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Noble PA, Hamilton BD, Gerber G. Stone decision engine accurately predicts stone removal and treatment complications for shock wave lithotripsy and laser ureterorenoscopy patients. PLoS One 2024; 19:e0301812. [PMID: 38696418 PMCID: PMC11065282 DOI: 10.1371/journal.pone.0301812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 03/24/2024] [Indexed: 05/04/2024] Open
Abstract
Kidney stones form when mineral salts crystallize in the urinary tract. While most stones exit the body in the urine stream, some can block the ureteropelvic junction or ureters, leading to severe lower back pain, blood in the urine, vomiting, and painful urination. Imaging technologies, such as X-rays or ureterorenoscopy (URS), are typically used to detect kidney stones. Subsequently, these stones are fragmented into smaller pieces using shock wave lithotripsy (SWL) or laser URS. Both treatments yield subtly different patient outcomes. To predict successful stone removal and complication outcomes, Artificial Neural Network models were trained on 15,126 SWL and 2,116 URS patient records. These records include patient metrics like Body Mass Index and age, as well as treatment outcomes obtained using various medical instruments and healthcare professionals. Due to the low number of outcome failures in the data (e.g., treatment complications), Nearest Neighbor and Synthetic Minority Oversampling Technique (SMOTE) models were implemented to improve prediction accuracies. To reduce noise in the predictions, ensemble modeling was employed. The average prediction accuracies based on Confusion Matrices for SWL stone removal and treatment complications were 84.8% and 95.0%, respectively, while those for URS were 89.0% and 92.2%, respectively. The average prediction accuracies for SWL based on Area-Under-the-Curve were 74.7% and 62.9%, respectively, while those for URS were 77.2% and 78.9%, respectively. Taken together, the approach yielded moderate to high accurate predictions, regardless of treatment or outcome. These models were incorporated into a Stone Decision Engine web application (http://peteranoble.com/webapps.html) that suggests the best interventions to healthcare providers based on individual patient metrics.
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Affiliation(s)
- Peter A. Noble
- Department of Microbiology, University of Alabama Birmingham, Birmingham, AL, United States of America
| | - Blake D. Hamilton
- School of Medicine, University of Utah, Salt Lake City, UT, United States of America
| | - Glenn Gerber
- University of Chicago Medical Center, Chicago, IL, United States of America
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Holmes AE, Chew BH, Laughlin R, Buckley J, Kiewice E, Dancel MJ, Blasko D, Wong VKF, Halawani A, Koo KC, Corl D, Fasolo P, Levy O, Thiel J, Bailey MR, Eichman J, Meegan JM, Haulena M. Application of novel burst wave lithotripsy and ultrasonic propulsion technology for the treatment of ureteral calculi in a bottlenose dolphin (Tursiops truncatus) and renal calculi in a harbor seal (Phoca vitulina). Urolithiasis 2024; 52:21. [PMID: 38189835 PMCID: PMC10774161 DOI: 10.1007/s00240-023-01515-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 11/29/2023] [Indexed: 01/09/2024]
Abstract
Marine mammals may develop kidney stones, which can be challenging to treat. We describe burst wave lithotripsy (BWL) and ultrasonic propulsion to treat ureteral calculi in a 48-year-old female bottlenose dolphin (Tursiops truncatus) and to reduce renal stone burden in a 23-year-old male harbor seal (Phoca vitulina). BWL and ultrasonic propulsion were delivered transcutaneously in sinusoidal ultrasound bursts to fragment and reposition stones. Targeting and monitoring were performed with real-time imaging integrated within the BWL system. Four dolphin stones were obtained and fragmented ex vivo. The dolphin case received a 10-min and a 20-min BWL treatment conducted approximately 24 h apart to treat two 8-10 mm partially obstructing right mid-ureteral stones, using oral sedation alone. For the harbor seal, while under general anesthesia, retrograde ureteroscopy attempts were unsuccessful because of ureteral tortuosity, and a 30-min BWL treatment was targeted on one 10-mm right kidney stone cluster. All 4 stones fragmented completely to < 2-mm fragments in < 20 min ex vivo. In the dolphin case, the ureteral stones appeared to fragment, spread apart, and move with ultrasonic propulsion. On post-treatment day 1, the ureteral calculi fragments shifted caudally reaching the ureteral orifice on day 9. On day 10, the calculi fragments passed, and the hydroureter resolved. In the harbor seal, the stone cluster was observed to fragment and was not visible on the post-operative computed tomography scan. The seal had gross hematuria and a day of behavior indicating stone passage but overall, an uneventful recovery. BWL and ultrasonic propulsion successfully relieved ureteral stone obstruction in a geriatric dolphin and reduced renal stone burden in a geriatric harbor seal.
