Publications by authors named "Margaret S Pearle"

136 Publications

International Alliance of Urolithiasis guideline on retrograde intrarenal surgery.

BJU Int 2022 Jun 22. Epub 2022 Jun 22.

Department of Urology, Medical School, Biruni University, Istanbul, Turkey.

Objectives: To set out the second in a series of guidelines on the treatment of urolithiasis by the International Alliance of Urolithiasis that concerns retrograde intrarenal surgery (RIRS), with the aim of providing a clinical framework for urologists performing RIRS.

Materials And Methods: After a comprehensive search of RIRS-related literature published between 1 January 1964 and 1 October 2021 from the PubMed database, systematic review and assessment were performed to inform a series of recommendations, which were graded using modified GRADE methodology. Additionally, quality of evidence was classified using a modification of the Oxford Centre for Evidence-Based Medicine Levels of Evidence system. Finally, related comments were provided.

Results: A total of 36 recommendations were developed and graded that covered the following topics: indications and contraindications; preoperative imaging; preoperative ureteric stenting; preoperative medications; peri-operative antibiotics; management of antithrombotic therapy; anaesthesia; patient positioning; equipment; lithotripsy; exit strategy; and complications.

Conclusion: The series of recommendations regarding RIRS, along with the related commentary and supporting documentation, offered here should help provide safe and effective performance of RIRS.
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http://dx.doi.org/10.1111/bju.15836DOI Listing
June 2022

Impact of an Enhanced Recovery After Surgery Protocol on Unplanned Patient Encounters in the Early Postoperative Period After Ureteroscopy.

J Endourol 2022 03 14;36(3):298-302. Epub 2021 Oct 14.

Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas, USA.

Ureteroscopy (URS) is associated with substantial patient-perceived morbidity. To improve the patient experience, we developed an enhanced recovery after surgery (ERAS) protocol for URS. We sought to determine if an ERAS protocol could reduce unplanned patient-initiated encounters. The ERAS protocol involves the preoperative administration of four medications to patients undergoing URS. We reviewed data on 100 consecutive patients undergoing URS with ureteral stent placement between April 2018 and August 2018. All unplanned postoperative encounters, including phone calls and electronic medical record messages, unplanned urology outpatient visits, emergency department (ED) visits, and re-admissions within 30 days of surgery, were recorded. A control group of patients undergoing URS between July 2013 and November 2014 served as a comparison group. Propensity score matching was performed. Statistical analysis included Mann-Whitney test, Student's -test, and Fischer's exact test. Univariable and multivariable (MVA) analyses were performed. Using propensity score matching, 71 pre-ERAS (median age 57 years, interquartile range [IQR] 44-65) and 71 post-ERAS (median age 56 years, IQR 47-68) patients were compared. Although ED visits and postoperative readmissions were comparable between the two groups, significantly more unplanned phone calls/messages occurred in the pre-ERAS group than in the post-ERAS group (71 27, respectively,  < 0.001). MVA regression analysis identified the ERAS protocol as a significant independent predictor of fewer patient calls (odds ratio 0.24, 95% confidence interval 0.12-0.50,  < 0.001). Analysis of an ERAS protocol for patients undergoing URS showed a reduction in unplanned patient-initiated communication, with implementation of the protocol. ClinicalTrials.gov: NCT04112160.
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http://dx.doi.org/10.1089/end.2021.0435DOI Listing
March 2022

Clinical and radiographic outcomes following salvage intervention for ureteropelvic junction obstruction.

Int Braz J Urol 2021 Nov-Dec;47(6):1209-1218

Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, United States.

Purpose: We aimed to assess failure rates of salvage interventions and changes in split kidney function (SKF) following failed primary repair of ureteropelvic junction obstruction (UPJO).

Materials And Methods: A retrospective review of adult patients at an academic medical center who underwent salvage intervention following primary treatment for UPJO was performed. Symptomatic failure was defined as significant flank pain. Radiographic failure was defined as no improvement in drainage or a decrease in SKF by ≥7%. Overall failure, the primary outcome, was defined as symptomatic failure, radiographic failure, or both.

Results: Between 2008-2017, 34 patients (median age 38 years, 50% men) met study criteria. UPJO management was primary pyeloplasty/secondary endopyelotomy for 21/34 (62%), primary pyeloplasty/secondary pyeloplasty for 6/34 (18%), and primary endopyelotomy/secondary pyeloplasty for 7/34 (21%). Median follow-up was 3.3 years following secondary intervention. Patients undergoing primary pyeloplasty/secondary endopyelotomy had significantly higher overall failure than those undergoing primary pyeloplasty/secondary pyeloplasty (16/21 [76%] vs. 1/6 [17%], p=0.015). Among patients undergoing secondary endopyelotomy, presence of a stricture on retrograde pyelogram, stricture length, and SKF were not associated with symptomatic, radiographic, or overall failure. Serial renography was performed for 28/34 (82%) patients and 2/28 (7%) had a significant decline in SKF.

