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Papatsoris A, Alba AB, Galán Llopis JA, Musafer MA, Alameedee M, Ather H, Caballero-Romeu JP, Costa-Bauzá A, Dellis A, El Howairis M, Gambaro G, Geavlete B, Halinski A, Hess B, Jaffry S, Kok D, Kouicem H, Llanes L, Lopez Martinez JM, Popov E, Rodgers A, Soria F, Stamatelou K, Trinchieri A, Tuerk C. Management of urinary stones: state of the art and future perspectives by experts in stone disease. Arch Ital Urol Androl 2024; 96:12703. [PMID: 38934520 DOI: 10.4081/aiua.2024.12703] [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: 06/01/2024] [Accepted: 06/13/2024] [Indexed: 06/28/2024] Open
Abstract
AIM To present state of the art on the management of urinary stones from a panel of globally recognized urolithiasis experts who met during the Experts in Stone Disease Congress in Valencia in January 2024. Options of treatment: The surgical treatment modalities of renal and ureteral stones are well defined by the guidelines of international societies, although for some index cases more alternative options are possible. For 1.5 cm renal stones, both m-PCNL and RIRS have proven to be valid treatment alternatives with comparable stone-free rates. The m-PCNL has proven to be more cost effective and requires a shorter operative time, while the RIRS has demonstrated lower morbidity in terms of blood loss and shorter recovery times. SWL has proven to be less effective at least for lower calyceal stones but has the highest safety profile. For a 6mm obstructing stone of the pelviureteric junction (PUJ) stone, SWL should be the first choice for a stone less than 1 cm, due to less invasiveness and lower risk of complications although it has a lower stone free-rate. RIRS has advantages in certain conditions such as anticoagulant treatment, obesity, or body deformity. Technical issues of the surgical procedures for stone removal: In patients receiving antithrombotic therapy, SWL, PCN and open surgery are at elevated risk of hemorrhage or perinephric hematoma. URS, is associated with less morbidity in these cases. An individualized combined evaluation of risks of bleeding and thromboembolism should determine the perioperative thromboprophylactic strategy. Pre-interventional urine culture and antibiotic therapy are mandatory although UTI treatment is becoming more challenging due to increasing resistance to routinely applied antibiotics. The use of an intrarenal urine culture and stone culture is recommended to adapt antibiotic therapy in case of postoperative infectious complications. Measurements of temperature and pressure during RIRS are vital for ensuring patient safety and optimizing surgical outcomes although techniques of measurements and methods for data analysis are still to be refined. Ureteral stents were improved by the development of new biomaterials, new coatings, and new stent designs. Topics of current research are the development of drug eluting and bioresorbable stents. Complications of endoscopic treatment: PCNL is considered the most invasive surgical option. Fever and sepsis were observed in 11 and 0.5% and need for transfusion and embolization for bleeding in 7 and 0.4%. Major complications, as colonic, splenic, liver, gall bladder and bowel injuries are quite rare but are associated with significant morbidity. Ureteroscopy causes less complications, although some of them can be severe. They depend on high pressure in the urinary tract (sepsis or renal bleeding) or application of excessive force to the urinary tract (ureteral avulsion or stricture). Diagnostic work up: Genetic testing consents the diagnosis of monogenetic conditions causing stones. It should be carried out in children and in selected adults. In adults, monogenetic diseases can be diagnosed by systematic genetic testing in no more than 4%, when cystinuria, APRT deficiency, and xanthinuria are excluded. A reliable stone analysis by infrared spectroscopy or X-ray diffraction is mandatory and should be associated to examination of the stone under a stereomicroscope. The analysis of digital images of stones by deep convolutional neural networks in dry laboratory or during endoscopic examination could allow the classification of stones based on their color and texture. Scanning electron microscopy (SEM) in association with energy dispersive spectrometry (EDS) is another fundamental research tool for the study of kidney stones. The combination of metagenomic analysis using Next Generation Sequencing (NGS) techniques and the enhanced quantitative urine culture (EQUC) protocol can be used to evaluate the urobiome of renal stone formers. Twenty-four hour urine analysis has a place during patient evaluation together with repeated measurements of urinary pH with a digital pH meter. Urinary supersaturation is the most comprehensive physicochemical risk factor employed in urolithiasis research. Urinary macromolecules can act as both promoters or inhibitors of stone formation depending on the chemical composition of urine in which they are operating. At the moment, there are no clinical applications of macromolecules in stone management or prophylaxis. Patients should be evaluated for the association with systemic pathologies. PROPHYLAXIS Personalized medicine and public health interventions are complementary to prevent stone recurrence. Personalized medicine addresses a small part of stone patients with a high risk of recurrence and systemic complications requiring specific dietary and pharmacological treatment to prevent stone recurrence and complications of associated systemic diseases. The more numerous subjects who form one or a few stones during their entire lifespan should be treated by modifications of diet and lifestyle. Primary prevention by public health interventions is advisable to reduce prevalence of stones in the general population. Renal stone formers at "high-risk" for recurrence need early diagnosis to start specific treatment. Stone analysis allows the identification of most "high-risk" patients forming non-calcium stones: infection stones (struvite), uric acid and urates, cystine and other rare stones (dihydroxyadenine, xanthine). Patients at "high-risk" forming calcium stones require a more difficult diagnosis by clinical and laboratory evaluation. Particularly, patients with cystinuria and primary hyperoxaluria should be actively searched. FUTURE RESEARCH Application of Artificial Intelligence are promising for automated identification of ureteral stones on CT imaging, prediction of stone composition and 24-hour urinary risk factors by demographics and clinical parameters, assessment of stone composition by evaluation of endoscopic images and prediction of outcomes of stone treatments. The synergy between urologists, nephrologists, and scientists in basic kidney stone research will enhance the depth and breadth of investigations, leading to a more comprehensive understanding of kidney stone formation.
