Perioperative Pregabalin as Part of a Multimodal Treatment Plan for Pain After Ureteroscopy With Stent Placement: a Pilot
Phase: PHASE3
Conditions: Nephrolithiasis, Urolithiasis, Perioperative/Postoperative Complications, Pain, Postoperative, Pain, Acute, Anesthesia, Urologic Diseases, Anesthesia Morbidity
Sponsor: University of Missouri-Columbia

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BIOMEDICAL RESEARCH PROTOCOL 
UNIVERSITY OF MISSOURI 
 
Project Title: Perioperative pregabalin as part of a multimodal treatment plan for pain after 
ureteroscopy with stent placement: a pilot 
 
IRB Number: 2013680 
Version Number: 1.1 
Version Date: 2/6/2019 
Principal Investigator: Katie Murray, DO 
Funding Source: Departmental   
Clinical Trial Phase: Not Phased  
Clinicaltrials.gov Number: NCT03927781 
Study Drug/Study Device: Pregabalin  
 
 
Principal Investigator 
Katie Murray, DO 
Department of Surgery Urology 
Division 
Co-Investigator 
Geoffrey Rosen, MD 
Department of Surgery Urology 
Division 
Consenting Professional(s) 
Department 
Department of Surgery-
Urology 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
University of Missouri University Hospital 
Department of Surgery Urology Division 
1 Hospital Drive 
Columbia, MO 65212 
 
 

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Table of Contents 
PROTOCOL SUMMARY AND/OR SCHEMA ........................................................................ 4 
OBJECTIVES AND SCIENTIFIC AIMS .................................................................................. 4 
Primary Hypothesis ................................................................................................................................ 4 
Exploratory Hypotheses ......................................................................................................................... 4 
Primary Endpoints ................................................................................................................................. 4 
Secondary Endpoints: ............................................................................................................................ 4 
BACKGROUND AND STUDY DESIGN/INTERVENTION .................................................. 4 
CRITERIA FOR SUBJECT ELIGIBILITY ............................................................................. 5 
Subject Population .................................................................................................................................. 5 
Subject Inclusion ..................................................................................................................................... 6 
Subject Exclusion .................................................................................................................................... 6 
OVERVIEW OF STUDY DESIGNATION ............................................................................... 6 
Design ....................................................................................................................................................... 6 
Pre-op standardized care ....................................................................................................................... 6 
Post-op standardized care ...................................................................................................................... 6 
THERAPEUTIC AND DIAGNOSTIC AGENTS ..................................................................... 7 
RECRUITMENT PLAN .............................................................................................................. 7 
PRETREATMENT EVALUATION ........................................................................................... 7 
SURGICAL PLAN ....................................................................................................................... 7 
EVALUATION DURING TREATMENT/INTERVENTION ................................................. 8 
Not part of usual care ............................................................................................................................. 8 
Usual care ................................................................................................................................................ 8 
TOXICITIES/SIDE EFFECTS ................................................................................................... 9 
CRITERIA FOR THERAPEUTIC RESPONSE/OUTCOME ASSESSMENT ..................... 9 
CRITERIA FOR REMOVAL FROM STUDY ....................................................................... 10 
BIOSTATISTICS ........................................................................................................................ 10 
Sample Size ............................................................................................................................................ 10 
Analysis .................................................................................................................................................. 10 
Proposed Analyses ................................................................................................................................ 10 
RESEARCH PARTICIPANT REGISTRATION AND RANDOMIZATION 
PROCEDURES ........................................................................................................................... 10 
Research Participant Registration ...................................................................................................... 10 
DATA MANAGEMENT ISSUES ............................................................................................. 11 
Quality Assurance ................................................................................................................................. 11 
Data and Safety Monitoring ................................................................................................................ 11 
PROTECTION OF HUMAN SUBJECTS ............................................................................... 11 
Benefits and Risks ................................................................................................................................. 11 
Toxicities and side effects ..................................................................................................................... 11 
Alternatives / Therapeutic options ...................................................................................................... 11 
Financial Costs and Burdens ............................................................................................................... 12 

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Privacy and Confidentiality ................................................................................................................. 12 
Volunteering Nature of the Study ....................................................................................................... 12 
Serious Adverse Event (SAE) Reporting ............................................................................................ 12 
INFORMED CONSENT PROCEDURES ............................................................................... 12 
REFERENCES ............................................................................................................................ 12 
APPENDICES ............................................................................................................................. 15 
Appendix 1 – REDCap instruments .................................................................................................... 15 
Appendix 2 – USSQ .............................................................................................................................. 15 
Appendix 3 – Aldrete ............................................................................................................................ 15 
Appendix 4 – Post-op study specific instruction ................................................................................ 15 
Appendix 5 – Written consent and HIPAA authorization ................................................................ 15 
Appendix 6 – HIPAA waiver of authorization ................................................................................... 15 
 
 
 
 

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PROTOCOL SUMMARY AND/OR SCHEMA 
We propose a pilot clinical trial on the use of perioperative pregabalin in order to decrease 
ureteral stent related symptoms and decrease opioid usage after ureteroscopy with stent 
placement. Patients undergoing ureteroscopy with stent placement will receive a single dose of 
300 mg pregabalin PO in the preoperative area. We will assess safety and feasibility of studying 
this regimen at our institution, with the aim of performing a randomized, placebo-controlled, 
double-blinded study in the future.  
OBJECTIVES AND SCIENTIFIC AIMS 
Primary Hypothesis 
It is safe and feasible to study perioperative pregabalin in ureteroscopy with stent placement at 
our institution. 
 
