Ocular radiation exposure in modern urological practice

Radiation exposure of urologists during endourological procedures: a systematic review

INTRODUCTION

Ionizing radiation is used daily during endourological procedures. Despite the dangers of both deterministic and stochastic effects of radiation, there is a lack of knowledge and awareness among urologists. This study reviewed the literature to identify the radiation exposure (RE) of urologists during endourological procedures.

METHODS

A literature search of the Medline, Web of Science, and Google Scholar databases was conducted to collect articles related to the radiation dose to urologists during endourological procedures. A total of 1966 articles were screened. 21 publications met the inclusion criteria using the PRIMA standards.

RESULTS

Twenty-one studies were included, of which 14 were prospective. There was a large variation in the mean RE to the urologist between studies. PCNL had the highest RE to the urologist, especially in the prone position. RE to the eyes and hands was highest in prone PCNL, compared to supine PCNL. Wearing a thyroid shield and lead apron resulted in a reduction of RE ranging between 94.1 and 100%. Educational courses about the possible dangers of radiation decreased RE and increased awareness among endourologists.

CONCLUSIONS

This is the first systematic review in the literature analyzing RE to urologists over a time period of more than four decades. Wearing protective garments such as lead glasses, a thyroid shield, and a lead apron are essential to protect the urologist from radiation. Educational courses on radiation should be encouraged to further reduce RE and increase awareness on the harmful effects of radiation, as the awareness of endourologists is currently very low.

Trends in the use of radiation protection and radiation exposure of European endourologists: a prospective trial from the EULIS-YAU Endourology Group

INTRODUCTION

Due to the radiation exposure for the urology staff during endourology, our aim was to evaluate the trends of radiation protection in the operation room by endourologists from European centers and to estimate their annual radiation.

METHODS

We conducted a multicenter study involving experienced endourologists from different European centers to evaluate whether the protection and threshold doses recommended by the International Commission on Radiation Protection (ICRP) were being followed. A 36-question survey was completed on the use of fluoroscopy and radiation protection. Annual prospective data from chest, extremities, and eye dosimeters were collected during a 4-year period (2017-2020).

RESULTS

Ten endourologists participated. Most surgeons use lead aprons and thyroid shield (9/10 and 10/10), while leaded gloves and caps are rarely used (2/10 both). Six out of ten surgeons wear leaded glasses. There is widespread use of personal chest dosimeters under the apron (9/10), and only 5/10 use a wrist or ring dosimeter and 4 use an eye dosimeter. Two endourologists use the ALARA protocol. The use of ultrasound and fluoroscopy during PCNL puncture was reported by 8 surgeons. The mean number of PCNL and URS per year was 30.9 (SD 19.9) and 147 (SD 151.9). The mean chest radiation was 1.35 mSv per year and 0.007 mSv per procedure. Mean radiation exposure per year in the eyes and extremities was 1.63 and 11.5 mSv.

CONCLUSIONS

Endourologists did not exceed the threshold doses for radiation exposure to the chest, extremities and lens. Furthermore, the ALARA protocol manages to reduce radiation exposure.

Ocular radiation exposure is negligible in normal volume endourological practice

INTRODUCTION

The annual dose limit for radiation exposure to the eye has been reduced recently; the eye is widely recognised as one of the most radiosensitive tissues in the body. There is minimal good quality research as to the radiation dose that the eye receives during endourological surgery and this study aimed to address this.

METHODS

A prospective study was performed over an 8-month period at a single large teaching hospital in the UK. Three index procedures were included: ureteric stent insertion, ureteroscopy (URS) and percutaneous nephrolithotomy (PCNL). Surgeons wore a dosimeter on the glabella with fluoroscopy time (FT) and dose area product (DAP) recorded for each case.

RESULTS

A total of 404 procedures were included (247 URSs, 150 ureteric stent insertions and 7 PCNLs). Dosimeters were worn by ten surgeons. Mean FTs (URS 20.56s; ureteric stent 18.96s; PCNL 360.67s) and mean DAP (URS 100.82cGy/m2, ureteric stent 119.82cGy/m2 and PCNL 1121.62cGy/m2) were identified with significant intersurgeon variability. No surgeon had a total dosimeter dose >0.00mSv.

CONCLUSIONS

The International Commission on Radiological Protection recently reduced the yearly eye dose limit from 150 to 20mSv. Cataractogenesis is no longer considered a typical deterministic effect, with a threshold level below which no effect occurs. Even in higher volume centres, these annual limits are unlikely to be reached. Lead glasses may be considered for surgeons and radiologists with the highest exposure but, for the majority, ocular radiation exposure is negligible.