Conclusions: Following failed primary pyeloplasty, secondary endopyelotomy had a greater overall failure rate than secondary pyeloplasty. No radiographic features assessed were associated with secondary endopyelotomy failure. Secondary intervention overall failure rates were higher than reported in the literature. Unique to this study, serial renography demonstrated that significant functional loss was overall infrequent.
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http://dx.doi.org/10.1590/S1677-5538.IBJU.2021.0303DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8486453PMC
September 2021

Causes and prevention of kidney stones: separating myth from fact.

BJU Int 2021 12 23;128(6):661-666. Epub 2021 Aug 23.

Department of Urology, UT Southwestern Medical Center, Dallas, TX, USA.

Despite high-level evidence supporting the use of pharmacotherapy therapy for the prevention of kidney stones, adherence to medications is often poor because of side-effects, inconvenience and cost. Furthermore, with a desire for more 'natural' products, patients seek dietary and herbal remedies over pharmacotherapy. However, patients are often unaware of the potential side-effects, lack of evidence and cost of these remedies. Therefore, in the present review we examine the evidence for a few of the commonly espoused non-prescription agents or dietary recommendations that are thought to prevent stone formation, including lemonade, fish oil (omega fatty acids), Phyllanthus niruri and the Dietary Approaches to Stop Hypertension (DASH) diet. While the present review includes only a few of the stone-modulating recommendations available to the lay community, we focussed on these four due to their prevalent use. Our goal is not to only dispel commonly held notions about stone disease, but also to highlight the lack of high-level evidence for many commonly utilised treatments.
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http://dx.doi.org/10.1111/bju.15532DOI Listing
December 2021

Artificial intelligence in stone disease.

Curr Opin Urol 2021 07;31(4):391-396

Professor of Urology and Internal Medicine, Charles and Jane Pak Center for Mineral Metabolism, UT Southwestern Medical Center, Dallas, TX, USA.

Purpose Of Review: Artificial intelligence (AI) is the ability of a machine, or computer, to simulate intelligent behavior. In medicine, the use of large datasets enables a computer to learn how to perform cognitive tasks, thereby facilitating medical decision-making. This review aims to describe advancements in AI in stone disease to improve diagnostic accuracy in determining stone composition, to predict outcomes of surgical procedures or watchful waiting and ultimately to optimize treatment choices for patients.

Recent Findings: AI algorithms show high accuracy in different realms including stone detection and in the prediction of surgical outcomes. There are machine learning algorithms for outcomes after percutaneous nephrolithotomy, extracorporeal shockwave lithotripsy, and for ureteral stone passage. Some of these algorithms show better predictive capabilities compared to existing scoring systems and nomograms.

Summary: The use of AI can facilitate the development of diagnostic and treatment algorithms in patients with stone disease. Although the generalizability and external validity of these algorithms remain uncertain, the development of highly accurate AI-based tools may enable the urologist to provide more customized patient care and superior outcomes.
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http://dx.doi.org/10.1097/MOU.0000000000000896DOI Listing
July 2021

Urolithiasis in the COVID Era: An Opportunity to Reassess Management Strategies.

Eur Urol 2020 12 31;78(6):777-778. Epub 2020 Jul 31.

Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA. Electronic address:

Delayed evaluation and/or treatment for urolithiasis during the COVID-19 pandemic provide a unique opportunity to organically reassess many well-established stone management strategies. Nonopioid analgesia for renal colic and spontaneous passage trials appear to be two avenues worthy of investigation.
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http://dx.doi.org/10.1016/j.eururo.2020.07.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7832767PMC
December 2020

Initial Results from the M-STONE Group: A Multi-Center Collaboration to Study Treatment Outcomes in Nephrolithiasis Evaluation.

J Endourol 2020 09;34(9):919-923

Department of Urology, UT Southwestern Medical Center, Dallas, Texas, USA.

Despite proven effectiveness of medications in preventing stone recurrence, compliance with pharmacotherapy (PT) is often poor because of cost, side effects, and impact on lifestyle. We sought to compare the risk of stone recurrence between patients managed with conservative therapy (CT) PT controlling for aggressiveness of stone disease. The Multi-center collaboration to Study Treatment Outcomes in Nephrolithiasis Evaluation (MSTONE) database contains patient data and outcomes from July 2001 to April 2015 across four centers. The database was queried for patients whose stone disease was managed with CT alone (fluid and dietary recommendations) PT. Patients were risk stratified according to number of previous passed stones. Within each risk group, we compared CT PT with respect to 2-year stone event rate and stone event-free survival (SEFS) using the Kaplan-Meier method. A total of 245 patients, with a median follow-up of 29 months (interquartile range = 16-44), were identified, including 93 on CT and 152 on PT. The overall 2-year stone event rate was 38% for all patients. Stone events at 2 years occurred less frequently in the PT group compared with the CT group (31% 44%,  = 0.043), with the difference most pronounced in the high-risk group (71% 32% for CT and PT, respectively,  = 0.058). The 30-month SEFS was significantly higher for PT (58%) than CT (46%) overall. When stratified by risk group, 30-month SEFS was statistically significantly higher for PT than CT in the intermediate risk group (65% 45% for PT and CT, respectively). Controlling for aggressiveness of stone disease, PT was more effective than CT in reducing and delaying stone-related events. However, CT appeared to be as effective as PT in low-risk patients. PT is best reserved for recurrent stone formers, regardless of metabolic background.
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http://dx.doi.org/10.1089/end.2020.0108DOI Listing
September 2020

EDITORIAL COMMENT.

