = 2) or do not mention it at all (n = 3). Pharmacotherapy with anticholinergics is often recommended, sometimes when urotherapy is insufficient, and by some guidelines simultaneously. The use of newer beta-3-agonists was only mentioned by recently (2019 and 2021) published guidelines. Only half of the guidelines mentioned the level of evidence with their recommendations, and when mentioned, the quality of the evidence is generally low. CONCLUSION:Overall, the recommendations for treating non-neurogenic DUI in children are generally consistent, with all the guidelines endorsing urotherapy as the initial treatment. However, differences exist regarding additional treatments such as neuromodulation and pharmacotherapy, both areas of active research with evolving insights. The observed differences can be explained by the publication date of the guidelines and the target audience. The evidence supporting the recommendations is generally of low quality, indicating a need for further research in the field of DUI in children. TRIAL REGISTRATION:As this is a review, no clinical trial registration was conducted. The review protocol has been registered in PROSPERO (CRD42021149059).

The aim of this study was to explore treatment options for chronic urinary retention (CUR) in men, including complications and consequences. Male patients diagnosed with a non-neurogenic, symptomatic and/or high-risk, CUR > 150 mL were included. Data for treatments, complications, and consequences were recorded and incidence rate ratios (IRRs) calculated. We enrolled 177 patients, most initially received a urethral catheter (74%) and some form of catheterization as final treatment (87%), 49 (28%) underwent de-obstructive prostate surgery. Catheterization was more likely to be stopped after surgery (16/49 patients), compared with non-surgical cases (8/128 patients) (IRR 4.18; p < 0.001). Urinary tract infection (IRR 3.68; p < 0.001) and macroscopic hematuria (IRR 5.35; p < 0.001) were more common with catheterization, but post-renal problems were more likely in patients without catheterization (IRR 25.36; p < 0.001). The lowest complication rate was with clean intermittent catheterization. In conclusion, most patients received catheterization for CUR, with clean intermittent catheterization preferred due to its comparatively lower complication risk. De-obstructive prostate surgery increases the chance of stopping catheterization.

Abstract Background In the Netherlands, parents of children with daytime urinary incontinence (UI) first consult general practitioners (GPs). However, GPs need more specific guidelines for daytime UI management, resulting in care and referral decisions being made without clear guidance. Objectives We aimed to identify Dutch GP considerations when treating and referring a child with daytime UI. Methods We invited GPs who referred at least one child aged 4–18 years with daytime UI to secondary care. They were asked to complete a questionnaire about the referred child and the management of daytime UI in general. Results Of 244 distributed questionnaires, 118 (48.4%) were returned by 94 GPs. Most reported taking a history and performing basic diagnostic tests like urine tests (61.0%) and physical examinations (49.2%) before referral. Treatment mostly involved lifestyle advice, with only 17.8% starting medication. Referrals were usually at the explicit wish of the child/parent (44.9%) or because of symptom persistence despite treatment (39.0%). GPs usually referred children to a paediatrician (n = 99, 83.9%), only referring to a urologist in specific situations. Almost half (41.4%) of the GPs did not feel competent to treat children with daytime UI and more than half (55.7%) wanted a clinical practice guideline. In the discussion, we explore the generalisability of our findings to other countries. Conclusion GPs usually refer children with daytime UI to a paediatrician after a basic diagnostic assessment, usually without offering treatment. Parental or child demand is the primary stimulus for referral.

To review the effect of bladder outlet procedures on urodynamic outcomes and symptom scores in males with detrusor underactivity (DU) or acontractile detrusors (AD).

Children with a solitary functioning kidney (SFK) have an increased risk of kidney injury. The exact risk of and risk factors for kidney injury remain unknown, which impedes personalized care. Here, we recruited a nationwide multicenter cohort of 944 patients with SFK to get more insight into this by consenting patients born in 1993-2020 and diagnosed with congenital or acquired SFK before adulthood. The median follow-up was 12.8 years and four indications of kidney injury were studied: urine protein-creatinine ratios, blood pressure, estimated glomerular filtration rate and use of anti-hypertensive/proteinuric medication. For each indicator except medication use, separate cut-off values for any injury and severe injury were used. Survival analyses indicated that at 18 years of age, any or severe kidney injury were present in 75% and 39% of patients with congenital SFK, respectively. Risk factors for kidney injury included kidney agenesis as cause of the SFK, anomalies in the SFK, and high body mass index at last follow-up. Kidney agenesis and being overweight were specifically associated with proteinuria and high blood pressure, whereas anomalies in the SFK were associated with reduced estimated glomerular filtration rates. The high prevalence of kidney injury in patients with SFK emphasizes the need for long-term follow-up, in which lifestyle is an important topic to address. More research into the etiological role of risk factors will help to translate our findings into individualized care strategies. Thus, our study shows that a significant proportion of children with SFK will develop kidney injury over time.

