Fluoroscopy time during uncomplicated unilateral ureteroscopy for urolithiasis decreases with urology resident experience

Radiation exposure during sacral neuromodulation lead placement: Multi-institutional descriptive study

OBJECTIVES

Fluoroscopy has significantly improved lead placement and decreased surgical time for implantable sacral neuromodulation (SNM). There is a paucity of data regarding radiation and safety of fluoroscopy during SNM procedures. Our study aims to characterize fluoroscopy time and dose used during SNM surgery across multiple institutions and assess for predictors of increased fluoroscopy time and radiation dose.

METHODS

Electronic medical records were queried for SNM procedures (Stage 1 and full implant) from 2016 to 2021 at four academic institutions. Demographic, clinical, and intraoperative data were collected, including fluoroscopy time and radiation dose in milligray (mGy). The data were entered into a centralized REDCap database. Univariate and multivariate analysis were performed to assess for predictive factors using STATA/BE 17.0.

RESULTS

A total of 664 procedures were performed across four institutions. Of these, 363 (54.6%) procedures had complete fluoroscopy details recorded. Mean surgical time was 58.8 min. Of all procedures, 79.6% were performed by Female Pelvic Medicine and Reconstructive Surgery specialists. There was significant variability in fluoroscopy time and dose based on surgical specialty and institution. Most surgeons (76.4%) were considered "low volume" implanters. In a multivariate analysis, bilateral finder needle testing, surgical indication, surgeon volume, and institution significantly predicted increased fluoroscopy time and radiation dose (p < 0.05).

CONCLUSIONS

There is significant variability in fluoroscopy time and radiation dose utilized during SNM procedures, with differences across institutions, surgeons, and subspecialties. Increased radiation exposure can have harmful impacts on the surgical team and patient. These findings demonstrate the need for standardized fluoroscopy use during SNM procedures.

2022 Recommendations of the AFU Lithiasis Committee: Radiation protection in the operating theater

It has been shown that the relative risk of cancer is higher in patients with urinary stone disease, probably due to the repeated radiological exams and procedures under fluoroscopic guidance. Reducing the radiation doses delivered to the patient also decreases the doses delivered to the operators and their assistants. The doses delivered during endoscopic procedures decrease with the urologist's experience. Training in radiation protection and the use of protocols can decrease the use of ionizing radiation in the operating room. METHODOLOGY: These recommendations were developed using two methods: the Clinical Practice Recommendation (CPR) method and the ADAPTE method, depending on whether the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis) [EAU Guidelines on urolithiasis. 2022] and whether they were adaptable to the French context.

Radiation protection measures during endourological therapies

Objective

The objective of this narrative review was to search the existing literature for studies reporting measures to minimize radiation use during endoscopic management of stone disease and present ways of reducing the exposure of both patients and operating room staff.

Methods

A literature review in PubMed was performed to identify studies describing protocols or measures to reduce radiation received during endourological procedures from January 1970 to August 2022. Eligible studies were those that reported outcomes for ureteroscopy or percutaneous nephrolithotripsy regarding measures to minimize radiation doses used intraoperatively, performed either in real-life theatres or using phantoms. Both comparative and non-comparative studies were deemed eligible.

Results

Protection can be achieved initially at the level of diagnosis and follow-up of patients, which should be done following an algorithm and choice of more conservative imaging methods. Certain protocols, which follow principles for minimized fluoroscopy use should be implemented and urologists as well as operating room staff should be continuously trained regarding radiation damage and protection measures. Wearing protective lead equipment remains a cornerstone for personnel protection, while configuration of the operating room and adjusting X-ray machine settings can also significantly reduce radiation energy.

Conclusion

There are specific measures, which can be implemented to reduce radiation exposure. These include avoiding excessive use of computed tomography scans and X-rays during diagnosis and follow-up of urolithiasis patients. Intraoperative protocols with minimal fluoroscopy use can be employed. Staff training regarding dangers of radiation plays also a major role. Use and maintenance of protective equipment and setting up the operating room properly also serve towards this goal. Machine settings can be customized appropriately and finally continuously monitoring of exposure with dosimeters can be adopted.