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Affiliation(s)
- Athanasios Papatsoris
- 2nd Department of Urology, School of Medicine, Sismanoglio Hospital, National and Kapodistrian University of Athens; U-merge Scientific Office.
| | - Alberto Budia Alba
- Urology Department, La Fe University and Polytechnic Hospital, Valencia.
| | | | | | | | | | | | - Antònia Costa-Bauzá
- Laboratory of Renal Lithiasis Research, University Institute of Health Sciences Research (IUNICS-IdISBa), University of Illes Balears, Palma de Mallorca.
| | - Athanasios Dellis
- 2nd Department of Surgery, Aretaieion Academic Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens.
| | | | - Giovanni Gambaro
- Division of Nephrology, Department of Medicine, University Hospital of Verona.
| | - Bogdan Geavlete
- "Carol Davila" University of Medicine and Pharmacy & "Saint John" Emergency Clinical Hospital, Bucharest.
| | - Adam Halinski
- Private Medical Center "Klinika Wisniowa" Zielona Gora.
| | - Bernhard Hess
- Internal Medicine & Nephrology, KidneyStoneCenter Zurich, Klinik Im Park, Zurich.
| | | | - Dirk Kok
- Saelo Scientific Support, Oegstgeest.
| | | | - Luis Llanes
- Urology Department, University Hospital of Getafe, Getafe, Madrid.
| | | | - Elenko Popov
- Department of Urology, UMHAT "Tzaritza Yoanna-ISUL", Medical University, Sofia.
| | | | - Federico Soria
- Experimental Surgery Department, Ramón y Cajal University Hospital, Madrid.
| | - Kyriaki Stamatelou
- MESOGEIOS Nephrology Center, Haidari Attica and NEPHROS.EU Private Clinic, Athens.
| | | | - Christian Tuerk
- Urologic Department, Sisters of Charity Hospital and Urologic Praxis, Wien.
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Rodriguez-Alvarez JS, Khooblall P, Brar H, Fedrigon D, Gutierrez-Aceves J, Monga M, De S. Endoscopic Stone Composition Identification: Is Accuracy Improved by Stone Appearance During Laser Lithotripsy? Urology 2023; 182:67-72. [PMID: 37802193 DOI: 10.1016/j.urology.2023.09.025] [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: 06/28/2023] [Revised: 09/05/2023] [Accepted: 09/23/2023] [Indexed: 10/08/2023]
Abstract
OBJECTIVE To evaluate if videos during laser lithotripsy increase accuracy and confidence of stone identification by urologists compared to still pictures. METHODS We obtained representative pictures and videos of 4 major stone types from 8 different patients during ureteroscopy with holmium laser lithotripsy. A REDCap survey was created and emailed to members of the Endourological Society. The survey included a picture followed by the corresponding video of each stone undergoing laser lithotripsy and additional clinical information. Each picture and video included multiple-choice questions about stone composition and response confidence level. Accuracy, confidence levels, and rates of rectification (change from incorrect to correct answer) or confounding (correct to incorrect) after watching videos were analyzed. RESULTS One hundred eighty-seven urologists responded to the survey. The accuracy rate of stone identification with pictures was 43.8% vs 46.1% with videos (P = .27). Accuracy for individual stones was low and highly variable. Video only improved accuracy for 1 cystine stone. After viewing videos, participants were more likely to rectify vs confound their answers. Urologists were more likely to be confident with videos than pictures alone (65.4% vs 53.7%, respectively; P <.001); however, confident answers were not more likely to yield accurate predictions with videos vs still pictures. CONCLUSION Stone identification by urologists is marginally improved with videos vs pictures alone. Overall, accuracy in stone identification is low irrespective of confidence level, picture, and lithotripsy video visualization. Urologists should be cautious in using endoscopic stone appearance to direct metabolic management.