Objectives: To compare the recurrence of non-muscle invasive bladder carcinoma (NMIBC) after transurethral resection employing cystoscopy with hexaminolevulinate-based photodynamic diagnosis (PDD) or with standard white light. Patients and methods: We included patients with newly suspected NMIBC in this retrospective cohort study and compared those undergoing transurethral resection by white light cystoscopy (WLC) (2008–2010) and PDD (2010–2012). All patients were treated following established criteria for good quality resection. The primary outcome was the difference in the recurrence rate after 60 months’ follow-up, but we also stratified recurrence by risk groups, as set by the European Organization for Research and Treatment of Cancer. The mean recurrence-free survival was compared between the cohorts. Odds ratios or hazard ratios are reported with their 95% confidence intervals. Results: The WLC and PDD cohorts comprised 124 and 91 subjects, respectively. There were no significant differences in recurrence rates between the cohorts at 6 months (recurrence rate 9/123; 7.3%), 12 months (17/118; 14.4%) or 60 months (39/102; 38.2%), with odds ratios of 1.23 (CI 0.48–3.25), 1.32 (CI 0.67–2.62) and 1.12 (CI 0.70–1.79), in favour of WLC, respectively. Further analysis showed no significant effect of PDD on either recurrence by risk group or on mean recurrence-free survival (hazard ratio, 1.12 [CI 0.70–1.79]). Conclusion: We found no relevant differences in the recurrence of NMIBC after the introduction of PDD with hexaminolevulinate compared to standard WLC when used for transurethral resection in our single institution.

INTRODUCTION AND HYPOTHESIS:Patients with recurrent urinary tract infection (rUTI) have limited knowledge of preventive strategies to lower the risk of UTI. We aimed to develop and test the feasibility of an eHealth system for women with rUTI, named myRUTIcoach, and explored the facilitators and barriers related to its adoption. METHODS:We developed myRUTIcoach in a structured iterative process and tested its feasibility among 25 women with rUTI over 2 months. Subsequent questionnaires covered satisfaction, accessibility, and experiences with myRUTIcoach. A random selection of participants and relevant stakeholders took part in semi-structured interviews to explore adoption. Data were analyzed and elaborated using inductive and deductive approaches using the Non-adoption, Abandonment, Spread, Scale-up, and Sustainability (NASSS) framework. RESULTS:MyRUTIcoach was not only widely accepted but also facilitated communication with health care professionals (HCPs) and contributed to greater knowledge of rUTI. Women graded the system a mean of 8.0 (±0.6) out of 10, with 89% stating that they would recommend it to others. Patients indicated that self-management skills were the major facilitators and barriers related to adoption, whereas HCPs stated that the disconnect between myRUTIcoach and electronic health care records (EHRs) was the major barrier. CONCLUSIONS:This research describes the development and testing of myRUTIcoach for women with rUTI. Patients and HCPs reported high satisfaction and compliance with myRUTIcoach. However, adoption by the intended users is complex and influenced by all examined domains of the NASSS framework. We have already improved linkage to EHRs, but further optimization to meet patient needs may improve the effectiveness of this self-management tool for rUTI.