Exploratory Hypotheses 
We hypothesize that the use of the perioperative pregabalin will:  
- 
decrease ureteral stent related symptoms at 3 days post-op 
- 
decrease the probability of a patient requiring narcotic pain medication 
- 
decrease the total amount of narcotic pain medication used 
- 
decrease the unplanned contact between the patient and the healthcare system related to 
the stent 
- 
improve patient satisfaction after ureteroscopy with stent placement 
 
Primary Endpoints 
The primary endpoints will be as follows: 
- 
Adverse events related to study drug 
- 
Verified correct administration of study drug 
- 
Correct use of study instruments 
 
Secondary Endpoints: 
Secondary endpoints include the following: 
- 
Ureteral Stent Related Symptom Questionnaire (USSQ) [1] score at 3 days post op 
- 
Monitored prescribing of narcotic pain medication 
- 
Number of patients taking narcotic pain medication at several time points 
- 
Oral morphine equivalents the patient has used at several time points 
- 
Number of unplanned contacts between the patient and the healthcare system within 30 
days 
- 
Score on standardized evaluation of patient satisfaction 
BACKGROUND AND STUDY DESIGN/INTERVENTION 
 
The prevalence of urolithiasis is greater than 8% and increasing in the United States (US) [2]. 
There are several treatment options, including ureteroscopy (with or without laser lithotripsy), 
extracorporeal shock wave lithotripsy, and percutaneous nephrolithotomy. A recent study in 
California demonstrated that ureteroscopic treatment was employed in more than 40% of 
interventions [3], with some nationwide estimates up to 59% [4]. At least 300,000 stone 

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interventions are performed yearly in the US on working age adults [5], thereby, at least 120,000 
ureteroscopies are. There are several other indications for ureteroscopy, including diagnosis of 
structural anomaly and diagnosis and management of ureteral and renal pelvic tumors. 
 
Depending on the specifics of the procedure, it may be advisable to place a ureteral stent 
intraoperatively [6]. The most commonly used variety of stent is the double J stent [7], which has 
long been known to cause post-operative pain in around 80% of patients, as well as irritative 
symptoms in a sizeable portion [8, 9]. A validated questionnaire (the Ureteral Stent Symptom 
Questionnaire [USSQ]) exists to evaluate symptoms of ureteral stents and their effects of quality 
of life [1].  
 
Alpha-blockers decrease ureteral stent discomfort when compared to placebo [10, 11]. Anti-
muscarinic medications (specifically tolteridine) have also been shown to be helpful with stent 
related discomfort independently, or in addition to alpha blockade [12], though the evidence is 
mixed [13]. A recent systematic review failed to find any studies of other medications for stent 
related discomfort that met inclusion criteria [14]. Subsequently, a well-designed study 
demonstrated the utility of mirabegron for indwelling stent symptoms [15]. 
 
Recent guidelines recommend the use of multimodal treatment strategies in the management of 
postoperative pain [16]. In several contexts gabapentin or pregabalin have been shown to be a 
beneficial part of such a strategy. For example, in percutaneous nephrolithotomy, a randomized, 
placebo-controlled, double-blind study demonstrated that a single dose of 600mg of oral 
gabapentin 1 hour before surgery significantly decreased catheter-related bladder discomfort, 
number of patients requiring opioid pain relief, and amount of opioid pain relief when used [17]. 
Similarly, outside urology, several well-designed trials demonstrate the positive effects of 
perioperative pregabalin or gabapentin in the elective, outpatient surgery setting [18-20]. Several 
reviews and meta analyses have also supported the use of perioperative gabapentin or pregabalin 
in various settings [21-24]. The principal side effects of pregabalin are temporary 
cognition/coordination changes, with a very low risk of serious side effects [25]. No well-
constructed studies to date have examined the perioperative use of gabapentinoids in post-
ureteroscopy ureteral stent related symptoms.  
 
We propose a study to extend the literature base on the use of perioperative pregabalin to 
ureteroscopy with stent placement through a prospective, randomized controlled trial. In order to 
ensure safety and feasibility of this future study, we will first perform a small pilot. We will 
administer study medication and study questionnaires. There will be additional components of 
study evaluation. This will be used to inform the design of a future trial. 
 
CRITERIA FOR SUBJECT ELIGIBILITY 
Subject Population 
Undergoing elective ureteroscopy with stent placement by Dr. Murray at University of Missouri 
Hospital and affiliated facilities 
 

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Subject Inclusion 
Age ³ 18 years 
 
Subject Exclusion 
- 
Renal insufficiency (eGFR < 30 mL/minute/1.73 m2 
- 
Chronic indwelling ureteral stent 
- 
Chronic opioid use 
- 
History of opioid abuse 
- 
Chronic gabapentinoid use 
- 
Plan for inpatient hospitalization 
- 
Pregnancy 
- 
Inability of the patient to consent for themselves in English 
- 
Allergy to gabapentinoid 
- 
Liver failure or hepatic dysfunction 
OVERVIEW OF STUDY DESIGNATION 
Design 
This is a pilot clinical trial on the use of perioperative pregabalin in order to decrease ureteral 
stent related symptoms and decrease opioid usage after ureteroscopy with stent placement. 
Patients undergoing ureteroscopy with stent placement will receive a single dose of 300 mg 
pregabalin PO in the preoperative area.  
 
Pre-op standardized care 
After obtaining written consent, patients will be enrolled. All patients will be told the following 
by a member of the study staff: 
“We will be administering several medications before, during, and after your procedure to help 
with pain. We expect that you will be able to go home with just non-steroidal pain medication.” 
They will also be counseled on the risks and benefits of non-steroidal anti-inflammatory drugs 
(NSAIDS).  
 
Subsequently, all patients will be given a single dose of pregabalin 300 mg PO with a sip of 
water approximately one hour before surgery. This will be administered per standard intuitional 
practice. It will be recorded in the regular medical chart of the patient. 
 
Post-op standardized care 
Perioperative care, surgery and anesthesia, for all subjects will be per standard hospital protocol. 
 
A standardized post-operative regimen will be used, consisting of a single belladonna & opium 
suppository, a single dose of ketorolac 30mg IV, and ondansetron 4mg IV. A single dose of 
hydrocodone 5mg with acetaminophen 325mg PO will be available PRN pain.  
 
To qualify for discharge from the PACU, all patients will have had to have met a standardized 
set of discharge criteria. They will have to have ambulated, voided, tolerated PO intake, and have 
pain subjectively adequately controlled.  
 