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Affiliation(s)
| | - Prajit Khooblall
- Cleveland Clinic Glickman Urological & Kidney Institute, Cleveland, OH
| | | | | | | | - Manoj Monga
- University of California San Diego, San Diego, CA
| | - Smita De
- Cleveland Clinic Glickman Urological & Kidney Institute, Cleveland, OH
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Randall JH, Whiles BB, Carrera RV, Ito WE, Thompson JA, Duchene DA, Neff DA, Molina WR. On the rocks: can urologists identify stone composition based on endoscopic images alone? A worldwide survey of urologists. World J Urol 2023; 41:575-579. [PMID: 36607392 DOI: 10.1007/s00345-022-04269-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 12/19/2022] [Indexed: 01/07/2023] Open
Abstract
PURPOSE As part of the management of nephrolithiasis, determination of chemical composition of stones is important. Our objective in this study is to assess urologists' accuracy in making visual, intraoperative determinations of stone composition. MATERIALS AND METHODS We conducted a REDCap survey asking urologists to predict stone composition based on intraoperative images of 10 different pure-composition kidney stones of 7 different types: calcium oxalate monohydrate (COM), calcium oxalate dihydrate (COD), calcium phosphate (CP) apatite, CP brushite, uric acid (UA), struvite (ST) and cystine (CY). To evaluate experience, we examined specific endourologic training, years of experience, and number of ureteroscopy (URS) cases/week. A self-assessment of ability to identify stone composition was also required. RESULTS With a response rate of 26% (366 completed surveys out of 1,370 deliveries), the overall accuracy of our cohort was 44%. COM, ST, and COD obtained the most successful identification rates (65.9%, 55.7%, and 52.0%, respectively). The most frequent misidentified stones were CP apatite (10.7%) and CY (14.2%). Predictors of increased overall accuracy included self-perceived ability to determine composition and number of ureteroscopies per week, while years of experience did not show a positive correlation. CONCLUSIONS Although endoscopic stone recognition can be an important tool for surgeons, it is not reliable enough to be utilized as a single method for stone identification, suggesting that urologists need to refine their ability to successfully recognize specific stone compositions intraoperatively.
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Affiliation(s)
- Joseph H Randall
- Department of Urology, The University of Kansas Health System, 3901 Rainbow Boulevard, Mail Stop #3016, Kansas City, KS, 66160, USA
| | - Bristol B Whiles
- Department of Urology, The University of Kansas Health System, 3901 Rainbow Boulevard, Mail Stop #3016, Kansas City, KS, 66160, USA
| | - Raphael V Carrera
- Department of Urology, The University of Kansas Health System, 3901 Rainbow Boulevard, Mail Stop #3016, Kansas City, KS, 66160, USA
| | - Willian E Ito
- Department of Urology, The University of Kansas Health System, 3901 Rainbow Boulevard, Mail Stop #3016, Kansas City, KS, 66160, USA
| | - Jeffrey A Thompson
- Department of Biostatistics, University of Kansas Medical Center, Kansas City, KS, USA
| | - David A Duchene
- Department of Urology, The University of Kansas Health System, 3901 Rainbow Boulevard, Mail Stop #3016, Kansas City, KS, 66160, USA
| | - Donald A Neff
- Department of Urology, The University of Kansas Health System, 3901 Rainbow Boulevard, Mail Stop #3016, Kansas City, KS, 66160, USA
| | - Wilson R Molina
- Department of Urology, The University of Kansas Health System, 3901 Rainbow Boulevard, Mail Stop #3016, Kansas City, KS, 66160, USA.