Fluoroless endourological surgery for high burden renal and proximal ureteric stones: A safe technique for experienced surgeons

Objective: To describe the feasibility of treating proximal ureteric and renal stones using flexible ureteroscopy (fURS) or a double approach (mini-percutaneous nephrolithotomy [PCNL] + fURS) without any use of radiation.

Patients and methods: We retrospectively reviewed the data of all patients operated by one surgeon for retrograde endoscopic removal of renal and ureteric lithiasis performed between June 2015 and January 2019 in our institution. Patients with anatomical complexities, high-burden stone disease (diameter >20 mm), and medical comorbidities (anti-platelet drug administration) were included in our study. Outcomes analysed included complication rate, stone-free rate (SFR, defined as no residual stone >1 mm), and repeat procedure rate.

Results: In all, 183 consecutive URS for proximal ureteric and renal lithiasis were conducted. C-arm fluoroscope guidance was not required, not even in the complex cases. Simultaneous ultrasonography and fURS guidance was used in patients where the mini-PCNL approach was indicated. Lead aprons were not needed by the operating room staff in any of the operations. The SFR was 91.8% after the first procedure, with no Clavien–Dindo Grade III or IV complications.

Conclusion: Our present series shows clearly that the fURS and mini-PCNL approach under fURS control is a feasible and safe technique for experienced surgeons. Patients had a high SFR and no technique-related complications, with no additional risk of X-ray exposure. However, a prospective study is required to test the reproducibility of this technique.

Abbreviations: GMSV: Galdakao-modified supine Valdivia; ICRP: International Commission on Radiological Protection; KUB: plain abdominal radiograph of the kidneys, ureters and bladder; OR: operating room; PCNL: percutaneous nephrolithotomy; SFR: stone-free rate; UAS: ureteric access sheath; (f)URS: (flexible) ureteroscopy; US: ultrasonography

Flat Panel Detector c-Arms Are Associated with Dramatically Reduced Radiation Exposure During Ureteroscopy and Produce Superior Images

Background: We wished to determine whether newly available flat panel detector (FPD) c-arms were (1) associated with lower radiation dose during ureteroscopy (URS) than conventional image intensifier (CII) c-arms and (2) to compare fluoroscopic image quality between the units. Materials and Methods: We retrospectively reviewed 44 consecutive patients undergoing URS at a pediatric hospital, with c-arms assigned by availability in the operating room. We performed dosimetry experiments using the same c-arms on standard phantoms. Results: Patient and case characteristics did not differ significantly between the two groups of patients. The median dose in the FPD group was less than a quarter of the dose in the CII group, 0.48 [0.42, 0.97] mGy vs 2.2 [1.1, 3.8] mGy, p < 0.0001. The FPD dose remained at less than one-third of the CII dose accounting for any difference in fluoroscopy time, and remained significant in a multivariate model including fluoroscopy time and patient weight (β = 2.4, p = 0.007). Phantom studies showed higher image quality for FPDs at all simulated patient sizes, even at lower radiation doses. Conclusions: This is the first report comparing radiation dose from c-arms of image intensifiers and FPDs in adults or children. Use of an FPD during URS was associated with a substantially decreased absorbed dose for patients while simultaneously improving image quality.

Factors Influencing Fluoroscopy Use During Ureteroscopy at a Residency Training Program

Introduction: Ionizing radiation is used throughout urologic surgery and is known to cause a greater cancer risk with increasing exposure. The International Commission on Radiological Protection states that "it is the control of radiation dose that is important, no matter the source." However, there are few reports on the amount of radiation used by urology residents during ureteroscopy (URS). We present the largest database evaluating fluoroscopy (fluoro) use during URS at a resident training program. Our objective is to assess the amount of fluoro use at varying levels of experience and to identify factors that lead to increased fluoro use. Methods: Retrospective data from 242 URSs performed at two resident training sites were collected. In total, 105 surgeries were done by two attending physicians without and 137 surgeries with residents (Uro1-Uro3). Patient data were collected from the electronic medical record. Statistical analyses included analysis of variance, Spearman correlations, and multiple linear regression (MLR). Results: Comparisons between years 1 and 2 revealed significantly (p < 0.05) decreased fluoro time (20.0 seconds) and operative time (OT) (12.2 minutes) for the year 2 resident. Total OT was significantly (p < 0.05) decreased (11.1 minutes) for attending physicians operating on their own compared with a year 1 resident. Significant (p < 0.05) correlations with fluoro time were demonstrated for OT, stone size, ureteral dilation, ureteral access sheath use, presence of a preoperative stent, resident year, and resident month. OT, ureteral dilation, and a preoperative stent placement were significant predictors of fluoro time on MLR (p < 0.05). Conclusion: Fluoro time during retrograde URS was significantly reduced as residents gained more experience in the operating room. An increase in fluoro time was also associated with ureteral dilation, access sheath use, increasing stone size, and lack of prestenting. With knowledge of these factors, emphasis can be placed on using and teaching techniques that limit radiation exposure.