Urology 2020 02;136:68-69

Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX.

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http://dx.doi.org/10.1016/j.urology.2019.07.058DOI Listing
February 2020

Puncture for percutaneous surgery: is the papillary puncture a dogma? No!

Curr Opin Urol 2019 07;29(4):472-473

Department of Urology, UT Southwestern Medical Center, Dallas, Texas, USA.

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http://dx.doi.org/10.1097/MOU.0000000000000627DOI Listing
July 2019

Medical therapy for nephrolithiasis: State of the art.

Asian J Urol 2018 Oct 3;5(4):243-255. Epub 2018 Sep 3.

Department of Urology, UT Southwestern Medical Center, Dallas, TX, USA.

The prevalence of nephrolithiasis is increasing worldwide. Understanding and implementing medical therapies for kidney stone prevention are critical to prevent recurrences and decrease the economic burden of this condition. Dietary and pharmacologic therapies require understanding on the part of the patient and the prescribing practitioner in order to promote compliance. Insights into occupational exposures and antibiotic use may help uncover individual risk factors. Follow-up is essential to assess response to treatment and to modify treatment plans to maximize therapeutic benefit.
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http://dx.doi.org/10.1016/j.ajur.2018.08.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6197179PMC
October 2018

Impact of Potassium Citrate vs Citric Acid on Urinary Stone Risk in Calcium Phosphate Stone Formers.

J Urol 2018 12 20;200(6):1278-1284. Epub 2018 Jul 20.

Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas; Division of Mineral Metabolism, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas. Electronic address:

Purpose: To our knowledge no medication has been shown to be effective for preventing recurrent calcium phosphate urinary stones. Potassium citrate may protect against calcium phosphate stones by enhancing urine citrate excretion and lowering urine calcium but it raises urine pH, which increases calcium phosphate saturation and may negate the beneficial effects. Citric acid can potentially raise urine citrate but not pH and, thus, it may be a useful countermeasure against calcium phosphate stones. We assessed whether these 2 agents could significantly alter urine composition and reduce calcium phosphate saturation.

Materials And Methods: In a crossover metabolic study 13 recurrent calcium phosphate stone formers without hypercalciuria were evaluated at the end of 3, 1-week study phases during which they consumed a fixed metabolic diet and received assigned study medications, including citric acid 30 mEq twice daily, potassium citrate 20 mEq twice daily or matching placebo. We collected 24-hour urine specimens to perform urine chemistry studies and calculate calcium phosphate saturation indexes.

Results: Urine parameters did not significantly differ between the citric acid and placebo phases. Potassium citrate significantly increased urine pH, potassium and citrate compared to citric acid and placebo (p <0.01) with a trend toward lower urine calcium (p = 0.062). Brushite saturation was increased by potassium citrate when calculated by the relative supersaturation ratio but not by the saturation index.

Conclusions: Citric acid at a dose of 60 mEq per day did not significantly alter urine composition in calcium phosphate stone formers. The long-term impact of potassium citrate on calcium phosphate stone recurrence needs to be studied further.
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http://dx.doi.org/10.1016/j.juro.2018.07.039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6300162PMC
December 2018

Dual-layer spectral detector CT: non-inferiority assessment compared to dual-source dual-energy CT in discriminating uric acid from non-uric acid renal stones ex vivo.

Abdom Radiol (NY) 2018 11;43(11):3075-3081

UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390-8827, USA.

Purpose: To assess the non-inferiority of dual-layer spectral detector CT (SDCT) compared to dual-source dual-energy CT (dsDECT) in discriminating uric acid (UA) from non-UA stones.

Methods: Fifty-seven extracted urinary calculi were placed in a cylindrical phantom in a water bath and scanned on a SDCT scanner (IQon, Philips Healthcare) and second- and third-generation dsDECT scanners (Somatom Flash and Force, Siemens Healthcare) under matched scan parameters. For SDCT data, conventional images and virtual monoenergetic reconstructions were created. A customized 3D growing region segmentation tool was used to segment each stone on a pixel-by-pixel basis for statistical analysis. Median virtual monoenergetic ratios (VMRs) of 40/200, 62/92, and 62/100 for each stone were recorded. For dsDECT data, dual-energy ratio (DER) for each stone was recorded from vendor-specific postprocessing software (Syngo Via) using the Kidney Stones Application. The clinical reference standard of X-ray diffraction analysis was used to assess non-inferiority. Area under the receiver-operating characteristic curve (AUC) was used to assess diagnostic performance of detecting UA stones.

