[Weak recommendation] Clinicians should utilize PSMA PET imaging preferentially, where available, as an alternative to conventional imaging due to greater sensitivity, or after negative conventional imaging, in patients with PSA recurrence after failure of local therapy. [Expert opinion] Based on panel consensus.
[Strong recommendation against] ADT should not be routinely initiated in this population (based on expert opinion). [Conditional recommendation] If ADT is initiated in the absence of metastatic disease, intermittent ADT may be offered in lieu of continuous ADT (based on moderate evidence from Grade B studies).
[WEAK recommendation, EXPERT OPINION evidence] [Weak recommendation] Clinicians may utilize electromyography biofeedback training to improve pelvic floor muscle resting tone and relaxation in patients with increased tone. [Expert opinion] This recommendation is based on expert consensus and uncontrolled studies, as evidence quality is low.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] Clinicians should not routinely implant male slings in patients with severe stress incontinence. [Low evidence] This is based on Grade C evidence, indicating low certainty.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should not routinely perform abdomino-pelvic CT scan or bone scan in asymptomatic patients with low- or intermediate-risk prostate cancer. [Expert opinion] This is based on expert consensus.
[STRONG recommendation, HIGH evidence] [Strong recommendation] Clinicians should not routinely recommend adjuvant radiation therapy after radical prostatectomy. [High evidence] This is based on high-quality evidence from well-conducted studies.
[MODERATE recommendation, MODERATE evidence] [Moderate recommendation] Clinicians should not routinely use ADT in patients with low- or favorable intermediate-risk prostate cancer electing radiation therapy. [Moderate evidence] This is based on moderate-quality evidence.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] A clinician should not routinely use urinary biomarkers or cytology. [Expert opinion] This is based on expert consensus.
[Moderate recommendation] Routine surveillance upper tract imaging should not be performed in asymptomatic low-risk NMIBC patients, based on expert opinion.
[STRONG recommendation] Clinicians should not routinely perform urodynamics, cystoscopy, or urinary tract imaging in the initial evaluation of OAB patients. [EXPERT OPINION evidence] This is based on clinical principle.
[STRONG recommendation] Clinicians should counsel patients that there is insufficient evidence to support the use of nutraceuticals, vitamins, supplements, or herbal remedies in OAB treatment. [EXPERT OPINION evidence] This is based on expert opinion.
[Strong recommendation] Do not routinely offer isotope bone scans. [Moderate evidence] Based on committee assessment and alignment with current practice.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Yes, clinicians should obtain a complete patient history and perform a pelvic examination in women presenting with rUTIs. [Expert opinion] This is based on clinical principles and expert consensus.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] Yes, clinicians should obtain urinalysis, urine culture, and sensitivity with each symptomatic acute cystitis episode prior to initiating treatment in patients with rUTIs. [Low evidence] This is based on evidence with low certainty.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should document evidence of inflammation (pyuria) and the presence of uropathogenic bacteria in association with symptomatic episodes to diagnose rUTI. [Expert opinion] This is based on clinical principles.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] No, cystoscopy and upper tract imaging should not be routinely obtained in the index patient presenting with rUTI. [Expert opinion] This is based on expert consensus.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Yes, clinicians may offer patient-initiated treatment (self-start treatment) to select rUTI patients with acute episodes while awaiting urine cultures. [Low evidence] This is based on evidence with low certainty.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] No, clinicians should omit surveillance urine testing, including urine culture, in asymptomatic patients with rUTIs. [Low evidence] This is based on evidence with low certainty.
[STRONG recommendation, MODERATE evidence] [Strong recommendation] Clinicians should use first-line therapy (i.e., nitrofurantoin, trimethoprim-sulfamethoxazole [TMP-SMX], fosfomycin) dependent on the local antibiogram for the treatment of symptomatic UTIs in women. [Moderate evidence] This is based on evidence with moderate certainty.
[MODERATE recommendation, MODERATE evidence] [Moderate recommendation] Clinicians should treat rUTI patients experiencing acute cystitis episodes with as short a duration of antibiotics as reasonable, generally no longer than seven days. [Moderate evidence] This is based on evidence with moderate certainty.
[CONDITIONAL recommendation, MODERATE evidence] [Conditional recommendation] Following discussion of risks, benefits, and alternatives, clinicians may prescribe antibiotic prophylaxis to decrease the risk of future UTIs in women of all ages previously diagnosed with UTIs. [Moderate evidence] This is based on evidence with moderate certainty.
[MODERATE recommendation, MODERATE evidence] [Moderate recommendation] Yes, clinicians should offer cranberry as an option for prophylaxis for women with rUTIs. [Moderate evidence] This is based on evidence with moderate certainty.