Background: Culture-based antibiotic prophylaxis is a plausible strategy to reduce infections after transrectal prostate biopsy (PB) related to fluoroquinolone-resistant pathogens.Objective: To assess the cost effectiveness of rectal culture-based prophylaxis com-pared with empirical ciprofloxacin prophylaxis. Design, setting, and participants: The study was performed alongside a trial in 11 Dutch hospitals investigating the effectiveness of culture-based prophylaxis in transrectal PB between April 2018 and July 2021 (trial registration number: NCT03228108).Intervention: Patients were 1:1 randomized for empirical ciprofloxacin prophylaxis (oral) or culture-based prophylaxis. Costs for both prophylactic strategies were determined for two scenarios: (1) all infectious complications within 7 d after biopsy and (2) culture-proven Gram-negative infections within 30 d after biopsy.Outcome measurements and statistical analysis: Differences in costs and effects (quality-adjusted life-years [QALYs]) were analyzed from a healthcare and societal perspective (including productivity losses, and travel and parking costs) using a bootstrap procedure presenting uncertainty surrounding the incremental cost-effectiveness ratio in a cost-effectiveness plane and acceptability curve.Results and limitations: For the 7-d follow-up period, culture-based prophylaxis (n = 636) was euro51.57 (95% confidence interval [CI] 6.52-96.63) more expensive from a healthcare perspective and euro16.95 (95% CI -54.29 to 88.18) from a societal perspective than empirical ciprofloxacin prophylaxis (n = 652). Ciprofloxacin-resistant bacteria were detected in 15.4%. Extrapolating our data, from a healthcare perspective, 40% ciprofloxacin resistance would lead to equal cost for both strate-gies. Results were similar for the 30-d follow-up period. No significant differences in QALYs were observed.Conclusions: Our results should be interpreted in the context of local ciprofloxacin resistance rates. In our setting, from a healthcare perspective, culture-based pro-phylaxis was significantly more expensive than empirical ciprofloxacin prophy-laxis. From a societal perspective, culture-based prophylaxis was somewhat more cost effective against the threshold value customary for the Netherlands (euro80.000).Patient summary: Culture-based prophylaxis in transrectal prostate biopsy was not associated with reduced costs compared with empirical ciprofloxacin prophylaxis.(c) 2023 The Author(s). Published by Elsevier B.V. on behalf of European Association of Urology. This is an open access article under the CC BY license (http://creativecommons. org/licenses/by/4.0/).

Introduction Posterior urethral valves (PUV) is a congenital disorder causing an obstruction of the lower urinary tract that affects approximately 1 in 4,000 male live births. PUV is considered a multifactorial disorder, meaning that both genetic and environmental factors are involved in its development. We investigated maternal risk factors for PUV. Methods We included 407 PUV patients and 814 controls matched on year of birth from the AGORA data- and biobank and three participating hospitals. Information on potential risk factors (family history of congenital anomalies of the kidney and urinary tract (CAKUT), season of conception, gravidity, subfertility, and conception using assisted reproductive techniques (ART), plus maternal age, body mass index, diabetes, hypertension, smoking, and use of alcohol and folic acid) was derived from maternal questionnaires. After multiple imputation, adjusted odds ratios (aORs) were estimated using conditional logistic regression corrected for minimally sufficient sets of confounders determined using directed acyclic graphs. Results A positive family history and low maternal age (<25 years) were associated with PUV development [aORs: 3.3 and 1.7 with 95% confidence intervals (95% CI) 1.4–7.7 and 1.0–2.8, respectively], whereas higher maternal age (>35 years) was associated with a lower risk (aOR: 0.7 95% CI: 0.4–1.0). Maternal preexisting hypertension seemed to increase PUV risk (aOR: 2.1 95% CI: 0.9–5.1), while gestational hypertension seemed to decrease this risk (aOR: 0.6 95% CI: 0.3–1.0). Concerning use of ART, the aORs for the different techniques were all above one, but with very wide 95% CIs including one. None of the other factors studied were associated with PUV development. Conclusion Our study showed that family history of CAKUT, low maternal age, and potentially preexisting hypertension were associated with PUV development, whereas higher maternal age and gestational hypertension seemed to be associated with a lower risk. Maternal age and hypertension as well as the possible role of ART in the development of PUV require further research.

To explore the treatment options for chronic urinary retention (CUR) in men, including treatment-related complications and consequences.This retrospective cohort study included male patients diagnosed with a non-neurogenic, symptomatic and/or high-risk, CUR >150 mL in a large Dutch non-academic teaching hospital. Data for treatments, complications, and consequences (e.g., diagnostics, additional treatments, and hospital contact) were recorded and incidence rate ratios (IRRs) were calculated.We enrolled 177 patients (median age, 77 years; range, 44-94) with a median follow-up of 68 months (range, 1-319) during which they had a median of 8 events (range, 1-51). Most patients initially received a urethral catheter (74%) and some form of catheterization as their final treatment (87%). Compared with non-surgical cases, catheterization was more likely to be stopped after de-obstructive prostate surgery (IRR, 4.18; p < 0.001). Urinary tract infection (IRR, 3.68; p < 0.001) and macroscopic hematuria (IRR, 5.35; p < 0.001) were more common with catheterization, but post-renal problems were more likely in patients with no catheterization (IRR, 25.36; p < 0.001). The lowest chance of complication was with clean intermittent catheterization, and complications were usually managed in outpatient (77%) or emergency (6%) departments, rather than by admission (17%).Most patients require catheterization for CUR, with clean intermittent catheterization preferred due to its comparatively lower complication risk. De-obstructive prostate surgery increases the chance of stopping catheterization and may be considered in suitable cases.