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Affiliation(s)
- Arturo E Holmes
- Dept. of Urology, University of Washington School of Medicine, Seattle, WA, USA
| | - Ben H Chew
- Department of Urological Sciences, University of British Columbia, Stone Centre at Vancouver General Hospital, British Columbia, Vancouver, Canada
| | - Robert Laughlin
- The Mirage Hotel, Hard Rock International, Las Vegas, NV, USA
| | - Jean Buckley
- Department of Urological Sciences, University of British Columbia, Stone Centre at Vancouver General Hospital, British Columbia, Vancouver, Canada
| | - Erica Kiewice
- The Mirage Hotel, Hard Rock International, Las Vegas, NV, USA
| | | | - David Blasko
- The Mirage Hotel, Hard Rock International, Las Vegas, NV, USA
| | - Victor K F Wong
- Department of Urological Sciences, University of British Columbia, Stone Centre at Vancouver General Hospital, British Columbia, Vancouver, Canada
| | | | - Kyo Chul Koo
- Department of Urology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | | | - Jeff Thiel
- Ctr. for Industrial and Medical Ultrasound, Applied Physics Lab, Univ. of Washington, Washington, USA
| | - Michael R Bailey
- Dept. of Urology, University of Washington School of Medicine, Seattle, WA, USA.
- Ctr. for Industrial and Medical Ultrasound, Applied Physics Lab, Univ. of Washington, Washington, USA.
| | - Jammy Eichman
- National Marine Mammal Foundation, San Diego, CA, USA
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Rassweiler-Seyfried MC, Mayer J, Goldenstedt C, Storz R, Marlinghaus E, Heine G, Alken P, Rassweiler JJ. High-frequency shock wave lithotripsy: stone comminution and evaluation of renal parenchyma injury in a porcine ex-vivo model. World J Urol 2023; 41:1929-1934. [PMID: 37284842 PMCID: PMC10352427 DOI: 10.1007/s00345-023-04441-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 05/12/2023] [Indexed: 06/08/2023] Open
Abstract
BACKGROUND The electrohydraulic high-frequency shock wave (Storz Medical, Taegerwilen, Switzerland) is a new way to create small fragments with frequencies up to 100 Hertz (Hz). This study evaluated the efficacy and safety of this method in a stone and porcine model. MATERIALS AND METHODS BEGO stones were put in a condom in a specifically designed fixture treated with different modulations to see stone comminution. Standardized ex vivo porcine model with perfused kidneys with 26 upper and lower poles of 15 kidneys was treated with the following modulations: voltage 16-24 kV, capacitor 12 nF and frequency up to 100 Hz. 2000-20,000 shock waves were applied to each pole. The kidneys were perfused with barium sulfate solution (BaSO4) and x-ray was performed to quantify the lesions using pixel volumetry. RESULTS There was no correlation between the number of shock waves and the powdering degree or the applied Energy and the grade of pulverization in the stone model. Regarding the perfused kidney model, the number of shock waves, applied voltage and frequency had no direct correlation with the occurrence of parenchymal lesions The detected lesions of the renal parenchyma were minimal, technical parameters had no significant impact and the lesions did not differ from the results of former experiments using 1-1.5 Hz in the same model. CONCLUSIONS High-frequency shock wave lithotripsy can produce small stone fragments to pass in a very short time. The injury to the renal parenchyma is comparable to the results of the conventional SWL using 1-1.5 Hz.
