From OR to office: How Break Wave changes urology practice workflow

Eliminating fluoroscopy from lithotripsy brings meaningful benefits in radiation exposure for patients and clinicians alike—but ultrasound's well-known limitations in visualizing mid- and proximal ureteral stones define the anatomic boundaries of where Break Wave lithotripsy can and cannot be used, according to Ben H. Chew, MD, MSc, FRCSC, in the final installment of a 3-part series on the SOUND pivotal trial.¹

The absence of radiation is among the most straightforward advantages of ultrasound-guided delivery. Clinicians do not need lead shielding, and patients avoid cumulative fluoroscopic exposure. But the same physics that make ultrasound safe also constrain its diagnostic reach. Bowel gas and bone impair visualization in the mid- and proximal ureter—the same reason ultrasound frequently misses ureteral stones in clinical practice.

"When we send patients out for ultrasound and they see hydronephrosis but can't identify a stone, they're always saying, get an X-ray or get a CT scan," Chew said. That diagnostic blind spot translates directly into a treatment limitation: if a stone cannot be visualized, it cannot be targeted.

"You cannot treat stones in the proximal ureter, mid ureter, and a little bit below that—it's got to get closer to the bladder," he said.

Upper pole renal stones present a related challenge. When the kidney sits high and lung tissue intervenes between the probe and the stone, the air-filled lung deadens the break waves before they reach the target. Chew noted that a small number of patients in the program have been screen failures after a stone migrated into the mid ureter between scheduling and treatment—a scenario practices will need to anticipate and communicate to patients upfront.

On the practice implementation side, Chew described a trajectory that reflects the technology's flexibility. His own program began performing Break Wave procedures in the operating room, then moved to a lithotripsy suite, then to a hallway outside the clinic, and ultimately to the office itself. The University of Washington has used the device in the emergency department.

"This is really going to make access to care a lot better, and workflow is going to be a lot easier," he said.

The infrastructure requirements are modest. Beyond the device itself, Chew identified a single dedicated, trained operator as the essential element—and argued that operator does not necessarily need to be a urologist, though urologist oversight is appropriate.

"The natural extension of this would probably be an ultrasound technologist," he said, noting that ultrasound techs' existing proficiency in stone identification and device operation makes them well suited for the role. Chew added an unexpected personal benefit: The ultrasound fluency he developed through the Break Wave study has since expanded into his percutaneous nephrolithotomy practice, where he now uses ultrasound for access—a skill he acquired without additional formal training.

REFERENCE

1. Chew BH, Harper JD, Ahn J, et al. SOUND pivotal trial of Break Wave lithotripsy for upper urinary tract stones. Presented at: 2026 American Urological Association Annual Meeting; May 15-18, 2026; Washington, DC. https://www.auajournals.org/doi/10.1097/01.JU.0001192572.07890.f8.03