Improving care to decrease stone recurrence and opioid use

In 2019, quality improvement has been a central theme throughout leading articles on nephrolithiasis. Real-world outcomes were published on the natural history of stones and residual fragments, patient compliance with medical therapy and treatment-related opioid use. In-depth review of these topics will enhance provider–patient counselling and shape future paradigms in stone disease.

Key advances

  • Compared with basketing, dusting of kidney stones sized 5–20 mm decreased operating times by 30 minutes without differences in stone-free rates, complications or additional procedures at ~6 weeks1.

  • Within 3 months after ureteroscopy, patients with residual stone fragments ≥3 mm had at least a fivefold increased risk for repeat future surgical intervention, particularly those without obesity2.

  • In a prospective analysis, 67% of first-time symptomatic stone formers had stone recurrence at 5 years; in patients with concurrent asymptomatic stones, 51% had stone passage at 5 years but only 52% of these reported symptoms3.

  • In a tertiary-care population, long-term adherence rates to stone prevention medications were 42% for alkali citrate and 52% for hydrochlorothiazide5.

  • In a population of uric acid stone formers with obesity, preventive drug adherence rates were ~53% and adherent patients had smaller stone recurrences and fewer stone surgeries than those who did not adhere to their regimen6.

  • In a nationally representative population, history of nephrolithiasis was associated with a 27% increase in current narcotic use, and 6–9% of previously opioid-naive patients prescribed an opioid for pain management continued use at 3–6 months after first prescription7,8,9.

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Fig. 1: Opioid use in kidney stone formers.


  1. 1.

    Humphreys, M. R. et al. Dusting versus basketing during ureteroscopy-which technique is more efficacious? A prospective multicenter trial from the EDGE Research Consortium. J. Urol. 199, 1272–1276 (2018).

  2. 2.

    Iremashvili, V. et al. Role of residual fragments on the risk of repeat surgery after flexible ureteroscopy and laser lithotripsy: single center study. J. Urol. 201, 358–363 (2019).

  3. 3.

    D’Costa, M. R. et al. Symptomatic and radiographic manifestations of kidney stone recurrence and their prediction by risk factors: a prospective cohort study. J. Am. Soc. Nephrol. 30, 1251–1260 (2019).

  4. 4.

    Dauw, C. A. et al. Medication nonadherence and effectiveness of preventive pharmacological therapy for kidney stones. J. Urol. 195, 648–652 (2016).

  5. 5.

    Golomb, D. et al. Long-term adherence to medications in secondary prevention of urinary tract stones. J. Endourol. 33, 469–474 (2019).

  6. 6.

    Canales, B. K. et al. Long-term recurrence rates in uric acid stone formers with or without medical management. Urology 131, 46–52 (2019).

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    Shoag, J. E. et al. Kidney stones and risk of narcotic use. J. Urol. 202, 114–118 (2019).

  8. 8.

    Tam, C. A. et al. New persistent opioid use after outpatient ureteroscopy for upper tract stone treatment. Urology 134, 103–108 (2019).

  9. 9.

    Hosier, G. W. et al. Persistent opioid use among patients with urolithiasis: a population based study. Eur. Urol. Focus. (2019).

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Author information

Correspondence to Jonathan G. Pavlinec or Benjamin K. Canales.

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Competing interests

B.K.C. receives grant funding through the National Institutes of Health and Allena Pharmaceuticals, consults for Alnylam Pharmaceuticals and Federation Bio, gives publication advice for Current Opinion in Urology and American Urological Association Content Review, and has investment relationships in AP LifeSciences LLC and ForTec Litho LLC. J.G.P. declares no competing interests.

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Pavlinec, J.G., Canales, B.K. Improving care to decrease stone recurrence and opioid use. Nat Rev Urol (2019) doi:10.1038/s41585-019-0275-2

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