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Affiliation(s)
- Marie-Claire Rassweiler-Seyfried
- Department of Urology and Urosurgery, Medical Faculty Mannheim, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, Mannheim, Germany.
| | | | | | | | | | | | - Peter Alken
- Department of Urology and Urosurgery, Medical Faculty Mannheim, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, Mannheim, Germany
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Yang H, Stoller M. Re: Fragmentation of Stones by Burst Wave Lithotripsy in the First 19 Humans. Eur Urol 2022; 82:569. [PMID: 35933243 DOI: 10.1016/j.eururo.2022.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 07/14/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Heiko Yang
- Department of Urology, University of California-San Francisco, San Francisco, CA, USA.
| | - Marshall Stoller
- Department of Urology, University of California-San Francisco, San Francisco, CA, USA
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Harper JD, Lingeman JE, Sweet RM, Metzler IS, Sunaryo PL, Williams JC, Maxwell AD, Thiel J, Cunitz BW, Dunmire B, Bailey MR, Sorensen MD. Fragmentation of Stones by Burst Wave Lithotripsy in the First 19 Humans. J Urol 2022; 207:1067-1076. [PMID: 35311351 PMCID: PMC9078634 DOI: 10.1097/ju.0000000000002446] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE We report stone comminution in the first 19 human subjects by burst wave lithotripsy (BWL), which is the transcutaneous application of focused, cyclic ultrasound pulses. MATERIALS AND METHODS This was a prospective multi-institutional feasibility study recruiting subjects undergoing clinical ureteroscopy (URS) for at least 1 stone ≤12 mm as measured on computerized tomography. During the planned URS, either before or after ureteroscope insertion, BWL was administered with a handheld transducer, and any stone fragmentation and tissue injury were observed. Up to 3 stones per subject were targeted, each for a maximum of 10 minutes. The primary effectiveness outcome was the volume percent comminution of the stone into fragments ≤2 mm. The primary safety outcome was the independent, blinded visual scoring of tissue injury from the URS video. RESULTS Overall, median stone comminution was 90% (IQR 20, 100) of stone volume with 21 of 23 (91%) stones fragmented. Complete fragmentation (all fragments ≤2 mm) within 10 minutes of BWL occurred in 9 of 23 stones (39%). Of the 6 least comminuted stones, likely causative factors for decreased effectiveness included stones that were larger than the BWL beamwidth, smaller than the BWL wavelength or the introduction of air bubbles from the ureteroscope. Mild reddening of the papilla and hematuria emanating from the papilla were observed ureteroscopically. CONCLUSIONS The first study of BWL in human subjects resulted in a median of 90% comminution of the total stone volume into fragments ≤2 mm within 10 minutes of BWL exposure with only mild tissue injury.
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Affiliation(s)
- Jonathan D. Harper
- Department of Urology, University of Washington School of Medicine, Seattle, Washington
| | - James E. Lingeman
- Department of Urology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Robert M. Sweet
- Department of Urology, University of Washington School of Medicine, Seattle, Washington
| | - Ian S. Metzler
- Department of Urology, University of Washington School of Medicine, Seattle, Washington
| | - Peter L. Sunaryo
- Department of Urology, University of Washington School of Medicine, Seattle, Washington
- Department of Urology, Northwest Permanente, Portland, Oregon
| | - James C. Williams
- Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Adam D. Maxwell
- Department of Urology, University of Washington School of Medicine, Seattle, Washington
- Center for Industrial and Medical Ultrasound, Applied Physics Laboratory, University of Washington,Seattle, Washington
| | - Jeff Thiel
- Center for Industrial and Medical Ultrasound, Applied Physics Laboratory, University of Washington,Seattle, Washington
| | - Bryan W. Cunitz
- Center for Industrial and Medical Ultrasound, Applied Physics Laboratory, University of Washington,Seattle, Washington
| | - Barbrina Dunmire
- Center for Industrial and Medical Ultrasound, Applied Physics Laboratory, University of Washington,Seattle, Washington
| | - Michael R. Bailey
- Department of Urology, University of Washington School of Medicine, Seattle, Washington
- Center for Industrial and Medical Ultrasound, Applied Physics Laboratory, University of Washington,Seattle, Washington
| | - Mathew D. Sorensen
- Department of Urology, University of Washington School of Medicine, Seattle, Washington
- Division of Urology, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