Low Dose Fluoroscopy During Ureteroscopy Does Not Compromise Surgical Outcomes

Objective: To evaluate whether reducing the dose of fluoroscopy to ¼ of standard dose during unilateral ureteroscopy for ureteral stone treatment would impact in a reduction of total radiation emitted and whether this strategy would impact operation time, stone-free rate, and complication rate. Methods: From August 2016 to August 2017, patients over 18 years submitted to ureteroscopy for ureteral stone between 5 and 20 mm were prospectively randomized for ¼ dose reduction or standard dose fluoroscopy. Patients with abnormal urinary anatomy such as horseshoe kidney, pelvic kidney, or duplex system were excluded from the study. Results: Ninety-four patients were enrolled. The fluoroscopic dose reduction strategy to ¼ of the standard dose was able to significantly reduce the cumulative radiation emitted by C-arm fluoroscopy and the dose area product (3.6 ± 4.5 mGy vs 16.2 ± 19.3 mGy, p = 0.0001 and 0.23 ± 0.52 mcGycm² vs 1.15 ± 2.74 mcGycm², p = 0.02, respectively). Fluoroscopy time was similar between groups (74.5 ± 84.8 seconds vs 88.3 ± 90 seconds, p = 0.44). There was no need to increase the fluoroscopy dose during any of the procedures. Surgical outcomes were not affected by fluoroscopic dose reduction strategy. Conclusion: Low dose fluoroscopy reduces the emitted radiation during ureteroscopy without compromising surgical outcomes.

Radiation exposure during retrograde intrarenal surgery (RIRS): a prospective multicenter evaluation

Purpose

Retrograde intrarenal surgery (RIRS) may require extensive X-ray usage. We evaluated the impact of preoperative surgeon briefing regarding the inclusion and evaluation of fluoroscopy time (FT) and dose area product (DAP) in a multicenter study on the applied X-ray usage.

Methods

A prospective multicenter study of 6 tertiary centers was performed. Each center recruited up to 25 prospective patients with renal stones of any size for RIRS. Prior to study´s onset, all surgeons were briefed about hazards of radiation and on strategies to avoid high doses in RIRS. Prospective procedures were compared to past procedures, as baseline data. FT was defined as the primary outcome. Secondary parameters were stone-free rate (SFR), complications according to the Clavien, SATAVA and postureteroscopic lesion scale. Results were analyzed using T test, chi-squared test, univariate analysis and confirmed in a multivariate regression model.

Results

303 patients were included (145 retro- and 158 prospective). Mean FT and DAP were reduced from 130.8 s/565.8 to 77.4 s/357.8 (p < 0.05). SFR was improved from 85.5% to 93% (p < 0.05). Complications did not vary significantly. Neither stone position (p = 0.569), prestenting (p = 0.419), nor surgeons’ experience (> 100 RIRS) had a significant impact on FT. Significant univariate parameters were confirmed in a multivariate model, revealing X-ray training to be radiation protective (OR − 44, p = 0.001).

Conclusions

Increased surgeon awareness of X-ray exposure risks has a significant impact on FT and DAP. This “awareness effect” is a simple method to reduce radiation exposure for the patient and OR staff without the procedures´ outcome and safety being affected.

The Impact of Endourological Experience on Flexible Ureteroscopy Outcomes and Performance at Different Levels of Expertise: Retrospective Multifactorial Analysis

INTRODUCTION

The aim of this study was to analyze the influence of residents' participation in flexible ureteroscopy (fURS) on intra- and postoperative outcomes.