Results: Six pure UA, 47 pure calcium-based, 1 pure cystine, and 3 mixed struvite stones were scanned. All pure UA stones were correctly separated from non-UA stones using SDCT and dsDECT (AUC = 1). For UA stones, median VMR was 0.95-0.99 and DER 1.00-1.02. For non-UA stones, median VMR was 1.4-4.1 and DER 1.39-1.69.

Conclusion: SDCT spectral reconstructions demonstrate similar performance to those of dsDECT in discriminating UA from non-UA stones in a phantom model.
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http://dx.doi.org/10.1007/s00261-018-1589-xDOI Listing
November 2018

Do Urinary Cystine Parameters Predict Clinical Stone Activity?

J Urol 2018 02 12;199(2):495-499. Epub 2017 Sep 12.

Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas; Jane and Charles Pak Center for Mineral Metabolism and Clinical Research, Dallas, Texas. Electronic address:

Purpose: An accurate urinary predictor of stone recurrence would be clinically advantageous for patients with cystinuria. A proprietary assay (Litholink, Chicago, Illinois) measures cystine capacity as a potentially more reliable estimate of stone forming propensity. The recommended capacity level to prevent stone formation, which is greater than 150 mg/l, has not been directly correlated with clinical stone activity. We investigated the relationship between urinary cystine parameters and clinical stone activity.

Materials And Methods: We prospectively followed 48 patients with cystinuria using 24-hour urine collections and serial imaging, and recorded stone activity. We compared cystine urinary parameters at times of stone activity with those obtained during periods of stone quiescence. We then performed correlation and ROC analysis to evaluate the performance of cystine parameters to predict stone activity.

Results: During a median followup of 70.6 months (range 2.2 to 274.6) 85 stone events occurred which could be linked to a recent urine collection. Cystine capacity was significantly greater for quiescent urine than for stone event urine (mean ± SD 48 ± 107 vs -38 ± 163 mg/l, p <0.001). Cystine capacity significantly correlated inversely with stone activity (r = -0.29, p <0.001). Capacity also correlated highly negatively with supersaturation (r = -0.88, p <0.001) and concentration (r = -0.87, p <0.001). Using the suggested cutoff of greater than 150 mg/l had only 8.0% sensitivity to predict stone quiescence. Decreasing the cutoff to 90 mg/l or greater improved sensitivity to 25.2% while maintaining specificity at 90.9%.

Conclusions: Our results suggest that the target for capacity should be lower than previously advised.
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http://dx.doi.org/10.1016/j.juro.2017.09.034DOI Listing
February 2018

Update of the ICUD-SIU consultation on stone technology behind ureteroscopy.

World J Urol 2017 Sep 25;35(9):1353-1359. Epub 2017 Jul 25.

Department of Urology, Tenon Hospital, Pierre et Marie Curie University, Paris, France.

Introduction: Ureteroscopy is now the most frequent treatment used around the world for stone disease. Technological advancement, efficiency, safety, and minimally invasiveness of this procedure are some of the reasons for this change of trend.

Materials And Methods: In this review of the literature, a search of the PubMed database was conducted to identify articles related to ureteroscopy and accessories. The committee assigned by the International Consultation on Urological Disease reviewed all the data and produced a consensus statement relating to the ureteroscopy and all the particularities around this procedure.

Conclusion: This manuscript provides literatures and recommendations for endourologists to keep them informed in regard to the preoperative, intraoperative, and postoperative consideration in regard of a ureteroscopy.
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http://dx.doi.org/10.1007/s00345-017-2073-xDOI Listing
September 2017

Percutaneous Access to the Kidney.

J Urol 2017 02 20;197(2S):S158-S159. Epub 2016 Dec 20.

Departments of Urology and Internal Medicine, UT Southwestern Medical Center, Dallas, Texas.

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http://dx.doi.org/10.1016/j.juro.2016.11.095DOI Listing
February 2017

A Novel Device to Prevent Stone Fragment Migration During Percutaneous Lithotripsy: Results from an In Vitro Kidney Model.

J Endourol 2016 11;30(11):1239-1243

1 Department of Urology, UT Southwestern Medical Center , Dallas, Texas.

Purpose: We developed a polyethylene sack (the PercSac) that fits over the shaft of a rigid nephroscope and is deployed into the collecting system to capture a stone and contain fragments during percutaneous nephrolithotomy (PCNL). We previously reported our results using the PercSac in a percutaneous cystolithopaxy model. In this study, we compare the efficiency of stone fragmentation with and without the PercSac in an anatomically correct in vitro PCNL model.

Materials And Methods: The PCNL model consisted of a human collecting system model created on a 3D printer. Ten BegoStones made in spherical molds of 2.0 cm diameter, matched for weight, were fragmented in the model using a 24F rigid nephroscope and an ultrasonic lithotripter, including five with and five without the PercSac. The total times for stone fragmentation and complete stone clearance, gross assessment of the stone-free status, and need for flexible nephroscopy to achieve a stone-free state were recorded.