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On PACU discharge, patients will be given a prescription for 20 tablets of 50mg diclofenac, 20 
tablets of acetaminophen 650mg to be taken on a scheduled basis every 6 hours, and mirabegron 
50mg once daily PO to be taken until stent removal [15]. There is no universal standard of care 
discharge regimen after ureteroscopy, but a similar one to this has been shown to be safe and 
effective [26]. Patients will receive a standardized sheet of return precautions. They will receive 
packets of questionnaires to be completed along with pre-addressed and pre-stamped envelopes. 
They will be instructed to only seek pain medication from the urology team for the next month. 
Should they have need for further pain medication, patients will be instructed to call the clinic 
[see supplementary material]. They will be offered their choice of another 3 days of NSAID or 
oxycodone 5mg q6h PRN pain 6 tablets. Further treatment will be at provider discretion. The 
clinic staff will be instructed to record these prescriptions.  
 
THERAPEUTIC AND DIAGNOSTIC AGENTS 
Pregabalin is an oral agent approved for use in fibromyalgia and neuropathic pain. A single dose 
of 300mg PO will be given to all patients.  
RECRUITMENT PLAN 
Patients will be recruited from the practice of Dr. Murray in the Division of Urology, 
Department of Surgery. The study will be introduced to every eligible patient scheduled for 
ureteroscopy with stent placement by the participating consenting physicians from the 
Department of Surgery-Urology Division and a written consent obtained prior to surgery by the 
consenting research personnel. Candidate subjects will be provided time to consider the study, to 
read the informed consent document at their convenience, and discuss the study with family and 
others, as desired. It will be clearly indicated that non-enrollment in the study will not negatively 
affect the patient’s care.  
PRETREATMENT EVALUATION 
This study does not require any additional pretreatment evaluations other than those which are 
part of current clinical care standards for a patient undergoing ureteroscopy with stent placement 
at University of Missouri. Preoperative evaluations typically include the following:  
- 
Routine history and physical examination to include documentation of any comorbidities, 
medications (including complementary and alternative medications), family history, 
social history (alcohol and tobacco usage), height, body weight 
- 
Past medical history including previous treatment for addiction 
- 
Past surgical history including other uses of stents in the patient’s lifetime 
- 
Evaluation of renal function 
- 
Any woman of child bearing age who believes she may be pregnant receives a pregnancy 
test 
 
SURGICAL PLAN 
The technique of surgery will have been determined to be ureteroscopy with stent placement 
based on the discretion of the surgeon and patient. None of the techniques utilized in the study 
are considered experimental and all are considered standard therapeutic options for patients with 

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indications for this procedure. Typical indications include nephroureterolithiasis and evaluation 
for malignancy.   
 
The operating team will consist of surgeons on faculty at University of Missouri Department of 
Surgery-Urology Division. The procedures are performed under standardized general anesthesia 
with standard intraoperative vital sign monitoring. 
EVALUATION DURING TREATMENT/INTERVENTION 
 
Not part of usual care 
This protocol requires several evaluations outside those typically used. These are all 
questionnaires.  
 
Timing 
Questionnaire 
Respondent 
Day of surgery 
Screening questionnaire 
Study staff 
 
Baseline surgery 
Patient 
 
Post-op surgeon 
Treatment staff 
 
PACU 
Patient/PACU nurse 
 
Aldrete 
PACU nurse 
 
Evaluation of trial 
Patient 
 
Evaluation of trial 
PACU nurse 
3 days post op 
Early patient questionnaire 
Patient 
 
USSQ 
Patient 
 
Evaluation of trial 
Patient 
7 days post op 
Early patient questionnaire 
Patient 
 
Evaluation of trial 
Patient 
30 days post op 
30 days post op study 
Study staff 
 
Late patient questionnaire 
Patient 
 
Evaluation of trial 
Patient 
90 days post op 
Late patient questionnaire 
Patient 
 
Evaluation of trial 
Patient 
6 months post op 
Late patient questionnaire 
Patient 
 
Evaluation of trial 
Patient 
1-year post op 
Late patient questionnaire 
Patient 
 
Evaluation of trial 
Patient 
Untimed 
Unanticipated contact 
Study staff/Treatment staff 
 
Evaluation of trial 
Patient 
 
Usual care 
Routine evaluation and management for those undergoing ureteroscopy with stent placement 
include: 
ASA classification, assigned by the anesthesiologist  
Deep venous thrombosis prophylaxis per standardized pathway 
Estimated blood loss 
Use of intraoperative fluids (crystalloid, colloid, blood products) 

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TOXICITIES/SIDE EFFECTS 
Various symptoms have been associated with the administration of pregabalin in the 
perioperative setting. The risk of serious adverse events in this use of pregabalin is low [25] and 
the potential benefits of this treatment may outweigh the risks. This will be recorded in the 
PACU side effect and PACU nursing questionnaires.  
 
Surgical complications will be assessed prospectively and retrospectively and reviewed using the 
institutional standard for complications reporting for all surgical patients as followed by the 
Department of Surgery. Standardized graded complications and adverse effects at UM utilize the 
five-point modified Clavien-Dindo system. Grade I include complications requiring monitoring 
but no intervention; Grade II requires bedside or medical treatment; Grade III constitute adverse 
events requiring surgical or procedural intervention with return to normal functioning; Grade IV 
includes disabling, life-threatening complications with resulting functional loss and grade V is 
death of the patient. This is a modification of the Clavien-Dindo system for reporting 
complications with defined, categorized and classified events that will be segregated into time 
periods of ≤30 days, 31-90 days and > 90 days after surgery and includes medication 
complications following NCI CTCAE version 5 guidelines. 
CRITERIA FOR THERAPEUTIC RESPONSE/OUTCOME 
ASSESSMENT 
If the surgery is aborted for any reason before placement of a ureteral stent, the patient will be 
removed from the study and replaced. Based on past experience these issues are rare events.  
 
The intraoperative period is defined as the period from anesthesia induction to the extubation of 
the trachea. The surgical time is determined from the incision to the final skin closure. 
 
The postoperative period is defined as the period from the extubation to various study endpoints. 
 
Blood loss is defined as the estimate accounted from the suction device and absorptive sponges 
during the procedure, as described and agreed upon by the surgeon, anesthesiologist, circulating 
nurse, and surgical technician as covered by institutional guidelines. 
 