BackgroundIt remains uncertain whether transrectal ultrasound (TRUS)-guided systematic biopsies can be omitted and rely solely on multiparametric magnetic resonance imaging–targeted biopsies (MRI-TBx) in biopsy-naïve men suspected of prostate cancer (PCa).ObjectiveTo compare PCa detection in biopsy-naïve men between systematic biopsy and MRI-TBx.Design, setting, and participantsA prospective cohort study was conducted in a Dutch teaching hospital. Consecutive patients with suspected PCa, no history of biopsy, and no clinical suspicion of metastasis underwent both TRUS-guided systematic biopsies and MRI-TBx by multiparametric magnetic resonance imaging (mpMRI)-ultrasound fusion, including sham biopsies in case of negative mpMRI.Outcome measurements and statistical analysisClinically significant PCa (csPCa), defined as group ≥2 on the International Society of Urological Pathology grading, was detected.Results and limitationsThe overall prevalence of csPCa, irrespective of biopsy technique, was 37.4% (132/353) in our population. MRI-TBx were performed in 263/353 (74.5%) patients with suspicious mpMRI (Prostate Imaging Reporting and Data System [PI-RADS] ≥3). The detection rates for csPCa were 39.5% for MRI-TBx and 42.9% for systematic biopsies. The added values, defined as the additional percentages of patients with csPCa detected by adding one biopsy technique, were 8.7% for the systematic biopsies and 5.3% for MRI-TBx. In patients with nonsuspicious mpMRI, five cases (6%) of csPCa were found by systematic biopsies.ConclusionsThis study in biopsy-naïve patients suspected for PCa showed that systematic biopsies have added value to MRI-TBx alone in patients with mpMRI PI-RADS >2.Patient summaryWe studied magnetic resonance imaging (MRI)-guided prostate biopsy for diagnosing prostate cancer and compared it with the standard method of prostate biopsy. Standard systematic biopsies cannot be omitted in patients with suspicious MRI, as they add to the detection of significant prostate cancer.

Abstract Background An increase in infections after transrectal prostate biopsy (PB), related to an increasing number of patients with ciprofloxacin-resistant rectal flora, necessitates the exploration of alternatives for the traditionally used empirical prophylaxis of ciprofloxacin. We compared infectious complication rates after transrectal PB using empirical ciprofloxacin prophylaxis versus culture-based prophylaxis. Methods In this nonblinded, randomized trial, between 4 April 2018 and 30 July 2021, we enrolled 1538 patients from 11 Dutch hospitals undergoing transrectal PB. After rectal swab collection, patients were randomized 1:1 to receive empirical prophylaxis with oral ciprofloxacin (control group [CG]) or culture-based prophylaxis (intervention group [IG]). Primary outcome was any infectious complication within 7 days after biopsy. Secondary outcomes were infectious complications within 30 days, and bacteremia and bacteriuria within 7 and 30 days postbiopsy. For primary outcome analysis, the χ2 test stratified for hospitals was used. Trial registration number: NCT03228108. Results Data from 1288 patients (83.7%) were available for analysis (CG, 652; IG, 636). Infection rates within 7 days postbiopsy were 4.3% (n = 28) (CG) and 2.5% (n = 16) (IG) (P value = .08; reduction: −1.8%; 95% confidence interval, −.004 to .040). Ciprofloxacin-resistant bacteria were detected in 15.2% (n = 1288). In the CG, the presence of ciprofloxacin-resistant rectal flora resulted in a 6.2-fold higher risk of early postbiopsy infection. Conclusions Our study supports the use of culture-based prophylaxis to reduce infectious complications after transrectal PB. Despite adequate prophylaxis, postbiopsy infections can still occur. Therefore, culture-based prophylaxis must be weighed against other strategies that could reduce postbiopsy infections. Clinical Trials Registration. NCT03228108.