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Bailey MR, Maxwell AD, Cao S, Ramesh S, Liu Z, Williams JC, Thiel J, Dunmire B, Colonius T, Kuznetsova E, Kreider W, Sorensen MD, Lingeman JE, Sapozhnikov OA. Improving burst wave lithotripsy effectiveness for small stones and fragments by increasing frequency: theoretical modeling and ex vivo study. J Endourol 2022; 36:996-1003. [PMID: 35229652 DOI: 10.1089/end.2021.0714] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION AND OBJECTIVE In clinical trial NCT03873259, a 2.6-mm lower pole stone was treated transcutaneously and ex vivo with 390-kHz burst wave lithotripsy (BWL) for 40 minutes and failed to break. The stone was subsequently fragmented with 650-kHz BWL after a 4-minute exposure. This study investigated how to fragment small stones and why varying BWL frequency may more effectively fragment stones to dust. METHODS A linear elastic model was used to calculate the stress created inside stones from shock wave lithotripsy (SWL) and different BWL frequencies mimicking the stone's size, shape, lamellar structure, and composition. To test model predictions about the impact of BWL frequency, matched pairs of stones (1-5 mm) were treated at 1) 390 kHz, 2) 830 kHz, and 3) 390 kHz followed by 830 kHz. The mass of fragments greater than 1 and 2 mm was measured over 10 minutes of exposure. RESULTS The linear elastic model predicts that the maximum principal stress inside a stone increases to more than 5.5 times the pressure applied by the ultrasound wave as frequency is increased, regardless of composition tested. The threshold frequency for stress amplification is proportionate to the wave speed divided by the stone diameter. Thus, smaller stones may be likely to fragment at higher frequency, but not lower frequency below a limit. Unlike with SWL, this amplification in BWL occurs consistently with spherical and irregularly shaped stones. In water tank experiments, stones smaller than the threshold size broke fastest at high frequency (p=0.0003), whereas larger stones broke equally well to sub-millimeter dust at high, low, or mixed frequency. CONCLUSIONS For small stones and fragments, increasing frequency of BWL may produce amplified stress in the stone causing the stone to break. Using the strategies outlined here, stones of all sizes may be turned to dust efficiently with BWL.
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Affiliation(s)
- Michael R Bailey
- University of Washington, Center for Industrial and Medical Ultrasound, Applied Physics Laboratory, 1013 NE 40th St., Seattle, Washington, United States, 98105;
| | - Adam D Maxwell
- University of Washington School of Medicine, 12353, Department of Urology, 1013 NE 40th St, Seattle, Washington, United States, 98105;
| | - Shunxiang Cao
- California Institute of Technology, Dept. of Mechanical Engineering, Pasadena, California, United States;
| | - Shivani Ramesh
- University of Washington Applied Physics Lab, Center for Industrial and Medical Ultrasound, Seattle, Washington, United States;
| | - Ziyue Liu
- Indiana University School of Medicine, Biostatistics, Indianapolis, Indiana, United States;
| | - James Caldwell Williams
- Indiana Univ Sch Med, Anatomy & Cell Biology, 635 Barnhill Dr MS5035, Department of Anatomy & Cell Biology, Indianapolis, Indiana, United States, 46202-5120.,United States;
| | - Jeff Thiel
- University of Washington School of Medicine, Radiology, Seattle, Washington, United States;
| | - Barbrina Dunmire
- University of Washington, Applied Physics Lab, 1013 NE 40th St, Seattle, Washington, United States, 98105;
| | - Tim Colonius
- California Institute of Technology, Dept. of Mechanical Engineering, Pasadena, California, United States;
| | - Ekaterina Kuznetsova
- University of Washington Applied Physics Lab, Center for Industrial and Medical Ultrasound, Seattle, Washington, United States;
| | - Wayne Kreider
- University of Washington Applied Physics Lab, Center for Industrial and Medical Ultrasound, Seattle, Washington, United States;
| | - Mathew D Sorensen
- University of Washington, Department of Urology, 1959 NE Pacific Street, Box 356510, Seattle, Washington, United States, 98195;
| | - James E Lingeman
- Indiana University School of Medicine, Dept. of Urology, 1801 North Senate Blvd., Suite 220, Indianapolis, Indiana, United States, 46202;
| | - Oleg A Sapozhnikov
- University of Washington Applied Physics Lab, Center for Industrial and Medical Ultrasound, Seattle, Washington, United States.,Moscow State University, 64935, Department of Acoustics, Physics Faculty, Moskva, Moskva, Russian Federation;
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Raskolnikov D, Bailey MR, Harper JD. Recent Advances in the Science of Burst Wave Lithotripsy and Ultrasonic Propulsion. BME FRONTIERS 2022; 2022. [PMID: 37090444 PMCID: PMC10117400 DOI: 10.34133/2022/9847952] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Nephrolithiasis is a common, painful condition that requires surgery in many patients whose stones do not pass spontaneously. Recent technologic advances have enabled the use of ultrasonic propulsion to reposition stones within the urinary tract, either to relieve symptoms or facilitate treatment. Burst wave lithotripsy (BWL) has emerged as a noninvasive technique to fragment stones in awake patients without significant pain or renal injury. We review the preclinical and human studies that have explored the use of these two technologies. We envision that BWL will fill an unmet need for the noninvasive treatment of patients with nephrolithiasis.