[MODERATE recommendation, MODERATE evidence] [Moderate recommendation] Clinicians should inform patients with rUTIs that D-mannose alone for prophylaxis may not be effective in UTI prevention. [Moderate evidence] This is based on evidence with moderate certainty.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Yes, clinicians may offer methenamine hippurate for prophylaxis for women with rUTIs. [Low evidence] This is based on evidence with low certainty.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] When women with rUTIs have a water intake below 1.5 L/day (50 oz), clinicians may offer increased water intake for prophylaxis. [Low evidence] This is based on evidence with low certainty.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Yes, clinicians should repeat urine cultures to guide further management when UTI symptoms persist following antimicrobial therapy. [Expert opinion] This is based on expert consensus.
[MODERATE recommendation, MODERATE evidence] [Moderate recommendation] Yes, in perimenopausal and postmenopausal women with rUTIs, clinicians should recommend vaginal estrogen therapy to reduce the risk of future UTIs if there is no contraindication. [Moderate evidence] This is based on evidence with moderate certainty.
[Moderate recommendation] Clinicians should omit surveillance urine testing, including urine culture, in asymptomatic patients with rUTIs. [Low evidence] This is based on observational studies or expert consensus indicating lack of benefit and potential harm from overtreatment.
[Strong recommendation] Clinicians should use first-line therapy (nitrofurantoin, TMP-SMX, or fosfomycin) based on the local antibiogram for symptomatic UTIs in women. [Moderate evidence] Supported by systematic reviews and randomized controlled trials demonstrating effectiveness and low resistance.
[Moderate recommendation] Clinicians should treat with as short a duration of antibiotics as reasonable, generally no longer than seven days, for acute cystitis in rUTI patients. [Moderate evidence] Based on systematic reviews indicating similar efficacy with shorter courses and reduced adverse events.
[Conditional recommendation] Clinicians may treat with culture-directed parenteral antibiotics for as short a course as reasonable, generally no longer than seven days, in rUTI patients with resistant cultures. [Expert opinion] Based on panel consensus due to insufficient direct evidence.
[Conditional recommendation] Following discussion of risks, benefits, and alternatives, clinicians may prescribe antibiotic prophylaxis to decrease future UTI risk in women of all ages with prior UTIs. [Moderate evidence] Based on randomized controlled trials showing reduced recurrence but increased adverse events.
[Moderate recommendation] Clinicians should offer cranberry as an option for prophylaxis in women with rUTIs. [Moderate evidence] Supported by randomized controlled trials showing reduced recurrence with minimal harm.
[Moderate recommendation] Clinicians should inform patients with rUTIs that D-mannose alone for prophylaxis may not be effective. [Moderate evidence] Based on a high-quality randomized controlled trial showing no benefit compared to placebo.
[Conditional recommendation] Clinicians may offer methenamine hippurate for prophylaxis in women with rUTIs. [Low evidence] Based on limited studies, such as a non-inferiority trial, showing potential benefit compared to antibiotics.
[Conditional recommendation] When women with rUTIs have water intake below 1.5 L/day, clinicians may offer increased water intake for prophylaxis. [Low evidence] Based on a single trial demonstrating reduced recurrence with higher fluid intake.
[Moderate recommendation] Clinicians should repeat urine cultures to guide further management when UTI symptoms persist following antimicrobial therapy. [Expert opinion] Based on panel consensus to ensure appropriate treatment and avoid misdiagnosis.
[Moderate recommendation] For patients with persistent UTI symptoms after microbiological cure, clinicians should evaluate for alternative causes. [Expert opinion] Based on panel consensus to identify conditions like overactive bladder or pelvic floor disorders.
[Moderate recommendation] In perimenopausal and postmenopausal women with rUTIs, clinicians should recommend vaginal estrogen therapy to reduce future UTI risk if no contraindications exist. [Moderate evidence] Supported by randomized controlled trials showing decreased recurrence with minimal systemic absorption.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should suggest the substitution, dose adjustment, or discontinuation of medications that may contribute to delayed ejaculation. [Expert opinion] Based on clinical principles and expert consensus.
[MODERATE recommendation] Surgeons should not perform substitution urethroplasty with allograft, xenograft, or synthetic materials except in experimental settings. [EXPERT OPINION] Based on expert consensus.
[Strong recommendation] Dipstick urine analysis should not be used for UTI screening. [Expert opinion] Based on EAU guideline consensus.
[Strong recommendation] Long-term antibiotics should be avoided for recurrent UTIs. [Expert opinion] Based on EAU guideline consensus.