The patient’s pain will be evaluated with a visual analogue scale of pain [27]. This may either be 
done digitally or by paper [28]. 
 
A validated questionnaire (the Ureteral Stent Symptom Questionnaire [USSQ]) exists to evaluate 
symptoms of ureteral stents and their effects of quality of life [1]. This will be used to evaluate 
how patients tolerate the stents.  
 
Patient satisfaction will be assessed at PACU discharge as part of the patient’s PACU discharge 
questionnaire. Similarly, satisfaction will be evaluated via questionnaires at subsequent time 
points.   
 

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CRITERIA FOR REMOVAL FROM STUDY 
Patients will be withdrawn from the study if they express a desire to do so, if it is determined to 
be in the patient’s best interest to do so, or if they do not undergo initiation of their surgical 
procedure as stipulated previously. For this pilot, if a patient fails to receive the study drug, they 
will be withdrawn from the study and analysis of this failure will be undertaken.  
BIOSTATISTICS 
Sample Size 
The primary purpose of this study is to evaluate safety and feasibility of studying perioperative 
pregabalin at our institution, with the aim of performing a randomized, placebo-controlled, 
double-blinded study in the future. 10 patients will complete the study. This is a number that will 
allow for evaluation of potential serious side effects and feasibility. This number is also small 
enough that it will not waste resources or delay the future larger study. We estimate that 20 
patients will need to be enrolled so that 10 will complete the study. This number of patients will 
be enrolled over 3 months.  
 
Analysis 
Descriptive statistics will be used in reporting patient outcomes in this pilot study. As there is no 
control group, significance tests will not be performed. Several questionnaires have narrative 
components which will be compiled and analyzed in a systematic method.  
 
Proposed Analyses 
Pre-specified parameters to be reported include the following: 
- 
Serious adverse events 
- 
All adverse events 
- 
Proportion of enrolled patients completing the study 
- 
Adverse events related to study drug 
- 
Ureteral Stent Related Symptom Questionnaire (USSQ) [1] score at 3 days post op 
- 
Monitored prescribing of narcotic pain medication 
- 
Number of patients taking narcotic pain medication at several time points 
- 
Oral morphine equivalents the patient has used at several time points 
- 
Number of unplanned contacts between the patient and the healthcare system within 30 
days 
- 
Score on standardized evaluation of patient satisfaction 
 
RESEARCH PARTICIPANT REGISTRATION AND 
RANDOMIZATION PROCEDURES 
Research Participant Registration 
We will confirm eligibility as defined in the section entitled Criteria for Patient/Subject 
Eligibility.  
 
We will obtain informed consent, by following procedures defined in section entitled Informed 
Consent Procedures. 

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DATA MANAGEMENT ISSUES 
The research team will be responsible for project compliance, data collection, abstraction and 
entry, data reporting, IRB correspondence, problem resolution and prioritization and 
coordination of the protocol study team activities. The data collected for this study will be 
entered into a secure departmental server or will be stored online in the university approved 
resource, REDCap [29]. Source documentation and regulatory binders will be stored in a locked 
filing cabinet within a locked department office space. These sites are exclusively used for 
research documents and only members of the research team will have access to files for this 
study.  
 
Quality Assurance 
Routine data quality reports will be generated to assess missing data and inconsistencies. Accrual 
rates, and extent and accuracy of evaluations will be monitored throughout the study period. 
Potential problems will be brought to the attention of the study team for discussion and action.  
 
Data and Safety Monitoring 
The MU Health Care Data and Safety Monitoring Plans can be found online.  
 
There are several different mechanisms by which clinical trials are monitored for data, safety and 
quality. There are institutional processes in place for quality assurance (e.g., protocol monitoring, 
compliance and data verification audits, therapeutic response and staff education on clinical 
research QA) and departmental procedures for quality control, plus institutional committees that 
are responsible for monitoring the activities of the clinical trials program.  
PROTECTION OF HUMAN SUBJECTS 
Benefits and Risks 
The experimental intervention (perioperative pregabalin administration) is currently used at 
University of Missouri Hospital through the ERAS protocol. Numerous studies have shown 
significant patient benefits in all fields, including Urology. Several reviews have demonstrated 
the efficacy and safety of perioperative gabapentinoid administration. The principal side effects 
of pregabalin are temporary cognition/coordination changes, with a very low risk of serious side 
effects. Therefore, we do not believe that the therapeutic aspects of this trail pose any serious risk 
different from patients undergoing ureteroscopy with stent placement under standard procedures.  
  
Toxicities and side effects 
Adverse outcomes are not anticipated with the regimen of pregabalin used in this study. Patients 
are closely monitored during the perioperative period and any serious events will be immediately 
brought to the attention of the study staff. All potential side effects will be recorded in 
questionnaires.  
 
Alternatives / Therapeutic options 
The alternative to participation in the trial would be to undergo ureteroscopy with stent 
placement according to the surgeon’s standard practice and not to participate in the study.  The 

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patient may or may not receive pregabalin in this case. No other aspect of patient care would 
differ. 
 
Financial Costs and Burdens 
Subjects will not be compensated for their participation. The cost involved in this study is study 
medication and administration. As these are potentially part of standard treatment, these will be 
billed to patients as other hospital charges.   
 
Privacy and Confidentiality 
We will keep the study records confidential. No identifiers will be used in any reports or 
publications resulting from the study.  
 
Volunteering Nature of the Study 
Participation is entirely voluntary. All aspects of patient’s care and monitoring will be unaffected 
by whether the patient chooses to consent for the study. 
 
Serious Adverse Event (SAE) Reporting 
Any SAE will be reported to the IRB as soon as possible, but no later than 5 calendar days. The 
reporting procedure will be followed as outlined in the University of Missouri protocol found in 
the “Core Standard Operating Procedure for Event Reporting.”.  
INFORMED CONSENT PROCEDURES 
Before protocol-specified procedures are carried out, consenting professionals will explain full 
details of the protocol and study procedures as well as the risks involved to participants prior to 
their inclusion in the study. Participants will also be informed that they are free to withdraw at 
any time. All participants must sign and date an IRB approved informed consent form indicating 
their consent to participate. This consent form meets the requirements of the Code of Federal 
Regulations and the Institutional Review Board.  
 