Results: The median time for stone fragmentation was significantly shorter in the PercSac group compared with the control group (217 seconds [IQR = 169-255] vs 340 seconds [IQR = 310-356], [p = 0.028]). Likewise, the total time for complete stone clearance from the kidney was significantly shorter for the PercSac group (293 seconds [IQR = 244-347] vs 376 seconds [IQR = 375-480], [p = 0.047]). In one trial with the PercSac, residual dust remained in the kidney, while in all five trials without the PercSac small residual fragments remained. All trials without the PercSac required flexible nephroscopy with basket extraction to become stone free, while none of the trials with the PercSac required flexible nephroscopy for stone clearance.

Conclusions: Ultrasonic lithotripsy using the novel PercSac stone entrapment device is more efficient and efficacious than traditional ultrasonic lithotripsy in an in vitro PCNL model. The advantage may be even more pronounced during clinical PCNL where residual fragments migrate into difficult-to-access calices. Further in vivo testing is underway.
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http://dx.doi.org/10.1089/end.2016.0466DOI Listing
November 2016

Surgical Management of Stones: American Urological Association/Endourological Society Guideline, PART I.

J Urol 2016 Oct 27;196(4):1153-60. Epub 2016 May 27.

American Urological Association Education and Research, Inc., Linthicum, Maryland.

Purpose: This Guideline is intended to provide a clinical framework for the surgical management of patients with kidney and/or ureteral stones. The summary presented herein represents Part I of the two-part series dedicated to Surgical Management of Stones: American Urological Association/Endourological Society Guideline. Please refer to Part II for an in-depth discussion of patients presenting with ureteral or renal stones.

Materials And Methods: A systematic review of the literature (search dates 1/1/1985 to 5/31/2015) was conducted to identify peer-reviewed studies relevant to the surgical management of stones. The review yielded an evidence base of 1,911 articles after application of inclusion/exclusion criteria. These publications were used to create the Guideline statements. Evidence-based statements of Strong, Moderate, or Conditional Recommendation were developed based on benefits and risks/burdens to patients. Additional directives are provided as Clinical Principles and Expert Opinions when insufficient evidence existed.

Results: The Panel identified 12 adult Index Patients to represent the most common cases seen in clinical practice. Three additional Index Patients were also created to describe pediatric and pregnant patients with such stones. With these patients in mind, Guideline statements were developed to aid the clinician in identifying optimal management.

Conclusions: Proper treatment selection, which is directed by patient- and stone-specific factors, remains the greatest predictor of successful treatment outcomes. This Guideline is intended for use in conjunction with the individual patient's treatment goals. In all cases, patient preferences and personal goals should be considered when choosing a management strategy.
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http://dx.doi.org/10.1016/j.juro.2016.05.090DOI Listing
October 2016

Surgical Management of Stones: American Urological Association/Endourological Society Guideline, PART II.

J Urol 2016 Oct 27;196(4):1161-9. Epub 2016 May 27.

American Urological Association Education and Research, Inc., Linthicum, Maryland.

Purpose: This Guideline is intended to provide a clinical framework for the surgical management of patients with kidney and/or ureteral stones. The summary presented herein represents Part II of the two-part series dedicated to Surgical Management of Stones: American Urological Association/Endourological Society Guideline. Please refer to Part I for introductory information and a discussion of pre-operative imaging and special cases.

Materials And Methods: A systematic review of the literature (search dates 1/1/1985 to 5/31/2015) was conducted to identify peer-reviewed studies relevant to the surgical management of stones. The review yielded an evidence base of 1,911 articles after application of inclusion/exclusion criteria. These publications were used to create the Guideline statements. Evidence-based statements of Strong, Moderate, or Conditional Recommendation were developed based on benefits and risks/burdens to patients. Additional directives are provided as Clinical Principles and Expert Opinions when insufficient evidence existed.

Results: The Panel identified 12 adult Index Patients to represent the most common cases seen in clinical practice. Three additional Index Patients were also created to describe the more commonly encountered special cases, including pediatric and pregnant patients. With these patients in mind, Guideline statements were developed to aid the clinician in identifying optimal management.

Conclusions: Proper treatment selection, which is directed by patient- and stone-specific factors, remains the greatest predictor of successful treatment outcomes. This Guideline is intended for use in conjunction with the individual patient's treatment goals. In all cases, patient preferences and personal goals should be considered when choosing a management strategy.
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http://dx.doi.org/10.1016/j.juro.2016.05.091DOI Listing
October 2016

The kidney stone and increased water intake trial in steel workers: results from a pilot study.

Urolithiasis 2017 Apr 26;45(2):177-183. Epub 2016 May 26.

Department of Urology, The University of Texas Southwestern Medical Center, Moss Bldg, 8th Fl, Ste 112, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA.