OBJECTIVE To explore the treatment options for chronic urinary retention (CUR) in men, including treatment-related complications and consequences.METHODS This retrospective cohort study included male patients diagnosed with a non-neurogenic, symptomatic and/or high-risk, CUR >150 mL in a large Dutch non-academic teaching hospital. Data for treatments, complications, and consequences (eg, diagnostics, additional treatments, and hospital contact) were recorded and incidence rate ratios (IRRs) were calculated.RESULTS We enrolled 177 patients (median age, 77 years; range, 44-94) with a median follow-up of 68 months (range, 1-319) during which they had a median of 8 events (range, 1-51). Most patients initially received a urethral catheter (74%) and some form of catheterization as their final treatment (87%). Compared with non-surgical cases, catheterization was more likely to be stopped after de-obstructive prostate surgery (IRR, 4.18; P < 0.001). Urinary tract infection (IRR, 3.68; P < 0.001) and macroscopic hematuria (IRR, 5.35; P < 0.001) were more common with catheterization, but post-renal problems were more likely in patients with no catheterization (IRR, 25.36; P < 0.001). The lowest chance of complication was with clean intermittent catheterization, and complications were usually managed in outpatient (77%) or emergency (6%) departments, rather than by admission (17%).CONCLUSION Most patients require catheterization for CUR, with clean intermittent catheterization preferred due to its comparatively lower complication risk. De-obstructive prostate surgery increases the chance of stopping catheterization and may be considered in suitable cases. UROLOGY 167: 185-190, 2022. (c) 2022 Elsevier Inc.

Congenital lower urinary tract obstructions (LUTO) are most often caused by posterior urethral valves (PUV), a male limited anatomical obstruction of the urethra affecting 1 in 4,000 male live births. Little is known about the genetic background of PUV. Here, we report the largest genome-wide association study (GWAS) for PUV in 4 cohorts of patients and controls. The final meta-analysis included 756 patients and 4,823 ethnicity matched controls and comprised 5,754,208 variants that were genotyped or imputed and passed quality control in all 4 cohorts. No genome-wide significant locus was identified, but 33 variants showed suggestive significance (P < 1 × 10-5). When considering only loci with multiple variants residing within < 10 kB of each other showing suggestive significance and with the same effect direction in all 4 cohorts, 3 loci comprising a total of 9 variants remained. These loci resided on chromosomes 13, 16, and 20. The present GWAS and meta-analysis is the largest genetic study on PUV performed to date. The fact that no genome-wide significant locus was identified, can be explained by lack of power or may indicate that common variants do not play a major role in the etiology of PUV. Nevertheless, future studies are warranted to replicate and validate the 3 loci that yielded suggestive associations.

Introduction and hypothesis Recommendations for preventing and diagnosing recurrent urinary tract infection (UTI) tend to vary between clinical practice guidelines (CPGs) because of low-quality scientific evidence, potentially leading to practice variation and suboptimal care. We assessed the quality of existing CPGs for recurrent UTI. Methods A systematic search was performed from January 2000 to June 2021 in PubMed and EMBASE for CPGs on recurrent UTI prevention or hospital diagnostics in Dutch, English, and Spanish. Each CPG was assessed by four appraisers in a multidisciplinary review team, using the Appraisal of Guidelines, Research, and Evaluation II (AGREE II) instrument. Results We identified and assessed eight CPGs published between 2013 and 2021. The scope and purpose (mean and standard deviation: 67.3 ± 21.8) and clarity of presentation (74.8 ± 17.6) domains scored highly. However, issues with methods, patient participation, conflict of interests, and facilitators and barriers were common and resulted in lower scores for the rigour of development (56.9 ± 25.9), applicability (19.6 ± 23.4), stakeholder involvement (50.4 ± 24.6), and editorial independence (62.1 ± 23.1) domains. Overall, two CPGs were recommended, three were recommended with modifications, and three were not recommended. Conclusions Significant room for improvement exists in the quality of CPGs for recurrent UTI, with most displaying serious limitations in the stakeholder involvement, rigour of development, and applicability domains. These aspects must be improved to decrease diagnostic and therapeutic uncertainty. Developers could benefit from using checklists and following guidelines when developing de novo CPGs.