Before any protocol-specific procedures can be carried out, the consenting professional will fully 
explain the aspects of patient privacy concerning research specific information. In addition to 
signing the IRB Informed consent, all patients must agree to the Research Authorization 
component of the informed consent form. 
 
Each participant and consenting professional will sign the consent form. The participant will 
receive a copy of the signed informed consent form. A copy of the signed informed consent form 
will be placed in the participant’s chart and subsequently scanned into the electronic medical 
record under Research Consents.   
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Harris, P.A., et al., Research electronic data capture (REDCap)-A metadata-driven 
methodology and workflow process for providing translational research informatics 
support. Journal of Biomedical Informatics, 2009. 42(2): p. 377-381. 
 
 
 
 

15 
 
APPENDICES 
Appendix 1 – REDCap instruments 
Appendix 2 – USSQ 
Appendix 3 – Aldrete  
Appendix 4 – Post-op study specific instruction 
Appendix 5 – Written consent and HIPAA authorization 
Appendix 6 – HIPAA waiver of authorization 
 
 
 
 

Appendix 1 – REDCap instruments 
 

	
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Appendix 2 – USSQ 
 
We are unable to include this due to copyright.  

Appendix 3 – Aldrete  
 

PACU Discharge form 
Subject ID: ________________ 
 
 
 
                  Baseline BP: _____ /_____ 
Date: _____ / _____ /__________ 
 
Record the first Aldrete score at 15 min and take off O2 mask 
Aldrete 
15 
min 
30 
min 
45 
min 
60 
min 
75 
min 
90 
min 
115 
min 
120 
min 
Comments 
Respiration 
 
 
 
 
 
 
 
 
 
O2 Saturation 
 
 
 
 
 
 
 
 
 
Consciousness 
 
 
 
 
 
 
 
 
 
Circulation 
 
 
 
 
 
 
 
 
 
Activity 
 
 
 
 
 
 
 
 
 
Total 
 
 
 
 
 
 
 
 
 
 
Time when Aldrete score is 9 or 10: _____ : _____       (record time or call anesthesia attending) 
 

Appendix 4 – Post-op study specific instruction 
 

Post-Operative Supplementary Instructions  
 
 
 
Thank you very much for participating in our study. Please see your other discharge forms for 
details of when to return to regular activity and when you need to contact a provider urgently. 
 
An important part of this study is to keep track of how you are doing. We will also be keeping 
track of any pain medicine you require. 
 
You should get a packet of questionnaires to leave with. Please complete these on the dates 
indicated. For some forms, we will either email you (if you provided authorization) or call you to 
ensure that you have done the questionnaire. 
 
You are being discharged with a pain regimen that we anticipate will be able to control your 
pain. If you need other pain medication, we ask that for the first 30 days after your procedure 
you only get this from the study team.  
 
To do this, please contact us as follows: 
During regular business hours, please call 573-884-8768 
After hours or if unable to reach anyone at the above number, please call 573-882-4141 and ask 
for the urology resident on call 
 
If you have feedback on the study at any time, please contact us 
 
If you have any major medical changes, please contact us 
 
If you have any issues related to your procedure or participation in this study, please contact us 
 
 
 
 
 
 
 
INVESTIGATOR’S NAME: 
KATIE MURRAY, DO  
 
PROJECT #  2013680 
 
Study Title: Perioperative pregabalin as part of a multimodal treatment plan for pain after 
ureteroscopy with stent placement: a pilot 
 
 
 

Appendix 5 – Written consent and HIPAA authorization 
 

 
 
 
 
MU IRB: BIOMEDICAL CONSENT FOR NON-FEDERALLY FUNDED,  
NO MORE THAN MINIMAL RISK RESEARCH STUDIES 
(JAN 2019) 
 
 
 
1 of 11
IRB USE ONLY 
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CONSENT FORM AND HIPAA AUTHORIZATION  
FOR PARTICIPATION IN A RESEARCH STUDY 
 
INVESTIGATOR’S NAME: 
KATIE MURRAY, DO  
 
 
PROJECT IRB #:  2013680 
 
STUDY TITLE: PERIOPERATIVE PREGABALIN AS PART OF A MULTIMODAL 
TREATMENT PLAN FOR PAIN AFTER URETEROSCOPY WITH STENT PLACEMENT: A 
PILOT 
 
We invite you to take part in this research study. This consent form tells you why we are doing 
the study, what will happen if you join the study, and other important information about the 
study. 
 
Please take as much time as you need to read this consent form. You can discuss it with your 
family, friends, or personal doctor. If there is anything you do not understand, please ask us to 
explain. Then you can decide if you want to take part in the study or not.  
 
The Principal Investigator (also called the study doctor) is Katie Murray, DO. The people 
working with her on this study are called the study team. 
This study is not being sponsored by any corporation. 
 
Research studies help us to learn new things and test new ideas about treating certain 
conditions/diseases. Taking part in a research study is voluntary. You decide if you want to take 
part, and you can stop taking part at any time.  
 

 
 
 
 
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We are doing this study to see if a drug called pregabalin is an effective way of treating pain and 
other problems following stent placement surgery. We hope the results of this study will show 
that pregabalin should be routinely added to the treatment plan for future patients undergoing the 
same surgery as you. 
There is no guarantee that taking part in this research will result in any improvement in 
your condition. 
We will only include you in this study if you give us your permission first by signing this 
consent form. 
 
HOW MANY PEOPLE WILL TAKE PART IN THIS STUDY? 
About 10 people will take part in this study at this institution. 
 
WHY ARE THE RESEARCHERS DOING THIS STUDY? 
We are doing this study to see if a drug called pregabalin is an effective way of treating pain and 
other problems following stent placement surgery. Pregabalin is approved by the FDA for use in 
treating pain in other conditions, and it is widely used here and at other institutions to treat post-
operative pain. We hope the results of this study will show that pregabalin should be routinely 
added to the treatment plan for future patients undergoing the same surgery as you. 
 