[Strong recommendation] UTI prophylaxis should be individualised due to lack of optimal measures. [Expert opinion] Based on EAU guideline consensus.
[Weak recommendation] It is recommended to await spontaneous resolution of asymptomatic preputial adhesions before puberty. [Expert opinion] Based on EAU guideline consensus.
[Strong recommendation] Use either University of Wisconsin or histidine tryptophane ketoglutarate preservation solutions for cold storage. [Expert opinion evidence] Based on EAU guideline consensus.
[Strong recommendation] Use Celsior or Marshall’s solution for cold storage if University of Wisconsin or histidine tryptophane ketoglutarate solutions are not available. [Expert opinion evidence] Based on EAU guideline consensus.
[STRONG recommendation, HIGH evidence] [Strong recommendation] Desmopressin is recommended as the only evidence-based pharmaceutical therapy for nocturia. [High evidence] This is supported by level 1a evidence from multiple randomized controlled trials.
[Strong recommendation] Systemic antimicrobials should not be used routinely for UTI prophylaxis in patients with short or long-term catheterization. [Low evidence] Based on low-quality evidence from systematic reviews and RCTs.
[Weak recommendation] Higher doses of PDE5 inhibitors may be considered but are not strongly recommended due to small and non-linear dose-response effects, with minimal additional clinical benefit. [High evidence] This is supported by data from fixed-dose randomized controlled trials.
[WEAK recommendation, EXPERT OPINION evidence] [Weak recommendation] Clinicians may treat with culture-directed parenteral antibiotics for as short a course as reasonable, generally no longer than seven days. [Expert opinion] This is based on expert consensus.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should evaluate for alternative causes to patient symptoms. [Expert opinion] This is based on expert consensus.
[Strong recommendation] Clinicians should not perform post-treatment test of cure urinalysis or urine culture in asymptomatic patients. [Expert opinion] Based on panel consensus to prevent overtreatment, extrapolated from asymptomatic bacteriuria data.
[MODERATE recommendation] No, surgeons should not use hair-bearing skin. [EXPERT OPINION] Based on clinical principle.
[Strong recommendation] Optimise neuro-urological symptom treatment and remove foreign bodies from the urinary tract. [Expert opinion] Based on EAU guideline consensus.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Surgery is recommended for patients with BPH who have complications such as renal insufficiency, refractory urinary retention, recurrent UTIs, bladder stones, gross hematuria, or LUTS refractory to other therapies. [Expert opinion] Based on clinical principles.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Low-intensity ESWT should be considered investigational for men with ED and not routinely recommended. [Low evidence] This is based on low-quality evidence from observational studies.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Intracavernosal stem cell therapy should be considered investigational for men with ED and not routinely recommended. [Low evidence] This is based on low-quality evidence from observational studies.
[WEAK recommendation, EXPERT OPINION evidence] [Weak recommendation] Platelet-rich plasma therapy should be considered experimental for men with ED and not recommended for routine use. [Expert opinion evidence] This is based on expert consensus due to lack of evidence.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Low-intensity extracorporeal shock wave therapy should be considered investigational for men with ED and only used in institutional review board-approved clinical trials. [Low evidence] Based on Grade C evidence from observational studies.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Intracavernosal stem cell therapy should be considered investigational for men with ED and only used in institutional review board-approved clinical trials. [Low evidence] Based on Grade C evidence from observational studies.
[CONDITIONAL recommendation, EXPERT OPINION evidence] [Conditional recommendation] Platelet-rich plasma therapy should be considered experimental for men with ED and should not be offered except in institutional review board-approved research trials. [Expert opinion] Based on expert consensus without direct evidence.
[Conditional recommendation] Ultra-hypofractionation can be offered as an alternative to conventional fractionation for intermediate-risk prostate cancer patients receiving EBRT, but the task force strongly recommends that these patients be treated as part of a clinical trial or multi-institutional registry. [Low evidence] Based on limited comparative data, with insufficient evidence from randomized trials.
[Conditional recommendation] Ultra-hypofractionation is not suggested for high-risk prostate cancer patients receiving EBRT outside of a clinical trial or multi-institutional registry due to insufficient comparative evidence. [Low evidence] Based on limited data, with no published RCTs comparing ultra-hypofractionation to conventional fractionation in this population.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] In patients who select artificial urinary sphincter, clinicians should preferentially utilize a single cuff perineal approach. [Low evidence] This is based on Grade C evidence, indicating low certainty.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] In patients selecting active surveillance, clinicians should utilize mpMRI to augment risk stratification, but not replace periodic biopsy. [Expert opinion] This is based on expert consensus.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should utilize available techniques like target localization and image-guidance to optimize the therapeutic ratio of EBRT. [Expert opinion] This is based on clinical principle and expert consensus.