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Estrade V, Denis de Senneville B, Facq L, Daudon M. Endoscopic in-situ recognition of urinary stones during LASER-induced stone fragmentation: a modern, effective and essential approach in the diagnostic process in urolithiasis. CR CHIM 2022. [DOI: 10.5802/crchim.162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Sierra A, Corrales M, Piñero A, Kolvatzis M, Somani B, Traxer O. Glossary of pre-settings given by laser companies: no consensus! World J Urol 2022; 40:2313-2321. [DOI: 10.1007/s00345-022-04090-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 06/30/2022] [Indexed: 11/30/2022] Open
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Henderickx MMEL, Stoots SJM, de Bruin DM, Wijkstra H, Freund JE, Wiseman O, Ploumidis A, Skolarikos A, Somani BK, Sener TE, Emiliani E, Dragos L, Villa L, Talso M, Daudon M, Traxer O, Kronenberg P, Doizi S, Tailly T, Tefik T, Hendriks N, Beerlage HP, Baard J, Kamphuis GM. How reliable is endoscopic stone recognition? A comparison between visual stone identification and formal stone analysis. J Endourol 2022; 36:1362-1370. [PMID: 35651279 DOI: 10.1089/end.2022.0217] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To assess the diagnostic accuracy and intra-observer agreement of endoscopic stone recognition compared with formal stone analysis. INTRODUCTION Stone analysis is a corner stone in the prevention of stone recurrence. Although X-ray diffraction and infrared spectroscopy are the recommended techniques for reliable formal stone analysis, this is not always possible, and the process takes time and is costly. Endoscopic stone recognition could be an alternative as it would give immediate information on stone composition. MATERIAL AND METHODS Fifteen endourologists predicted stone composition based on 100 videos from ureterorenoscopy. Diagnostic accuracy was evaluated by comparing the prediction from visual assessment with stone analysis by X-ray diffraction. After 30 days, the videos were reviewed again in a random order to assess intra-observer agreement. RESULTS The median diagnostic accuracy for calcium oxalate monohydrate was of 54% in questionnaire 1 (Q1) and 59% in questionnaire 2 (Q2), whereas calcium oxalate dihydrate had a median diagnostic accuracy of 75% in Q1 and 50% in Q2. The diagnostic accuracy for calcium hydroxyphosphate was 10% in Q1 and 13% in Q2. The median diagnostic accuracy for calcium hydrogen phosphate dihydrate and calcium magnesium phosphate was 0% in both questionnaires. The median diagnostic accuracy for magnesium ammonium phosphate was in 20% in Q1 and 40% in Q2. The median diagnostic accuracy for uric acid was 22% in both questionnaires. Finally, there was a diagnostic accuracy of 60% in Q1 and 80% in Q2 for cystine. The intra-observer agreement ranged between 45-72%. CONCLUSION Diagnostic accuracy of endoscopic stone recognition is limited and intra-observer agreement is below the threshold of acceptable agreement.
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Affiliation(s)
- Michaël M E L Henderickx
- Amsterdam UMC Locatie Meibergdreef, 26066, Department of Urology, Amsterdam, North Holland, Netherlands;
| | - Simone J M Stoots
- Amsterdam UMC Locatie Meibergdreef, 26066, Department of Urology, Amsterdam, North Holland, Netherlands;
| | - D Martijn de Bruin
- Amsterdam UMC Locatie Meibergdreef, 26066, Biomedical Engineering & Physics, Amsterdam, North Holland, Netherlands.,Amsterdam UMC Locatie Meibergdreef, 26066, Department of Urology, Amsterdam, North Holland, Netherlands;
| | - Hessel Wijkstra
- Amsterdam UMC Locatie Meibergdreef, 26066, Department of Urology, Amsterdam, North Holland, Netherlands.,Eindhoven University of Technology, 3169, Department of Electrical Engineering, Eindhoven, Noord-Brabant, Netherlands;
| | - Jan Erik Freund
- Amsterdam UMC Locatie Meibergdreef, 26066, Department of Pathology, Amsterdam, North Holland, Netherlands;
| | - Oliver Wiseman
- Cambridge University Hospitals NHS Foundation Trust, Urology, 14 Herons Close, Cambridge, Cambridgeshire, United Kingdom of Great Britain and Northern Ireland, CB1 8NS;
| | | | - Andreas Skolarikos
- University of Athens, 2nd Department of Urology, 6 LASKAREOS ST, NEA ZOI PERISTERI, Athens, Greece, 12137;
| | - Bhaskar K Somani
- University Hospitals Southampton NHS Trust, Urology, Southampton, United Kingdom of Great Britain and Northern Ireland;
| | - Tarik Emre Sener
- Marmara University School of Medicine, Urology, Fevzi Çakmak Mah. Muhsin Yazıcıoğlu Cad. No: 10 Üst Kaynarca / Pendik / İSTANBUL, Istanbul, Turkey, 34890;
| | | | - Laurian Dragos