MATERIALS AND METHODS

Intra- and postoperative parameters were compared in a retrospective monocentric setting between 3 groups: "resident group" (47 cases) for surgeries performed by experienced residents alone, "consultant group" (245 cases) for surgeries performed by consultants alone, "resident plus consultant group" (124 cases) for training surgeries between September 2013 and June 2017.

RESULTS

Patients operated by residents alone had a significantly smaller median kidney stone diameter (5.0 vs. 7.0 mm for "consultant group" and 6.0 mm for "resident plus consultant group," p = 0.011), shorter operating time (median 47.0 vs. 63.0 and 77.0 min, p < 0.001) and fluoroscopy time (median 39.0 vs. 69.5 and 89.0 s, p < 0.001), as well as shorter postoperative hospital stay (p = 0.013). The laser application rate was the smallest in the "resident group" (10.64 vs. 31.43 and 29.84%, p = 0.009). Univariate analysis revealed no relevant differences regarding flexible ureteroscope defect rate, postoperative stone-free rate, or ≥2 Clavien-Dindo classification complications between the groups (p > 0.05).

CONCLUSION

A proper case selection of less complicated cases, especially without laser application, could balance the experience deficit of the residents. fURS can be incorporated as a part of residents' training without an impact on fURS device defect rate or clinical outcomes.

Impact of Surgical Experience on Radiation Exposure during Retrograde Intrarenal Surgery: A Propensity-Score Matching Analysis

BACKGROUND

The impact of surgical experience on radiation exposure (RE) during endourological procedures has been poorly investigated.

OBJECTIVE

To assess the impact of surgical experience on fluoroscopy time (FT) and RE during retrograde intrarenal surgery (RIRS).

DESIGN, SETTING, AND PARTICIPANTS

The study included 140 patients who underwent RIRS performed either by a senior surgeon (expertise of >100 RIRSs) (group A) or by two junior residents (expertise of <15 RIRSs) (group B) between January 2016 and May 2018.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We tested the hypothesis that surgical experience had a limited impact on RE during RIRS. To adjust for potential baseline confounders, propensity-score matching was performed. Descriptive statistics and linear regression models tested the association between clinical variables and FT and patients' effective doses.

RESULTS AND LIMITATIONS

There was no significant difference between the two groups for baseline, intraoperative, and postoperative characteristics. Overall FT (p=0.97) and effective dose (p=0.79) did not differ between groups. A statistically significant association was found between male sex (all p<0.03), stone burden (all p<0.001), operative time (all p<0.003), and postoperative double-J placement (all p<0.02) with both FT and effective dose. Linear multivariable analysis revealed that body mass index was significantly associated with effective dose (p=0.002). Similarly, longer operative time (all p<0.03) and double-J placement (all p<0.04) were significantly associated with increased FT and effective dose.

CONCLUSIONS

Surgical experience has a limited impact on FT and RE during RIRS. Longer operative time and double-J placement were associated with increased FT and effective dose.

PATIENT SUMMARY

In this study, we assessed whether surgical experience affects fluoroscopy time and patient's effective dose during retrograde intrarenal surgery (RIRS). We found that radiation exposure (RE) was not affected by surgeon's experience and that the standardisation of the surgical technique at the beginning of the learning curve of young surgeons may represent the key factor in reducing RE during RIRS.

Does Previous Failed Shockwave Lithotripsy Treatment Have an Influence on Retrograde Intrarenal Surgery Outcome?

Background: The prevalence of urolithiasis is nearly 20% and patients with urolithiasis constitute an essential part of the patients referred to the urology clinic. Many parameters should be considered for the management of renal stones and authors recommend extracorporeal shockwave lithotripsy (SWL), retrograde intrarenal surgery (RIRS), and percutaneous nephrolithotripsy (PNL), as treatment options. Among these techniques, SWL does not require general anesthesia, has 89% success rate for renal pelvic stones: 83% for upper caliceal stones, 84% for middle caliceal stones, and 68% for lower caliceal stones. In this study, we aimed to investigate whether the previously failed SWL treatment affects RIRS outcome. Methods: Patients who underwent RIRS for kidney stones between January 2012 and December 2017 in Diskapi Yildirim Beyazit Training and Research Hospital were reviewed retrospectively. Patients treated with primary RIRS (186 patients) were classified as Group 1. The outcomes of these patients were compared with those of 186 patients who underwent RIRS after failed SWL treatment using matched-pair analysis, and these patients were classified as Group 2. Results: The procedure success was defined as the sum of the stone-free and clinically insignificant residual fragments (CIRFs); final success rates were 90.3% and 91.9%, respectively. If we compare the final success rates, there was no statistically significant difference between both groups (P = .584). Conclusions: As a result, there is no negative effect of the previous unsuccessful SWL treatment on the RIRS success. Patients with CIRF should be followed up more carefully in terms of becoming symptomatic.