Preventing dehydration in subjects at risk may provide a means of primary prevention of kidney stones. The purpose of this pilot study was to assess the hydration status of an at-risk group of steel plant workers based on end-of-shift ('post-shift') spot urine osmolality and 24-h urinary stone risk parameters. 100 volunteers were recruited from Gerdau Midlothian steel mill in Texas on 11/14/14 and 12/5/14. Clinical data were recorded and post-shift spot urine sample was used to measure urine osmolality. Participants were invited to submit a 24-h urine sample within 4 weeks of enrollment. The mean age was 41 years and 95 % were men. The majority of subjects were white (75 %), followed by 10 % Hispanic and 9 % black. The mean body mass index was 30.1 kg/m and overall 16 % had a past history of stone disease. Mean post-shift urine spot osmolality was 704.5 mOsm (169-1165 mOsm) and was >800 and >700 mOsm in 39 and 57 %, respectively. Among 59 24-h urines samples, the mean volume was 1.89 ± 0.92 l/day, with 56 % < 2 L and 17 % < 1 L. Elevated levels of urinary analytes were found in 29 % of subjects for calcium (>250 mg/TV), 39 % for uric acid (>700 mg/TV), 25 % for oxalate (>45 mg/TV) and 50 % for sodium (>200 meq/TV). The prevalence of stone disease in this population of steel workers was higher than the published prevalence of stone disease in the general population. A significant number of workers had concentrated post-shift and 24-h urines and elevated levels of urinary analytes.
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http://dx.doi.org/10.1007/s00240-016-0892-7DOI Listing
April 2017

Kidney stones.

Nat Rev Dis Primers 2016 02 25;2:16008. Epub 2016 Feb 25.

Division of Urology, Department of Clinical Sciences, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.

Kidney stones are mineral deposits in the renal calyces and pelvis that are found free or attached to the renal papillae. They contain crystalline and organic components and are formed when the urine becomes supersaturated with respect to a mineral. Calcium oxalate is the main constituent of most stones, many of which form on a foundation of calcium phosphate called Randall's plaques, which are present on the renal papillary surface. Stone formation is highly prevalent, with rates of up to 14.8% and increasing, and a recurrence rate of up to 50% within the first 5 years of the initial stone episode. Obesity, diabetes, hypertension and metabolic syndrome are considered risk factors for stone formation, which, in turn, can lead to hypertension, chronic kidney disease and end-stage renal disease. Management of symptomatic kidney stones has evolved from open surgical lithotomy to minimally invasive endourological treatments leading to a reduction in patient morbidity, improved stone-free rates and better quality of life. Prevention of recurrence requires behavioural and nutritional interventions, as well as pharmacological treatments that are specific for the type of stone. There is a great need for recurrence prevention that requires a better understanding of the mechanisms involved in stone formation to facilitate the development of more-effective drugs.
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http://dx.doi.org/10.1038/nrdp.2016.8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5685519PMC
February 2016

Editorial Comment.

Urology 2016 05;91

Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX.

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http://dx.doi.org/10.1016/j.urology.2016.01.036DOI Listing
May 2016

Medical management of renal stones.

BMJ 2016 Mar 14;352:i52. Epub 2016 Mar 14.

Department of Urology, UT Southwestern Medical Center, Dallas, TX 75390-9110, USA

The prevalence of kidney stones is increasing in industrialized nations, resulting in a corresponding rise in economic burden. Nephrolithiasis is now recognized as both a chronic and systemic condition, which further underscores the impact of the disease. Diet and environment play an important role in stone disease, presumably by modulating urine composition. Dietary modification as a preventive treatment to decrease lithogenic risk factors and prevent stone recurrence has gained interest because of its potential to be safer and more economical than drug treatment. However, not all abnormalities are likely to be amenable to dietary therapy, and in some cases drugs are necessary to reduce the risk of stone formation. Unfortunately, no new drugs have been developed for stone prevention since the 1980s when potassium citrate was introduced, perhaps because the long observation period needed to demonstrate efficacy discourages investigators from embarking on clinical trials. Nonetheless, effective established treatment regimens are currently available for stone prevention.
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http://dx.doi.org/10.1136/bmj.i52DOI Listing
March 2016

Use of an Electronic Medical Record to Assess Patient-Reported Morbidity Following Ureteroscopy.

J Endourol 2016 May 16;30 Suppl 1:S46-51. Epub 2016 Mar 16.

2 Department of Urology, University of Texas Southwestern Medical Center , Dallas, Texas.

Background And Purpose: With the extensive documentation afforded by our electronic medical record (EMR), we observed an unusually high number of patient-initiated encounters following ureteroscopy (URS). We sought to quantify and categorize patient encounters following URS to determine if we could identify avoidable common problems.

Materials And Methods: Following IRB approval, we reviewed the records of 298 consecutive patients with stones who underwent 314 URS procedures between July 2013 and November 2014. Patient demographics, stone characteristics and operative details, as well as telephone encounters, secure online patient-initiated (MyChart) messages, and emergency department (ED) visits following URS were extracted from our EMR (Epic, Verona, WI). We performed univariate (UVA) and multivariate (MVA) analysis to identify factors predictive of postoperative patient encounters and compared URS patients to a group of 56 patients undergoing transurethral resection of bladder tumor (TURBT) for number and type of encounters.