- Cambridge University Hospitals NHS Foundation Trust, 2153, Department of Urology, Cambridge, Cambridgeshire, United Kingdom of Great Britain and Northern Ireland;
| | - Luca Villa
- Università Vita-Salute San Raffaele, Urology, Via Olgettina, 60, Milan, Italy, 20132;
| | - Michele Talso
- ASST Fatebenefratelli Sacco, 472674, Urology - Ospedale Luigi Sacco University Hospital, Milano, Italy;
| | - Michel Daudon
- Hôpital Tenon, 55705, Department of Urology, Paris, Île-de-France, France.,Sorbonne Universite, 27063, GRC n°20, Groupe de Recherche Clinique sur la Lithiase Urinaire, Paris, Île-de-France, France;
| | - Olivier Traxer
- Hopital Tenon, 55705, Department of Urology, Paris, Île-de-France, France.,Sorbonne Universite, 27063, GRC n°20, Groupe de Recherche Clinique sur la Lithiase Urinaire, Paris, Île-de-France, France;
| | - Peter Kronenberg
- Hospital CUF Descobertas, 162265, Department of Urology , Lisboa, Lisboa, Portugal;
| | - Steeve Doizi
- Hopital Tenon, 55705, Department of Urology, Paris, Île-de-France, France.,Sorbonne Universite, 27063, GRC n°20, Groupe de Recherche Clinique sur la Lithiase Urinaire, Paris, Île-de-France, France;
| | | | - Tzevat Tefik
- Istanbul University Istanbul Faculty of Medicine, 64041, Department of Urology, Istanbul, Istanbul, Turkey;
| | - Nora Hendriks
- Amsterdam UMC Locatie AMC, 26066, Department of Urology, Amsterdam, Netherlands;
| | - Harrie P Beerlage
- Amsterdam UMC Locatie Meibergdreef, 26066, Department of Urology, Amsterdam, North Holland, Netherlands;
| | - Joyce Baard
- Amsterdam UMC Locatie Meibergdreef, 26066, Department of Urology, Amsterdam, North Holland, Netherlands;
| | - Guido M Kamphuis
- Amsterdam UMC Locatie Meibergdreef, 26066, Department of Urology, Amsterdam, North Holland, Netherlands;
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Kim US, Kwon HS, Yang W, Lee W, Choi C, Kim JK, Lee SH, Rim D, Han JH. Prediction of the composition of urinary stones using deep learning. Investig Clin Urol 2022; 63:441-447. [PMID: 35670006 PMCID: PMC9262483 DOI: 10.4111/icu.20220062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 03/31/2022] [Accepted: 04/17/2022] [Indexed: 12/13/2022] Open
Abstract
PURPOSE This study aimed to predict the composition of urolithiasis using deep learning from urinary stone images. MATERIALS AND METHODS We classified 1,332 stones into 31 classes according to the stone composition. The top 4 classes with a frequency of 110 or more (class 1: calcium oxalate monohydrate [COM] 100%, class 2: COM 80%+struvite 20%, class 3: COM 60%+calcium oxalate dihydrate [COD] 40%, class 4: uric acid 100%) were selected. With the 965 stone images of the top 4 classes, we used the seven convolutional neural networks (CNN) to classify urinary stones and compared their classification performances. RESULTS Among the seven models, Xception_Ir0.001 showed the highest accuracy, precision, and recall and was selected as the CNN model to predict the stone composition. The sensitivity and specificity for the 4 classes by Xception_Ir0.001 were as follows: class 1 (94.24%, 91.73%), class 2 (85.42%, 96.14%), class 3 (86.86%, 99.59%), and class 4 (94.96%, 98.82%). The sensitivity and specificity of the individual components of the stones were as follows. COM (98.82%, 94.96%), COD (86.86%, 99.64%), struvite (85.42%, 95.59%), and uric acid (94.96%, 98.82%). The area under the curves for class 1, 2, 3, and 4 were 0.98, 0.97, 1.00, and 1.00, respectively. CONCLUSIONS This study showed the feasibility of deep learning for the diagnostic ability to assess urinary stone composition from images. It can be an alternative tool for conventional stone analysis and provide decision support to urologists, improving the effectiveness of diagnosis and treatment.
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Affiliation(s)
- Ui Seok Kim
- Department of Urology, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea
| | - Hyo Sang Kwon
- Department of Urology, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea
| | - Wonjong Yang
- Department of Urology, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea
| | - Wonchul Lee
- Department of Urology, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea
| | - Changil Choi
- Department of Urology, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea
| | - Jong Keun Kim
- Department of Urology, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea
| | - Seong Ho Lee
- Department of Urology, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea
| | - Dohyoung Rim
- Department of Cognitive Science, Yonsei University, Seoul, Korea
| | - Jun Hyun Han
- Department of Urology, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea.
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