The effect of surgeon versus technologist control of fluoroscopy on radiation exposure during pediatric ureteroscopy: A randomized trial

BACKGROUND

Fluoroscopy is commonly used during pediatric ureteroscopy (PURS) for urolithiasis, and the most important contributor to overall radiation exposure is fluoroscopy time (FT). One factor that may impact FT is who controls activation of the fluoroscope: the urologist (with a foot pedal) or the radiation technologist (as directed by the urologist). While there are plausible reasons to believe that either approach may lead to reduced FT, there are no systematic investigations of this question. We sought to compare FT with surgeon-control versus technologist control during PURS for urolithiasis.

METHODS

We conducted a randomized controlled trial (Clinicaltrials.gov ID number: NCT02224287). Institutional Review Board approval was sought and obtained for this study. All subjects (or their legal guardians) provided informed consent. Each patient (age 5-26 years) was randomized to surgeon- or technologist-controlled fluoroscope activation. Block randomization was stratified by the surgeon. For technologist control, the surgeon verbally directed the technologist to activate the fluoroscope. For surgeon control, a foot pedal was used by the surgeon. The technologist controlled c-arm positioning, settings, and movement. The primary outcome was total FT for the procedure. Secondary outcomes included radiation exposure (entrance surface air kerma [ESAK] mGy). We also analyzed clinical and procedural predictors of FT and exposure. Mixed linear models accounting for clustering by surgeon were developed.

RESULTS

Seventy-three procedures (5 surgeons) were included. The number of procedures per surgeon ranged from seven to 36. Forty-three percent were pre-stented. Thirty-one procedures were left side, 35 were right side, and seven were bilateral. Stones were treated in 71% of procedures (21% laser, 14% basket, and 65% laser/basket). Stone locations were distal ureter (11.5%), proximal/mid-ureter (8%), renal (69%), and ureteral/renal (11.5%). An access sheath was used in 77%. Median stone size was 8.0 mm (range 2.0-20.0). Median FT in the surgeon control group was 0.5 min (range 0.01-6.10) versus 0.55 min (range 0.10-5.50) in the technologist-control group (p = 0.284). Median ESAK in the surgeon control group was 46.02 mGy (range 5.44-3236.80) versus 46.99 mGy (range: 0.17-1039.31) in the technologist-control group (p = 0.362). Other factors associated with lower FT on univariate analysis included female sex (p = 0.015), no prior urologic surgeries (p = 0.041), shorter surgery (p = 0.011), and no access sheath (p = 0.006). On multivariable analysis only female sex (p = 0.017) and no access sheath (p = 0.049) remained significant. There was significant variation among surgeons (p < 0.0001); individual surgeon median FT ranged from 0.40 to 2.95 min.

CONCLUSIONS

Fluoroscopy time and radiation exposure are similar whether the surgeon or technologist controls fluoroscope activation. Other strategies to reduce exposure might focus on surgeon-specific factors, given the significant variation between surgeons.

Impact of surgeon's experience on outcome parameters following ureterorenoscopic stone removal