Results: We identified 443 encounters generated by 201 URS patients, including 334 telephone calls, 71 MyChart messages, and 38 ED visits. Among these encounters, 352 (79%) were medically related (pain comprised 45%) and the remainder involved scheduling issues. By UVA age, bilateral versus unilateral URS, stone location (both kidney and ureter), ureteral access sheath size, and total number of stones predicted a postoperative encounter. By MVA, only younger age and larger UAS size were independent predictors. When compared with TURBT patients, URS patients had a 2.5-fold higher risk of having a pain-related postoperative encounter (OR 2.54, 95% CI 1.08-7.04, P=0.03).

Conclusions: Among patients undergoing URS for stones, two-thirds made unprompted contact with a healthcare provider and 80% of contacts involved postoperative pain, a finding that is distinct from another endoscopic procedure that does not involve upper tract manipulation. Patients do not perceive URS as the benign procedure doctors do.
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http://dx.doi.org/10.1089/end.2016.0079DOI Listing
May 2016

Is Ureteroscopy as Good as We Think?

J Urol 2016 04 22;195(4 Pt 1):823-4. Epub 2016 Jan 22.

Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas.

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http://dx.doi.org/10.1016/j.juro.2016.01.061DOI Listing
April 2016

A novel device to prevent stone fragment migration during percutaneous lithotripsy.

J Endourol 2014 Dec;28(12):1395-8

1 Department of Urology, University of Texas Southwestern Medical Center , Dallas, Texas.

Purpose: We developed a novel device to capture stones in vivo in an enclosed bag (PercSac) to prevent dispersion of stone fragments during percutaneous nephrolithotomy (PCNL) or cystolitholapaxy. We report on our initial feasibility trials of the PercSac device.

Materials And Methods: PercSac consists of a specially designed polyethylene bag that is fitted over the shaft of a rigid nephroscope. The bag is used to first entrap the target stone, then tighten around it to allow fragmentation within the bag. Matched pairs of 10 canine bladder stones (2.5 cm maximum diameter) were fragmented in a human bladder model using the CyberWand (Olympus America, Inc.), and the procedure was assessed for markers of efficiency and effectiveness.

Results: Median time to entrap the stone within the PercSac was 67 seconds (range 51-185 sec). Median time for stone fragmentation was significantly shorter with the PercSac than without (182.0 sec [range 108-221] vs 296.5 sec [range 226-398], P=0.004). Overall, however, there was no significant difference in the total time to entrap and fragment the stones between the two groups. A stone-free state was not achieved for any trial without the PercSac, while 9 of 10 trials with the PercSac resulted in a stone-free state.

Conclusions: Use of the PercSac in conjunction with stone fragmentation has the potential to reduce the occurrence of residual fragments after PCNL or cystolitholapaxy. Further in vitro testing in a kidney model is planned.
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http://dx.doi.org/10.1089/end.2014.0231DOI Listing
December 2014

Use of the National Health and Nutrition Examination Survey to calculate the impact of obesity and diabetes on cost and prevalence of urolithiasis in 2030.

Eur Urol 2014 Oct 9;66(4):724-9. Epub 2014 Jul 9.

University of Texas, Southwestern Medical Center, Dallas, TX, USA. Electronic address:

Background: The prevalence of urolithiasis and its risk factors such as obesity and diabetes have increased over time.

Objective: Determine the future cost and prevalence of kidney stones using current and projected estimates for stones, obesity, diabetes, and population rates.

Design, Setting, And Participants: The stone prevalence in 2000 was estimated from the National Health and Nutrition Examination Survey (NHANES) 1988-1994 and 2007-2010. The cost per percentage prevalence of stones in 2000, calculated using Urologic Diseases in America Project data, was used to estimate the annual cost of stones in 2030, adjusting for inflation and increases in population, stone prevalence, obesity and diabetes rates.

Outcome Measurements And Statistical Analysis: The primary outcome was prevalence and cost of stones in 2030. The secondary outcomes were the impact of obesity and diabetes on these values, calculated using odds ratios for stones by body mass index and diabetes status.

Results And Limitations: The annual cost of stone disease in 2000, adjusted for inflation to 2014 US dollars, was approximately $2.81 billion. After accounting for increases in population and stone prevalence from 2000, the estimated cost of stones in 2007 in 2014 US dollars was $3.79 billion. Future population growth alone would increase the cost of stone disease by $780 million in 2030. Based on projected estimates for 2030, obesity will independently increase stone prevalence by 0.36%, with an annual cost increase of $157 million. Diabetes will independently increase stone prevalence by 0.72%, associated with a cost increase of $308 million annually by 2030. NHANES data, however, capture patient self-assessment rather than medical diagnosis, which is a potential bias.

Conclusions: The rising prevalence of obesity and diabetes, together with population growth, is projected to contribute to dramatic increases in the cost of urolithiasis, with an additional $1.24 billion/yr estimated by 2030.

