A Systematic Review of Patients' Values, Preferences, and Expectations for the Diagnosis and Treatment of Male Lower Urinary Tract Symptoms.

CONTEXT: Understanding men's values and preferences in the context of personal, physical, emotional, relational, and social factors is important in optimising patient counselling, facilitating treatment decision-making, and improving guideline recommendations. OBJECTIVE: To systematically review the available evidence regarding the values, preferences, and expectations of men towards the investigation and treatment (conservative, pharmacological, and surgical) of male lower urinary tract symptoms (LUTS). EVIDENCE ACQUISITION: We searched electronic databases until August 31, 2020 for quantitative and qualitative studies that reported values and preferences regarding the investigation and treatment of LUTS in men. We assessed the quality of evidence and risk of bias using the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) and GRADE Confidence in the Evidence from Reviews of Qualitative Research (CERQual) approaches. EVIDENCE SYNTHESIS: We included 25 quantitative studies, three qualitative studies, and one mixed-methods study recruiting 9235 patients. Most men reported urodynamic testing to be acceptable, despite discomfort or embarrassment, as it significantly informs treatment decisions (low certainty evidence). Men preferred conservative and less risky treatment options, but the preference varied depending on baseline symptom severity and the risk/benefit characteristics of the treatment (moderate certainty). Men preferred pharmacological treatments with a low risk of erectile dysfunction and those especially improving urgency incontinence (moderate certainty). Other important preference considerations included reducing the risk of acute urinary retention or surgery (moderate certainty). CONCLUSIONS: Men prefer lower-risk management options that have fewer sexual side effects and are primarily effective at improving urgency incontinence and nocturia. Overall, the evidence was rated to be of low to moderate certainty. This review can facilitate the treatment decision-making process and improve the trustworthiness of guideline recommendations. PATIENT SUMMARY: We thoroughly reviewed the evidence addressing men's values and preferences regarding the management of urinary symptoms and found that minimising adverse effects is particularly important. Further research to understand other factors that matter to men is required.

In-vitro comparison of different slice thicknesses and kernel settings for measurement of urinary stone size by computed tomography.

Non-contrast enhanced computed tomography (NCCT) is widely used measuring stone size in patients with urolithiasis. We performed an evaluation of the accuracy of stone size measuring via NCCT. In an in-vitro study, we analyzed a total of 38 uric acid and 38 phantom stones. Within NCCT, we used different slice thicknesses (1.5 mm, 2.0 mm, and 3.0 mm) and kernel settings (bone and soft-tissue window). Maximal height, maximal length, and maximal width of each stone were measured on a picture archiving and communication system workstation. Blinded to these results, a second physician measured stone size in the same way using a caliper (real stone size). We used the Bland-Altman method for the analysis of agreement between the two measuring methods. The limit of agreement that was deemed clinical insignificant was ± 1.0 mm. All measurements via NCCT correlated significantly with the real stone size (p < 0.001). This was more pronounced for bone window and smaller slice thickness. Bland-Altman plots showed limits of agreement that exceeded the a priori defined level for all types of measurement with bone window and small slice thickness (1.5 mm) being better than soft-tissue window and large slice thickness (3.0 mm). We conclude that stone size measurement by NCCT with established settings is not exact. Stone size can easily be over- or underestimated by several millimeters. Using bone window and small slice thickness leads to more accurate results.

Systematic Review of the Performance of Noninvasive Tests in Diagnosing Bladder Outlet Obstruction in Men with Lower Urinary Tract Symptoms.