Within the BUSTER trial, we analyzed the surgeon's amount of experience and other parameters associated with URS procedures regarding the stone-free rate, complication rate, and operative time. Patient characteristics and surgical details on 307 URS procedures were prospectively documented according to a standardized study protocol at 14 German centers 01-04/2015. Surgeon's experience was correlated to clinical characteristics, and its impact on the stone-free rate, complication rate, and operative time subjected to multivariate analysis. 76 (25%), 66 (21%) and 165 (54%) of 307 URS procedures were carried out by residents, young specialists, and experienced specialists (> 5 years after board certification), respectively. Median stone size was 6 mm, median operative time 35 min. A ureteral stent was placed at the end of 82% of procedures. Stone-free rate and stone-free rate including minimal residual stone fragments (adequate for spontaneous clearance) following URS were 69 and 91%, respectively. No complications were documented during the hospital stays of 89% of patients (Clavien-Dindo grade 0). According to multivariate analysis, experienced specialists achieved a 2.2-fold higher stone-free rate compared to residents (p = 0.038), but used post-URS stenting 2.6-fold more frequently (p = 0.023). Surgeon's experience had no significant impact on the complication rate. We observed no differences in this study's main endpoints, namely the stone-free and complication rates, between residents and young specialists, but experienced specialists' stone-free rate was significantly higher. During this cross-sectional study, 75% of URS procedures were performed by specialists. The experienced specialists' more than two-fold higher stone-free rate compared to residents' justifies ongoing efforts to establish structured URS training programs.

The Impact of Technique Standardization on Total Operating and Fluoroscopy Times in Simple Endourological Procedures: A Prospective Study

PURPOSE

To present the positive impact of technique standardization on successful outcome, fluoroscopy, and total operating time (TOT) shortening in a prospective study.

METHODS

Six experienced endourologists participated. To assess whether the adaptation of standardized surgical steps improved their methodology with time, 253 patients were prospectively divided in three consecutive 1-month groups. Patients underwent stent placement and exchange and total operating and fluoroscopy times (FTs) were recorded. All surgeons were unaware of their mean recorded results until the end of the study. At the end of the third month, we evaluated if the suggested technique standardization established a decrease for both FT and TOT. Statistical significance was set to p < 0.05.

RESULTS

Total operating and FTs were significantly reduced with time between all groups of patients. For stent placement, TOT showed significant reduction between Groups A and C (p < 0.001), while between other group comparisons did not reach significance. FT showed a significant reduction (p < 0.001) in all group comparisons. For stent exchange, TOT reached significant improvement (p = 0.003) between Groups A and C, whereas between other groups was insignificant. FT improvement was significant between Groups A and C (p < 0.001) and Groups B and C (p < 0.001), but insignificant between Groups A and B.

CONCLUSIONS

Even in experienced hands, the adaptation of technique standardization results in significant decrease of total operating and FTs and it is independent from feedback regarding their time performance.

LOCAL LEVELS OF PATIENT RADIATION EXPOSURE IN A UROLOGY OPERATING ROOM IN ITALY

The data analysed came from 545 patients and were related to five types of procedures performed in the urology operating room: percutaneous nephrolithotomy (PCNL), retrograde intrarenal surgery (RIRS), ureteropyeloscopy (UPS), ureteral catheterisation and nephrostomy. Local reference levels (75th percentiles) were determined for the various procedures. The peak entrance skin dose for a patient 20 cm thick was highest for PCNL, being 82 mGy, followed by 43 mGy for nephrostomy, 23 mGy for RIRS, 23 mGy for UPS and 17 mGy for stenting. Even taking into account the maximum values measured (296 mGy for UPS), the doses reached at the skin were not such as to cause deterministic effects. However, the threshold dose for male temporary sterility could be reached (150 mGy).

Retrograde intrarenal surgery using the single - use flexible ureteroscope Uscope 3022 (Pusen™): evaluation of clinical results

Introduction

Reusable endoscopes have some limitations regarding their continued use. To sort out these problems, several disposable devices have appeared on the market. Our objective is to show our clinical results with a new digital flexible single-use ureteroscope.

Materials and methods

This study presents a prospective series of patients who underwent endoscopic surgery as treatment for renal stones using the digital disposable endoscope Uscope 3022™. Demographic, procedure and stone information were registered including surgery time, stone-free rate, need of ureteral catheterization and complications, among others. The behavior of the ureteroscope in terms of image quality and problems associated with flexibility and the working channel were also registered.