Patient Summary: Obesity, diabetes, and population rates will contribute to an estimated $1.24 billion/yr increase in the cost of kidney stones by 2030.
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http://dx.doi.org/10.1016/j.eururo.2014.06.036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4227394PMC
October 2014

A prospective, multi-institutional study of flexible ureteroscopy for proximal ureteral stones smaller than 2 cm.

J Urol 2015 Jan 9;193(1):165-9. Epub 2014 Jul 9.

Johns Hopkins Medical Institutions, Baltimore, Maryland. Electronic address:

Purpose: Flexible ureteroscopy is rapidly becoming a first line therapy for many patients with renal and ureteral stones. However, current understanding of treatment outcomes in patients with isolated proximal ureteral stones is limited. Therefore, we performed a prospective, multi-institutional study of ureteroscopic management of proximal ureteral stones smaller than 2 cm to better define clinical outcomes associated with this approach.

Materials And Methods: Adult patients with proximal ureteral calculi smaller than 2 cm were prospectively identified. Patients with concomitant ipsilateral renal calculi or prior ureteral stenting were excluded from study. Flexible ureteroscopy, holmium laser lithotripsy and ureteral stent placement was performed. Ureteral access sheath use, laser settings and other details of perioperative and postoperative management were based on individual surgeon preference. Stone clearance was determined by the results of renal ultrasound and plain x-ray of the kidneys, ureters and bladder 4 to 6 weeks postoperatively.

Results: Of 71 patients 44 (62%) were male and 27 (38%) were female. Mean age was 48.2 years. ASA(®) score was 1 in 12 cases (16%), 2 in 41 (58%), 3 in 16 (23%) and 4 in 2 (3%). Mean body mass index was 31.8 kg/m(2), mean stone size was 7.4 mm (range 5 to 15) and mean operative time was 60.3 minutes (range 15 to 148). Intraoperative complications occurred in 2 patients (2.8%), including mild ureteral trauma. Postoperative complications developed in 6 patients (8.7%), including urinary tract infection in 3, urinary retention in 2 and flash pulmonary edema in 1. The stone-free rate was 95% and for stones smaller than 1 cm it was 100%.

Conclusions: Flexible ureteroscopy is associated with excellent clinical outcomes and acceptable morbidity when applied to patients with proximal ureteral stones smaller than 2 cm.
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http://dx.doi.org/10.1016/j.juro.2014.07.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4449255PMC
January 2015

Diet: from food to stone.

World J Urol 2015 Feb 18;33(2):179-85. Epub 2014 Jun 18.

Department of Urology, UT Southwestern Medical Center, 5323 Harry Hines Blvd, J8.106, Dallas, TX, 75390-09110, USA,

Dietary factors have been shown to influence urine composition and modulate the risk of kidney stone disease. With the rising prevalence of stone disease in many industrialized nations, dietary modification as therapy to improve lithogenic risk factors and prevent stone recurrence has gained appeal, as it is both relatively inexpensive and safe. While some dietary measures, such as a high fluid intake, have been shown in long-term randomized clinical trials to have durable effectiveness, other dietary factors have been subjected to only short-term clinical or metabolic studies and their efficacy has been inferred. Herein, we review the current literature regarding the role of diet in stone formation, focusing on both the effect on urinary stone risk factors and the effect on stone recurrence.
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http://dx.doi.org/10.1007/s00345-014-1344-zDOI Listing
February 2015

Medical management of kidney stones: AUA guideline.

J Urol 2014 Aug 20;192(2):316-24. Epub 2014 May 20.

American Urological Assocation Education and Research, Inc., Linthicum, Maryland.

Purpose: The purpose of this guideline is to provide a clinical framework for the diagnosis, prevention and follow-up of adult patients with kidney stones based on the best available published literature.

Materials And Methods: The primary source of evidence for this guideline was the systematic review conducted by the Agency for Healthcare Research and Quality on recurrent nephrolithiasis in adults. To augment and broaden the body of evidence in the AHRQ report, the AUA conducted supplementary searches for articles published from 2007 through 2012 that were systematically reviewed using a methodology developed a priori. In total, these sources yielded 46 studies that were used to form evidence-based guideline statements. In the absence of sufficient evidence, additional statements were developed as Clinical Principles and Expert Opinions.

Results: Guideline statements were created to inform clinicians regarding the use of a screening evaluation for first-time and recurrent stone formers, the appropriate initiation of a metabolic evaluation in select patients and recommendations for the initiation and follow-up of medication and/or dietary measures in specific patients.

Conclusions: A variety of medications and dietary measures have been evaluated with greater or less rigor for their efficacy in reducing recurrence rates in stone formers. The guideline statements offered in this document provide a simple, evidence-based approach to identify high-risk or interested stone-forming patients for whom medical and dietary therapy based on metabolic testing and close follow-up is likely to be effective in reducing stone recurrence.
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http://dx.doi.org/10.1016/j.juro.2014.05.006DOI Listing
August 2014
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