WHAT WILL HAPPEN IF I TAKE PART IN THIS STUDY? 
If you take part in this study, you will receive one dose of pregabalin one hour before your 
surgery. This will be one pill that you will swallow with a mouthful of water.  We will also ask 
you to complete 2 questionnaires before your surgery. 
 
You will then have your scheduled surgery, which would be done even if you were not in the 
study. All of your post-operative care is standard care that you would receive without being in 
the study. 
 

 
 
 
 
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After your surgery, we will give you a packet of questionnaires to take home with you along with 
pre-addressed, pre-stamped envelopes. These questionnaires are for the research only. We will 
ask you to complete and return these questionnaires to us at least 6 times: 
x 3 days after surgery 
x 7 days after surgery 
x 30 days after surgery 
x 90 days after surgery 
x 6 months after surgery 
x 1 year after surgery 
 
HOW LONG WILL I BE IN THE STUDY? 
You will be in this study for about a year. 
 
CAN I STOP BEING IN THE STUDY? 
You can stop being in the study at any time without giving a reason. If you stop being in the 
study, your regular medical care will not change. Leaving the study will not affect your future 
medical care at the University of Missouri.  
 
There is no penalty to you if you do not join the study or if you leave it early. You will not 
lose any benefits you are entitled to if you leave the study. 
 
The study doctor may decide to take you off this study at any time, even if you want to stay in 
the study. The study doctor will tell you the reason why you need to stop being in the study. 
These reasons may be: 
x If it is in your best interest 
x You do not follow the study rules 
x The whole study is stopped 
x New information becomes available about pregabalin 
 

 
 
 
 
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If necessary, the study doctor will arrange for you to continue your medical care with your 
regular doctor. 
 
WHAT HEALTH RISKS OR PROBLEMS CAN I EXPECT FROM THE STUDY? 
There are risks to taking part in any research study. There may be problems caused by the study 
that we do not know about yet. If we learn about new important risks and side effects, we will 
tell you. We will tell you about any new information we learn that may affect your decision to 
continue taking part in the study. 
 
We will closely watch everyone in the study for problems. You need to tell the study doctor 
immediately if you have any problems related to the procedures in the study. Dr. Murray’s 
telephone number is 573-884-8768.  For more information about risks ask the investigator or 
contact the University of Missouri Institutional Review Board (which is a group of people who 
review the research studies to protect participants’ rights) at (573) 882-3181. 
 
Risks and side effects related to the drug we are studying include: 
Very likely: None 
Less likely but serious: serious allergic reaction, dizziness, being off balance, blurred vision, 
tremor, being more tired or confused than normal, leg swelling, dry mouth, and constipation.   
 
Reproductive risks: The effects of the pregabalin on the developing fetus are unknown but could 
cause harm. For this reason, you cannot be part of this study if you are pregnant. If you a woman 
who is capable of becoming pregnant, we will ask you to take a urine pregnancy test. A man’s 
sperm count may decrease temporarily after taking the study medication. It does not otherwise 
affect the sperm and is temporary.  If you have any questions about the reproductive issues 
please discuss them with the investigator or your doctor. 
 
ARE THERE BENEFITS TO TAKING PART IN THE STUDY? 
We don’t know if this study will help you. Your condition may get better, but it could stay the 
same or even get worse. We hope that this study will help us to learn more about pregabalin and 

 
 
 
 
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to develop new treatments for stent related symptoms in the future. The possible benefits of 
taking part in the study include a decreased need for pain medications, especially opioid 
medications, and fewer stent related problems.  
 
WHAT OTHER CHOICES DO I HAVE? 
You do not have to take part in this study. You are free to say yes or no. If you do not want to 
join this study, your doctor will discuss other choices with you. 
Instead of being in this study, you have these options: 
x Undergoing usual care with ureteroscopy and stent placement 
x No therapy at this time with care to help you feel more comfortable 
 
You may get pregabalin even if you do not take part in the study. 
An alternative is to not participate in this research study. 
Please discuss these and other options with the investigator and your doctor. 
 
WHAT ABOUT PRIVACY AND CONFIDENTIALITY? 
The study team needs to access some of your health/personal information. This information 
comes from questions we ask you, forms you fill out, and your medical record. One risk of 
taking part in a research study is that more people will handle your personal health information. 
We are committed to respecting your privacy and to keeping your personal information 
confidential. The study team will make every effort to protect your information and keep it 
confidential to the extent allowed by law. However, it is possible that an unauthorized person 
will see it.  
 
State and federal privacy laws (HIPAA) protect the use and release of your health information. If 
you decide to take part in this study, you also give us your permission to use your private health 
information, including the health information in your medical records and information that can 
identify you.  
You have the right to refuse to give us your permission for us to use your health information. 
However, doing so would mean that you could not take part in this study.  

 
 
 
 
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The following identifiers will be obtained from your health records:  
Name 
 
 
 
 
 
Address 
Dates related to you 
 
 
 
Telephone number(s) 
Email Address 
 
 
 
 
Medical Record Number 
Any other characteristic that could identify you 
 
The following is the type of protected health information that will be used in the study:  
Discharge Summaries 
 
 
 
Consultations 
Progress Notes 
 
 
 
 
Medications 
History and Physical Exams 
 
 
Emergency Medicine Reports 
Operative Reports  
 
 
 
Demographics (age, race, etc.) 
Questionnaires, Surveys, Diaries 
Other: Information regarding phone conversations, information regarding conversations 
through the electronic medical record 
 
We may share any of this information with the following:  
x Authorized members and staff of the University of Missouri Institutional Review Board 
(IRB).  
x Laboratories and other individuals and organizations that may need to see your health  
information in connection with this study. 
x Study monitors and auditors who make sure that the study is being done properly.  
 
Any research information shared with outside entities will not contain your name, address, 
telephone or social security number, or any other personal identifier unless it is necessary for 
review or required by law. 
The people who get your health information may not be required by Federal privacy laws (such 
as the HIPAA Privacy Rule) to protect it. Some of those people may be able to share your 
information with others without your separate permission. 
Your permission for us to use and/or release your information will not expire unless you cancel 
your permission.  