Results

A total of 71 procedures were included in the analysis. The mean age was 49.9 years old, with 70.4% of male patients. Mean stone size was 11.4 mm (4 to 40 mm). The most frequent stone location was in the lower calyces (28.2%). The stone burden was high (>2 cm) in 8.4% of patients. The mean surgical time was 56.6 minutes (15–180 min). In 94.4% of the cases, a laser was used with dusting parameters. The global stone-free rate (SFR) was 95.2%, but in the subgroups analysis SFR were significantly superior in stones less than 10 mm (97.9%) versus stones between 10 and 20 mm (94.5%) and greater than 20 mm (78.3%) (p <0.01). The postoperative placement of double-J stents was required in 66.2% of patients. Two minor complications were recorded and they were related to the ureteral access sheath used. There were no problems regarding the performance of the ureteroscope.

Conclusions

The clinical data observed in this series does not differ from the results traditionally obtained with other reusable devices. To our knowledge, this series is the first worldwide report evaluating the clinical behavior and results in humans of the Uscope 3022.

Ultralow Radiation Exposure During Flexible Ureteroscopy in Patients With Nephrolithiasis-How Far Can We Go?

OBJECTIVE

To evaluate the feasibility and clinical performance of a novel surgeon technique and protocol targeting ultralow fluoroscopy usage in retrograde intrarenal surgery (RIRS).

MATERIALS AND METHODS

All RIRS procedures between 2009 and 2015 for 10- to 20-mm renal calculi performed by the same 2 experienced urologists were eligible. All procedures were performed using a highly standardized step-by-step RIRS technique. This technique was modified by the ultralow radiation exposure RIRS protocol; herein, as much as possible of the standardized steps were performed without radiation control targeting ultralow fluoroscopy usage. Primary end points were fluoroscopy time and dose area product. Secondary end points were stone-free rate (SFR) and intraoperative complications according to Satava classification. End points were evaluated using scatter plots and linear regression model.

RESULTS

Overall, 174 procedures were assessed. Over the study period, fluoroscopy time and dose area product could be reduced from 167.7 s/318.4 cGy/cm² in 2009 to 7.4 s/6.4 cGy/cm² in 2015 (P <.001). SFR (66.7% in 2009; 100% in 2015) and complications (Satava 1 and 2: 28.5% and 4.8%, respectively) improved P <.1), and the surgical duration was reduced (91 minutes and 65 minutes, respectively, P <.001).

CONCLUSION

Our findings revealed a continuous reduction of the amount of radiation used by the implementation of a novel ultralow X-ray usage protocol. SFR, complications, and surgical duration all improved, demonstrating that the novel protocol is as effective as current methods. Exposure to ionizing radiation can be significantly reduced if the presented protocol is followed strictly.

Should surgeons control fluoroscopy during urology procedures?

INTRODUCTION

Our study explored the impact of switching from surgeon- to radiation technologist (RT)-controlled fluoroscopy on fluoroscopy and operative times. We also identified factors impacting fluoroscopy and operative times for ureteroscopy (URS) with laser lithotripsy.

METHODS

Patients undergoing urological procedures requiring fluoroscopy six months before and after the change from surgeon- to RT-controlled fluoroscopy were identified. Median fluoroscopy and operative times were compared between cohorts. Subgroup analyses were performed based on procedure performed. A multivariate analysis identified factors associated with increased fluoroscopy and operative times for URS with laser lithotripsy.

RESULTS

Overall, no difference was found between surgeon and RT cohorts for fluoroscopy (58.0 vs. 56.7 seconds; p=0.34) or operative times (39 vs. 36 minutes; p=0.14). For URS with laser lithotripsy, fluoroscopy and operative times were longer in the surgeon-controlled cohort (76.0 vs. 54.0 seconds; p<0.01 and 48 vs. 40 minutes; p<0.01, respectively). For URS only, fluoroscopy time was decreased in the surgeon-controlled cohort (47.0 vs. 73.0 seconds; p=0.01). For URS with laser lithotripsy, factors independently associated with increased fluoroscopy time were male sex, flexible URS, glidewire use, and difficult ureteric stent insertion (p<0.05). Flexible ureteroscopy, glidewire use, previous ureteric stent placement, and difficult ureteric stent insertion were independently associated with increased operative time (p<0.05).

CONCLUSIONS

Fluoroscopy and operative times are not significantly influenced by who controls fluoroscopy during urologic procedures. Patients undergoing URS with laser lithotripsy have decreased fluoroscopy and operative times with RT-controlled fluoroscopy. Patients undergoing URS only have decreased fluoroscopy times with surgeon-controlled fluoroscopy.