[STRONG recommendation, HIGH evidence] [Strong recommendation] Clinicians should utilize dose escalation when EBRT is the primary treatment for patients with prostate cancer. [High evidence] This is based on high-quality evidence from well-conducted studies.
[STRONG recommendation, MODERATE evidence] [Strong recommendation] When treating pelvic lymph nodes with radiation, clinicians should utilize IMRT with doses between 45 Gy to 52 Gy. [Moderate evidence] This is based on moderate-quality evidence.
[Conditional recommendation] Clinicians may consider the utilization of testicular sperm in nonazoospermic males with an elevated sperm DNA Fragmentation Index. [Expert opinion] This is based on clinical principles and expert consensus.
[Moderate recommendation] Clinicians should counsel patients that the benefits of supplements (e.g., antioxidants, vitamins) are of questionable clinical utility in treating male infertility, and data are inadequate for specific recommendations. [Moderate evidence] This is supported by moderate-quality evidence.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Repeat urinalysis after resolution; if microhematuria persists or etiology unclear, perform risk-based urologic evaluation. [Expert opinion] Based on clinical principles and expert consensus.
[STRONG recommendation, LOW evidence] [Strong recommendation] Obtain a urinalysis with microscopic evaluation after treatment to ensure resolution of hematuria. [Low evidence] Based on observational studies with low certainty.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] May utilize MR urography. [Low evidence] Based on observational studies with low certainty.
[CONDITIONAL recommendation, EXPERT OPINION evidence] [Conditional recommendation] May utilize retrograde pyelography with non-contrast imaging or renal ultrasound. [Expert opinion] Based on expert consensus.
[STRONG recommendation, LOW evidence] [Strong recommendation] No, they should not be routinely used. [Low evidence] Based on observational studies with low certainty.
[STRONG recommendation, LOW evidence] [Strong recommendation] No, they should not be routinely used. [Low evidence] Based on observational studies with low certainty.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] A clinician may utilize maintenance therapy. [Low evidence] Based on Grade C evidence.
[STRONG recommendation] Clinicians should use antimuscarinic medications with extreme caution in OAB patients who have narrow-angle glaucoma, impaired gastric emptying, or a history of urinary retention. [EXPERT OPINION evidence] This is based on clinical principle.
[Conditional recommendation] Clinicians may offer bladder augmentation cystoplasty or urinary diversion to severely impacted patients with OAB who have not responded to all other therapeutic options. [Expert opinion] This is based on expert opinion.
[Conditional recommendation] Clinicians may offer extracorporeal shock wave therapy to improve penile pain, considering the natural history of pain resolution and potential adverse events. [Moderate evidence] Based on evidence strength Grade B from RCTs showing pain reduction.
[WEAK recommendation, Expert Opinion evidence] [Weak recommendation] Clinicians may utilize penile duplex Doppler ultrasound when the diagnosis is indeterminate. [Expert opinion] This is based on expert consensus.
[MODERATE recommendation, Low evidence] [Moderate recommendation] Clinicians should utilize intracavernosal phenylephrine if conservative management fails. [Low evidence] Based on Grade C evidence.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] RMB should be obtained on a utility-based approach when it may influence management, but is not required for young/healthy patients unwilling to accept uncertainties or older/frail patients managed conservatively. [Expert opinion evidence] Based on expert opinion and consensus.
[Moderate recommendation] Discuss stage, grade, histology, recurrence risks, and sequelae; for benign masses, occasional evaluation and testing are sufficient without routine imaging. [Expert opinion] Based on consensus.
[Moderate recommendation] Site-specific imaging can be ordered based on clinical symptoms; PET scans should not be routine but may be considered selectively. [Low evidence] Based on observational studies.
[MODERATE recommendation] Clinicians should not utilize synthetic midurethral slings in patients undergoing concomitant urethral diverticulectomy, fistula repair, or mesh excision. [EXPERT OPINION evidence] Based on clinical principles to prevent complications.
[CONDITIONAL recommendation, MODERATE evidence] [Conditional recommendation] Clinicians may utilize either prone or supine positioning for adult patients undergoing PCNL. [Moderate evidence] Based on Grade B evidence.