CONTEXT: Several noninvasive tests have been developed for diagnosing bladder outlet obstruction (BOO) in men to avoid the burden and morbidity associated with invasive urodynamics. The diagnostic accuracy of these tests, however, remains uncertain. OBJECTIVE: To systematically review available evidence regarding the diagnostic accuracy of noninvasive tests in diagnosing BOO in men with lower urinary tract symptoms (LUTS) using a pressure-flow study as the reference standard. EVIDENCE ACQUISITION: The EMBASE, MEDLINE, Cochrane Database of Systematic Reviews, Cochrane Central, Google Scholar, and WHO International Clinical Trials Registry Platform Search Portal databases were searched up to May 18, 2016. All studies reporting diagnostic accuracy for noninvasive tests for BOO or detrusor underactivity in men with LUTS compared to pressure-flow studies were included. Two reviewers independently screened all articles, searched the reference lists of retrieved articles, and performed the data extraction. The quality of evidence and risk of bias were assessed using the QUADAS-2 tool. EVIDENCE SYNTHESIS: The search yielded 2774 potentially relevant reports. After screening titles and abstracts, 53 reports were retrieved for full-text screening, of which 42 (recruiting a total of 4444 patients) were eligible. Overall, the results were predominantly based on findings from nonrandomised experimental studies and, within the limits of such study designs, the quality of evidence was typically moderate across the literature. Differences in noninvasive test threshold values and variations in the urodynamic definition of BOO between studies limited the comparability of the data. Detrusor wall thickness (median sensitivity 82%, specificity 92%), near-infrared spectroscopy (median sensitivity 85%, specificity 87%), and the penile cuff test (median sensitivity 88%, specificity 75%) were all found to have high sensitivity and specificity in diagnosing BOO. Uroflowmetry with a maximum flow rate of <10ml/s was reported to have lower median sensitivity and specificity of 68% and 70%, respectively. Intravesical prostatic protrusion of >10mm was reported to have similar diagnostic accuracy, with median sensitivity of 68% and specificity of 75%. CONCLUSIONS: According to the literature, a number of noninvasive tests have high sensitivity and specificity in diagnosing BOO in men. However, although the majority of studies have a low overall risk of bias, the available evidence is limited by heterogeneity. While several tests have shown promising results regarding noninvasive assessment of BOO, invasive urodynamics remain the gold standard. PATIENT SUMMARY: Urodynamics is an accurate but potentially uncomfortable test for patients in diagnosing bladder problems such as obstruction. We performed a thorough and comprehensive review of the literature to determine if there were less uncomfortable but equally effective alternatives to urodynamics for diagnosing bladder problems. We found that some simple tests appear to be promising, although they are not as accurate. Further research is needed before these tests are routinely used in place of urodynamics.

KIT D816V and JAK2 V617F mutations are seen recurrently in hypereosinophilia of unknown significance.

Myeloproliferative neoplasms with eosinophilia are commonly characterized by a normal karyotype and remain poorly defined at the molecular level. We therefore investigated 426 samples from patients with hypereosinophilia of unknown significance initially referred for screening of the FIP1L1-PDGFRA (FP) fusion gene also for KIT D816V and JAK2 V617F mutations. Overall, 86 (20%) patients tested positive: FP+ in 55 (12%), KIT D816V+ in 14 (3%), and JAK2 V617F+ in 17 (4%) patients, respectively. To gain better insight into clinical characteristics, we compared these cases with 31 additional and well-characterized KIT D816V+ eosinophilia-associated systemic mastocytosis (SM-eo) patients enrolled within the "German Registry on Disorders of Eosinophils and Mast cells." Significant differences included younger age, male predominance, and higher eosinophil counts for FP+ cases while abdominal lymphadenopathy, ascites, and serum tryptase levels >100 µg/l were characteristic for those with KIT D816V. Leukocytes, hemoglobin, and splenomegaly did not differ significantly. A median of three additional mutations, most frequently TET2 and SRSF2, were identified in 12/13 KIT D816V+ SM-eo patients with available material indicating a more complex molecular pathogenesis. Median survival was not reached for FP+ cases but was only 26 and 41 months for KIT D816V+ SM and JAK2 V617F+ MPN-eo, respectively. Eosinophilia of ≥2 × 10(9) /l was identified as discriminator for inferior survival in KIT D816V+ and/or JAK2 V617F+ patients (median survival 20 months vs. not reached, P = 0.002). Thus, there is a clear prognostic and therapeutic rationale for detection of KIT D816V and JAK2 V617F in the diagnostic work up of eosinophilia.