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Affiliation(s)
- Dima Raskolnikov
- Department of Urology, University of Washington School of Medicine, Seattle, WA, USA
| | - Michael R. Bailey
- Department of Urology, University of Washington School of Medicine, Seattle, WA, USA
- Center for Industrial and Medical Ultrasound, Applied Physics Laboratory, University of Washington, Seattle, WA, USA
| | - Jonathan D. Harper
- Department of Urology, University of Washington School of Medicine, Seattle, WA, USA
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Harper JD, Metzler I, Hall MK, Chen TT, Maxwell AD, Cunitz BW, Dunmire B, Thiel J, Williams JC, Bailey MR, Sorensen MD. First In-Human Burst Wave Lithotripsy for Kidney Stone Comminution: Initial Two Case Studies. J Endourol 2021; 35:506-511. [PMID: 32940089 PMCID: PMC8080914 DOI: 10.1089/end.2020.0725] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Purpose: To test the effectiveness (Participant A) and tolerability (Participant B) of urinary stone comminution in the first-in-human trial of a new technology, burst-wave lithotripsy (BWL). Materials and Methods: An investigational BWL and ultrasonic propulsion system was used to target a 7-mm kidney stone in the operating room before ureteroscopy (Participant A). The same system was used to target a 7.5 mm ureterovesical junction stone in clinic without anesthesia (Participant B). Results: For Participant A, a ureteroscope inserted after 9 minutes of BWL observed fragmentation of the stone to <2 mm fragments. Participant B tolerated the procedure without pain from BWL, required no anesthesia, and passed the stone on day 15. Conclusions: The first-in-human tests of BWL pulses were successful in that a renal stone was comminuted in <10 minutes, and BWL was also tolerated by an awake subject for a distal ureteral stone. Clinical Trial NCT03873259 and NCT02028559.
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Affiliation(s)
- Jonathan D. Harper
- Department of Urology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Ian Metzler
- Department of Urology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Michael Kennedy Hall
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Tony T. Chen
- Department of Urology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Adam D. Maxwell
- Department of Urology, University of Washington School of Medicine, Seattle, Washington, USA
- Center for Industrial and Medical Ultrasound, Applied Physics Laboratory, University of Washington, Seattle, Washington, USA
| | - Bryan W. Cunitz
- Center for Industrial and Medical Ultrasound, Applied Physics Laboratory, University of Washington, Seattle, Washington, USA
| | - Barbrina Dunmire
- Center for Industrial and Medical Ultrasound, Applied Physics Laboratory, University of Washington, Seattle, Washington, USA
| | - Jeff Thiel
- Center for Industrial and Medical Ultrasound, Applied Physics Laboratory, University of Washington, Seattle, Washington, USA
| | - James C. Williams
- Department of Anatomy, Cell Biology & Physiology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Michael R. Bailey
- Department of Urology, University of Washington School of Medicine, Seattle, Washington, USA
- Center for Industrial and Medical Ultrasound, Applied Physics Laboratory, University of Washington, Seattle, Washington, USA
| | - Mathew D. Sorensen
- Department of Urology, University of Washington School of Medicine, Seattle, Washington, USA
- Division of Urology, VA Puget Sound Health Care System, Seattle, Washington, USA
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Zhong P. Editorial Comment on: " In Vitro Evaluation of Urinary Stone Comminution with a Clinical Burst Wave Lithotripsy System" by Ramesh et al. J Endourol 2020; 34:1173-1174. [PMID: 32336158 DOI: 10.1089/end.2020.0358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Pei Zhong
- Department of Mechanical Engineering and Materials Science, Duke University, Durham, North Carolina, USA
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