[CONDITIONAL recommendation, MODERATE evidence] [Conditional recommendation] Clinicians may utilize intraoperative US, fluoroscopy, or combination image guidance for access during PCNL in adult patients. [Moderate evidence] Based on Grade B evidence.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Clinicians may utilize a suction sheath during mini-PCNL in adult patients to improve stone-free rates and reduce secondary procedures, when available. [Low evidence] Based on Grade C evidence.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Clinicians may utilize either a holmium:YAG or thulium fiber laser for lithotripsy during URS in adult patients for kidney and/or ureteral stones. [Low evidence] Based on Grade C evidence.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Clinicians should utilize laser settings with the lowest total power that will accomplish clinical stone ablation for adult and pediatric patients undergoing URS with laser lithotripsy. [Expert opinion] Based on expert consensus.
[CONDITIONAL recommendation, MODERATE evidence] [Conditional recommendation] Clinicians may utilize a strategy of fragmenting and basketing or dusting for laser lithotripsy during URS in adult and pediatric patients for kidney and/or ureteral stones. [Moderate evidence] Based on Grade B evidence.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] Clinicians should utilize a multi-modal, non-opioid analgesic regimen and minimize use of opioids for post-operative pain management in adult patients undergoing surgical intervention for kidney and/or ureteral stones. [Low evidence] Based on Grade C evidence.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Clinicians should utilize US as first-line imaging for pregnant patients with suspected symptomatic kidney and/or ureteral stones; if needed, non-contrast MRI or CT are appropriate alternatives. [Expert opinion] Based on expert consensus.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Clinicians should suggest the substitution, dose adjustment, or gradual discontinuation of medications that may contribute to delayed ejaculation. [Expert opinion] Based on clinical principle.
[MODERATE recommendation] Yes, clinicians should include urethral stricture in the differential diagnosis for patients presenting with decreased urinary stream, incomplete emptying, dysuria, UTI, or rising PVR. [LOW evidence] Based on low quality evidence.
[WEAK recommendation] Surgeons may utilize urethral endoscopic management or immediate suprapubic cystostomy. [EXPERT OPINION] Based on expert consensus.
[Strong recommendation] A validated symptom score questionnaire that includes bother and quality of life assessment should be used during initial evaluation and for re-evaluation. [Low evidence] Based on observational studies (LE 3) showing utility in screening and categorisation.
[Weak recommendation] In locally-advanced urethral carcinoma, use cisplatin-based chemotherapeutic regimens with curative intent prior to surgery. [Expert opinion evidence] Based on consensus guidelines.
[Strong recommendation] Use prognostic factors to risk-stratify patients for therapeutic guidance. [Expert opinion evidence] Based on consensus guidelines.
[Weak recommendation] For upper tract follow-up after negative second look URS, perform cross sectional imaging urography at 3 and 6 months then yearly for 5 years, with or without URS. [Low evidence] Based on follow-up practices with limited evidence on URS utility.
[Weak recommendation] For upper tract follow-up after negative second look URS, perform cross sectional imaging urography and URS at 3 and 6 months, then imaging every 6 months for 2 years, then yearly for 5 years, with or without URS. [Low evidence] Based on follow-up protocols with limited evidence on URS utility.
[Strong recommendation] Do not screen or treat asymptomatic bacteriuria in conditions such as women without risk factors, patients with well-regulated diabetes, post-menopausal women, elderly institutionalised patients, those with dysfunctional lower urinary tracts, renal transplants, prior to arthroplasty surgeries, or recurrent UTIs. [Expert opinion] Based on EAU guideline consensus.
[Strong recommendation] Sexual concerns should be addressed routinely to improve sexual health management, based on expert consensus.
[Moderate recommendation] Pressure traces should be scrutinized throughout the study to confirm genuine pressure recordings, based on expert opinion from ICS standards.
[Strong recommendation] The trace must be scrutinized after the test to confirm that pressure and flow values accurately reflect urinary tract function, based on expert opinion from ICS standards.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Alpha-blockers must be used with caution due to the risk of exacerbating postural hypotension, based on low evidence.
[STRONG recommendation, LOW evidence] [Strong recommendation] Overutilization of diagnostic testing and overdiagnosis should be avoided to prevent patient harm and resource waste. [Low evidence] This is supported by observational studies and expert opinion on minimizing unnecessary interventions.
[Moderate recommendation] The trial phase (PNE or staged lead) is the key tool for predicting therapeutic success in urinary indications. [Moderate evidence] This is based on cohort studies and clinical trials.
[Strong recommendation] Urinary catheters should be used only as necessary in operative patients, rather than routinely. [Low evidence] Based on low-quality evidence from systematic reviews and observational studies.
[Conditional recommendation] ICS does not recommend routine immediate repetition of urodynamic tests if the initial test was technically adequate and answered the clinical question. However, [Strong recommendation] repetition is recommended when there is doubt about the test's validity or when technical errors are observed. [Expert Opinion] This is based on expert consensus due to lack of convincing evidence for routine repetition.