 
 
 
 
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You can cancel your permission at any time by contacting to:  
Investigator’s Name: Katie Murray, DO 
Institution: University of Missouri 
Department: Surgery, Division of Urology 
Address: 1 Hospital Dr, Columbia, MO 65212 
 
The information we have already collected may still be used for this research study, but we will 
not collect anymore information after we receive your letter.  
 
You will not be allowed to access your protected health information that is obtained or created 
during this research project until the end of the study. 
 
If you have not already received a copy of the University of Missouri Healthcare Privacy Notice, 
you may request one. If you have any questions or concerns about your privacy rights, you may 
contact the Privacy Officer at 573-882-9054. 
 
We will scan a copy of this consent form into your medical record. We may also record your 
research information, including the results of tests and procedures, in your medical record. The 
medical information produced by this study will become part of your hospital medical record, 
and people allowed to look at your medical records may see this research information.  
 
Information that does not become part of your medical record will be stored in the investigator’s 
electronic/computer or paper files. Computer files are protected with a password and the 
computer is in a locked office that only study team members can open. Paper files are kept in a 
locked drawer in a locked office that only study team members can open. 
 
Your records will be given a code number and will not contain your name or other information 
that could identify you.  The code number that connects your name to your information will be 
kept in a separate, secure location.  Information that may identify you may not be given to 
anyone who is not working on this study without your written consent, or if required by law.   
 

 
 
 
 
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The people who may use and/or release your research information include: 
x Those working on the study team at the University of Missouri 
x The members of the University of Missouri Institutional Review Board (IRB) 
x Those who check on research activities to make sure it is being done correctly and safely  
x Other government or inspection agencies  
 
If the study investigator is not your regular doctor, he/she must ask your permission before 
contacting your regular doctor for your health history. 
 
We may present the results of this study in public talks or written articles, but we will not use 
information that can identify you.   
 
ARE THERE ANY COSTS TO BEING IN THE STUDY? 
All tests and procedures done during this study, except the questionnaires, are routine care for 
your surgery. You would receive these tests and procedures even if you weren’t in this study. 
You and/or your health plan/insurance will be billed for all the tests and procedures in this study, 
except for the questionnaires. Some health plans/insurance companies will not pay for these costs 
for people who are in research studies. Check with your health plan/insurance company to find 
out what they will pay for. 
 
WILL I BE PAID FOR TAKING PART IN THIS STUDY? 
There is no payment to you for taking part in this study. 
 
WHAT HAPPENS IF I AM INJURED DURING THE STUDY?  
It is not the policy of the University of Missouri to compensate human subjects in the event the 
research results in injury.  The University of Missouri, in fulfilling its public responsibility, has 
provided medical, professional and general liability insurance coverage for any injury in the event 
such injury is caused by the negligence of the University of Missouri, its faculty and staff.   
 

 
 
 
 
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The University of Missouri also will provide, within the limitations of the laws of the State of 
Missouri, facilities and medical attention to subjects who suffer injuries while participating in the 
research projects of the University of Missouri.   
 
In the event you have suffered injury as the result of participation in this research program, you are 
to contact the Risk Management Officer, telephone number (573) 882-1181, at the Health Sciences 
Center, who can review the matter and provide further information.   
This statement is not to be construed as an admission of liability. 
 
WHAT ARE MY RIGHTS AS A STUDY PARTICIPANT? 
Taking part in this study is voluntary.  You do not have to take part.  Your present or future 
medical care will not be affected if you decide not to take part.   
 
If you do decide to take part, you can change your mind and drop out of the study at any time. 
This will not affect your current or future care at the University of Missouri Hospitals and 
Clinics. There is no penalty for leaving the study and you will not lose any benefits that you are 
entitled to receive. 
 
If the study investigator decides to take you off the study, she will explain the reasons and help 
arrange for your continued care by your own doctor, if needed.   
 
We will tell you about any new information discovered during this study that might affect your 
health, welfare, or change your mind about taking part.  
 
WHO CAN ANSWER MY QUESTIONS ABOUT THE STUDY? 
You may ask more questions about the study at any time.  For questions about the study or a 
research-related injury, contact Dr. Katie Murray or Dr. Geoff Rosen. 
 
During regular business hours, please call 573-884-8768 

 
 
 
 
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After hours or if unable to reach anyone at the above number, please call 573-882-4141 and ask 
to have Dr. Murray or Dr. Rosen paged 
 
You may also contact the University of Missouri Institutional Review Board (IRB) if you: 
x Have any questions about your rights as a study participant; 
x Want to report any problems or complaints; or 
x Feel under any pressure to take part or stay in this study.  
 
The IRB is a group of people who review research studies to make sure the rights of participants 
are protected. Their phone number is 573- 882-3181.  
 
If you want to talk privately about your rights or any issues related to your participation in this 
study, you can contact University of Missouri Research Participant Advocacy by calling 888-
280-5002 (a free call), or emailing MUResearchRPA@missouri.edu. 
 
We will give you a copy of this consent form. Please keep it where you can find it easily. It will 
help you to remember what we discussed today. 
 
 
SIGNATURE OF STUDY PARTICIPANT OR LEGALLY AUTHORIZED 
REPRESENTATIVE 
 
Consent to Participate in Research 
By signing my name below, I confirm the following: 
x I have read/had read to me this entire consent form. 
x All of my questions were answered to my satisfaction. 
x The study’s purpose, procedures, risks and possible benefits were explained to me. 
x I voluntarily agree to take part in this research study. I have been told that I can stop at 
any time. 
 

 
 
 
 
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Subject’s Signature 
Date  
 
 
 
 
 
Signature of Witness (if applicable)*  
Date  
 
*The presence and signature of an impartial witness is required during the entire informed consent 
discussion if the patient or patient’s legally authorized representative is unable to read.   
 
SIGNATURE OF STUDY REPRESENTATIVE 
I have explained the purpose of the research, the study procedures, identifying those that are 
investigational, the possible risks and discomforts as well as potential benefits and have 
answered questions regarding the study to the best of my ability. 
 
