PONE-D-20-00720

Evaluation and comparison of different nomograms for predicting stone-free status after flexible ureteroscopy for renal and ureteral stones

PLOS ONE

Dear Mr. Kleinclauss,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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We look forward to receiving your revised manuscript.

Kind regards,

Antonio Riveiro Rodríguez, PhD

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The study aims to compare four previously developed predictive scores for stone-free rate (SFR) after flexible ureterorenoscopy (f-URS) with holmium-YAG laser fragmentation of renal and ureteral lithiasis. The study was single-center and used between 669-800 procedures to evaluate the four predictive scores. Two scores have been previously validated- the Resolu Unsal Stone Score (RUSS) and modified Seoul National University Renal Stone Complexity (S-ReSC) score. The other two scores, the S.T.O.N.E score described by Molina et al. and Ito’s nomogram have not been validated in any other cohorts.

The study has a clear objective, the end point is concretely defined, and the analysis is straightforward. However, the generalizability of the findings is unclear especially since this is a single center study with fewer than 1000 cases and the use of a single rater. Overall, this manuscript sets the stage for future studies that can further validate the clinical utility of the predictive scores.

Major points:

1) Inclusion of the absolute numbers of patients would be informative for Tables 1 and 2. For example, how many patients are in UR and RO groups for Table 1? How many patients are in the Yes and No groups for Table 2?

2) It is very difficult for this reader to decipher information in Table 2. It is difficult to calculate the percentages by how the authors display the numbers. The authors describe the proportion of patients by no/yes and %yes. I believe it is easier to interpret the percentages if the authors present the fraction of patients who were yes/total patients. For example, the pre-stenting group is show as "207/385". It should be changed to 385/592 or 65% so that the reader can see more easily for how the percentages were calculated. This should be done for all of the fractions in Tables 2 and 3.

3) Table 3: STONE score section is very difficult to interpret. What do the numbers represent? I believe that it is unrealistic to expect the reader to be familiar with the STONE score section without an explanation for what the scores mean. Some context in the manuscript would be helpful so that the reader can understand the basics of the STONE score system.

4) Table 3 has error in reporting the data

Lower pole location- %yes = 85.7%, not 14.3% (yes group)

Lower pole location- %yes = 75.9%, not 24.1% (no group)

Stone number in different calyces > 1 - %yes = 22.8%, not 37.4% (yes group)

Stone number in different calyces > 1 - %yes = 37.4%, not 22.8% (no group)

Hydronephrosis- %absent = 61%, not 39% (yes group)

Hydronephrosis- %absent = 60.4%, not 39.6% (no group)

5) For a non-urology audience it is unclear what role a predictive score for SFR would play in clinical decision making. It would be helpful to address the following in the discussion: if there was a perfect predictive score that was 100% sensitive and specific, would a particular score keep a physician from intervening with f-URS or rather is the score meant to be helpful for patient counseling and managing patient expectations. Explicitly stating the clinical impact of using a predictive score would be useful context.

Reviewer #2: The authors evaluated four predictive scoring models for stone-free rate after flexible ureteroscopic urinary stone surgery. Major pitfall of the study is lack of systemic and consistent post-operative imaging to evaluate stone-free. I have some other concerns and questions.

1. Title: I think all of them are not nomograms, but they are predictive model or scoring system. Thus, the title should be revised with appropriate term.

2. Stone composition analysis is importance information when interpreting results of urinary stone surgery. Please, provide the results (at lease, proportion of uric acid stone)

3. How many surgeons involved the study? Didn't they have different patient selection or surgical outcomes? How did you adjust for surgeon effect?

Please, additionally provide brief description of their experience.

4. The major advantage of the study is concurrent comparison of 4 existing predictive models to predict stone-free after flexible ureteroscopic stone surgery. If you discuss it in practical aspect with balanced manner, not only focusing to the predictive ability, it can be very valuable discussion. For example, granularity of score or how many factors do they need can effect the predictive ability. By contrast, how difficult to calculate the score and how much time do they need can diminish the ability and clinical usefulness.

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Reviewer #1: No

Reviewer #2: Yes: Chang Wook Jeong

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.]

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PONE-D-20-00720R1

Evaluation and comparison of scoring systems for predicting stone-free status after flexible ureteroscopy for renal and ureteral stones

PLOS ONE

Dear Dr. Kleinclauss,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

From a scientific point of view, this work is acceptable, however, it is suggested the improvement of the quality of the text as pointed out by Reviewer 1.

Please submit your revised manuscript by Aug 10 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Antonio Riveiro Rodríguez, PhD

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The following comments were adequately addressed:

1. The authors have added UR and RO patient numbers to Tables 1 and 2 and now provide helpful context.

2. The authors have provided fractions in Table 2 and now the data presentation is more clear.

3. The authors have provided a range for the S.C.OR.E system and they now provide an explanation for the meaning of a high score in line 103.

Minor Revisions:

1. We request that the authors take the time to make sure that the writing is clear and that grammar is used correctly. For example, there is a passage in the Discussion section that reads (starting line 259):

"Independently of the information gave to patients and maybe to help the choice of surgical technique this kind of scores are not clinically very usefull and are not routinely used for many reasons (difficulty and time to calculate)."

It is not clear to me what the authors are trying to say here. Please also spell check the document.

Starting line 261: "The RUSS score needs IPA angle definition on CT scan, the Ito’s score required the use of nomogram and the measurement of the stone volume, the STONE score can be calculated mentally in daily practice and the Seoul score would be the more easy to use."

There are 5 sentences here that are connected together into 1 large sentence. Please make this sentence more clear to the reader, perhaps the authors should break up the sentence into smaller sentences.

2. Please make uniform use of the decimal point or the comma. Please be consistent with the usage according to PLOS-ONE guidelines. For example:

Table 2, Lines 1 and 2 should read "25.9" and "27.9" as opposed to "25,9" and "27,9."

Table 3, missing a paranthesis before "14.7)" and should read "36.1" as opposed to "36,1".

3. In the Discussion section, there are three 1-sentence paragraphs and two 2-3 sentence paragraphs. In general, paragraphs should contain a collection of sentences that convey a related thought or message. The Discussion section could benefit from fewer paragraphs that are longer, rather than several 1-2 sentence paragraphs.

Reviewer #2: Thanks for the appropriate revision.

One minor thing should be corrected before publication; "uriq acid" --> "uric acid".

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Evaluation and comparison of scoring systems for predicting stone-free status after flexible ureteroscopy for renal and ureteral stones

PONE-D-20-00720R2

Dear Dr. Kleinclauss,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Antonio Riveiro Rodríguez, PhD

Academic Editor

PLOS ONE

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: All comments addressed from the previous review.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No