 
 
Signature of Study Representative  
Date  
 

Appendix 6 – HIPAA waiver of authorization 
 

 
 
 
 
 
 
Page 1 
 
 
 
                                
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Approved Date: March 13, 2019 
 
 
UNIVERSITY OF MISSOURI – COLUMBIA 
 INSTITUTIONAL REVIEW BOARD  
 
Waiver or Alteration of Health Information Portability and Accountability Act (HIPAA) Authorization for 
the Use and/or Disclosure of Protected Health Information (PHI) Resulting from Participation in a Research 
Study 
 
 
PRINCIPAL INVESTIGATOR NAME: Murray, Katie 
IRB PROJECT #: 2013680 
PROJECT TITLE: Perioperative pregabalin as part of a multimodal, opioid-sparing treatment plan for ureteral stent 
symptoms after ureteroscopy: a pilot 
 
Please check whether you are requesting a HIPAA waiver or alteration: 
 Waiver 
 Alteration 
If you selected alteration, indicate what is being altered: 
      
 
Why do you need this waiver or alteration? Select all that apply: 
 Pre-Screening of health care records to identify potential subjects for the research. 
 Retrospective review of records that exist at this time, to obtain information without the subject’s written 
authorization. 
 Prospective review of records to obtain information that is still being collected or that will be collected in the 
future, without the subject’s written authorization. 
 
Justification for a Waiver or Alteration: 
To obtain approval for a waiver or alteration of Health Information Portability and Accountability Act (HIPAA) 
authorization for the use and/or disclosure of Protected Health Information (PHI) resulting from participation in a 
research study, the project must meet the criteria listed below.  Please explain how your study meets these criteria. 
 
1. Check the identifiers to be collected: 
 Name 
 
 
 
 
 Address 
 
 
 Elements of Dates related to an individual 
 Telephone numbers  
 Fax Number 
 
 
 
 Email Address 
 Social Security Number 
 
 
 Medical Record Number 
 Health plan beneficiary number 
 
 Account numbers 
 Certificate or license numbers 
 
 Any vehicle or other device serial number 
 Web URL  
 
 
 
 Internet Protocol (IP) Address numbers 
 Biometric identifiers (finger or voice print)  
 Photographic image – (Not limited to images of the face) 
 Any other characteristic that could uniquely identify the individual 
  
2. Check the type of information to be collected: 
 Radiology Images  
 
 
 Discharge Summaries 
 
 
 Radiology Imaging Reports  
 
 Health Care Billing or Financial Records 
 EKG 
 
 
 
 
 Consultations  
 Progress notes 
 
 
 
 Medications 
 History and Physical exams  
 
 Emergency Medicine reports 
 Operative Reports  
 
 
 Dental Records 
 Pathology Reports  
 
 
 Demographic information such as age, race, etc. 
 Laboratory Reports  
 
 
 Questionnaires, Surveys and/or Subject Diaries 
 Photographs and or Videotapes 
 
 Audiotapes 
 Social Security Number (This is only collected for billing purposes and not shared with the sponsor) 
  
 Other (List Here):       
 

 
 
 
 
 
 
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3. List the source(s) of the PHI. 
 Paper record in clinical areas 
 
 Electronic Medical Record (EMR) 
 
 
 Data being extracted from an MU databank   
 Electronic databases in ancillary units (lab/pathology, radiology, pharmacy, etc.) 
 
 
 Other – Describe:       
 
4.  Provide a brief explanation of why the research activity to be permitted by this waiver or alteration 
involves no more than minimal risk to the subjects. 
The minimum amount of information required for research purposes will be used. Only collection of this information will be 
covered by the waiver. This portion of the study represents a retrospective examination of information gathered for clinical 
purposes. There is no chance of physical harm or discomfort to the subject.   
 
5.  Explain why this waiver or alteration will not adversely affect the privacy rights and welfare of the 
subjects. 
All data will maintained according to university policy. This will be in a secure online or physical repository. Only the 
necessary staff will have research to the data. If used, the data will be reported without any identifiers. This use of data is very 
unlikely to result in harm, insult, injury to relationship, loss of johb or insurance, or well being of the patient.   
 
6. Demonstrate the research involves no more than minimal risk to the privacy of subjects by describing the 
plans requested below: 
 
a. Describe the plan to protect the identifiers from improper use and disclosure. 
No identifiable data will be reported.  
b. Indicate where the PHI will be stored. 
PHI will be stored according to university policy in an online secure repository or in a physically secure location.  
c. Indicate who will have access to this information. 
Only research staff who require access to this information will have it. 
         d. Describe the plan to destroy the identifiers at the earliest opportunity consistent with the conduct of   
the research. Include how and when identifiers will be destroyed.  If there is a health or research 
justification for retaining the identifiers or such retention is otherwise required by law, provide the 
reason to retain identifiers. 
In accordance with recordkeeping requirements for the pilot study, identifiers must be retained. 
Timeline to Destroy: 
 End of Study 
 
 Months or years after end of study – Specify #: 7 years 
 Other – Specify:        
 
7. Explain how your research meets both of the following criteria for a waiver or alteration: 
 
a.  The research could not practicably be conducted without the waiver or alteration [indicate why it is very 
difficult to obtain authorization from the participants (inconvenience, time, resources are not acceptable 
criteria)]. 
This is for pre-screening to find patients for a larger study. It is not possible to have all patients consent to this.  
 
b. The research could not practicably be conducted without access to and use of PHI. 
This is for pre-screening which requires access to PHI. 
 
As the Principal Investigator or the PI’s designee, I confirm the information I have provided in this request is 
accurate and complete; the PHI I am requesting is the minimum amount of identifiable private information 
necessary for my research project; and the PHI will not be reused or disclosed to any other person or entity, except 
(a) as required by law, (b) for authorized oversight of the research study, or (c) for other permitted uses or 
disclosures according to federal regulations.  
 
Katie Murray        
 
 
 
 
02/19/2019 
Principal Investigator Digital Signature                            Date  
(A typed name is accepted as a digital signature)