[Radiation-induced cataract-an occult risk for urologists]

BACKGROUND

Radiation-induced cataracts represent a relevant risk to people occupationally exposed to radiation. The annual limit dose for the eye lens was reduced to 20 mSv per year by German legislation (radiation protect law StrlSchG 2017; 2013/59/Euratom) based on recommendation of International Commission on Radiation Protection (2011 ICRP) to avoid radiation-induced cataracts.

OBJECTIVES

Is there a risk of exceeding the annual limit dose for the eye lens in routine urological practice without special radiation protection for the head?

METHODS

As part of a prospective, monocentric dosimetry study, of 542 different urological, fluoroscopically guided interventions, the eye lens dose was determined using a forehead dosimeter (thermo-luminescence dosemeter TLD, Chipstrate) over a period of 5 months.

RESULTS

An average head dose of 0.05 mSv per intervention (max. 0.29 mSv) was found with an average dose area product of 485.33 Gy/cm². Significant influencing factors for a higher dose were a higher patient body mass index (BMI), a longer operation time, and a higher dose area product. The level of experience of the surgeon showed no significant influence.

DISCUSSION

With 400 procedures per year or an average of 2 procedures per working day, the critical annual limit value for the eye lenses or for the risk of radiation-induced cataract would be exceeded without special protective measures.

CONCLUSION

Consistently effective radiation protection of the eye lens is essential for daily work in uroradiological interventions. This may require further technical developments.

Safety During Ureteroscopy: Radiation, Eyes, and Ergonomics

It is known that urologic surgeons are at risk of work-place injury due to the physical requirements of operating and exposure to hazards. These hazards include radiation, exposure to body fluids, use of laser energy, and orthopedic injury due to the physical nature of operating. The risks that these hazards present can be mitigated by implementing several evidence-based safety measures. The methods to protect against radiation exposure include keeping radiation usage in the operating room as low as reasonably achievable, donning lead aprons, and wearing protective glasses. Additionally, protective glasses decrease the risk of eye injury from laser injury and exposure to body fluids. Finally, practicing sound surgical ergonomics is essential to minimize the risk of orthopedic injury and promote career longevity. The interventions discussed herein are simple and easy to implement in one's daily practice of urology.

Effect of Structured Educational Program on Practices of Radiation Safety Measures Among Health Care Providers in Urology Operation Theater

Introduction Endourologists are at increased risk of exposure to radiations. Many studies are available that have studied awareness in doctors in general, but very few studies available regarding any intervention to improve the knowledge of radiation safety measures. We have made an attempt to study the role of an educational intervention to improve the knowledge of our Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) urology operation theater health care providers (HCPs). Materials and methods Our study was an Interventional study (prospective clinical trial), conducted in the Department of Urology, JIPMER from January 2017 to March 2018. All, that is, 40 operation theater HCPs were given a questionnaire as baseline. The baseline response was compared to the response after the Structured Education Program (SEP) by using the same questionnaire. The knowledge of participants before SEP was compared with the knowledge after SEP using the chi-square test. All statistical analysis was carried out at a 5% level of significance and p-value < 0.05 was considered as significant. Result In our study after SEP, participants use of lead apron has increased from 72.5% to 92.5%, indicating improvement. There is an increase in the use of thyroid shield from 22.5% to 95%. In our study after SEP, knowledge about background radiations improved in participants from 25% to 87.5%. Knowledge about Radiation dose of chest X-ray improved from 22.5% to 52.5%. Knowledge about ALARA (As Low As Reasonably Achievable) improved from 47.5% to 95% after SEP. Knowledge that MRI and USG do not have ionizing radiation improved from 62.5% to 97.5%, and from 75% to 92.5% for MRI and USG, respectively, after SEP. Regarding organ sensitivity, 100% HCPs had given correct answers after SEP as compared to 80 before SEP. Conclusion Our study shows that SEP at regular intervals has made significant improvements in daily practice in operation theater HCPs. SEP has increased the use of radiation protective gears among HCP. Hence we recommend SEP at regular intervals for urology operation theater HCPs for a healthy and safe working environment.

Application of ultrasound during electrode implantation for sacral neuromodulation in patients with neurogenic bladder secondary to spinal cord disease: a retrospective study

PURPOSE

To compare the use of intraoperative ultrasound with X-ray fluoroscopy during sacral neuromodulation lead electrode placement in patients with neurogenic bladder secondary to spinal cord disease.

METHODS

We reviewed the medical records of 52 patients who underwent sacral neuromodulation (SNM) lead electrode implantation under fluoroscopy or ultrasound guidance from July 2016 to July 2019. The operating time, number of electrode contacts with stimulus responses, minimum voltage that causes a stimulus response, and rate of standard lead electrode placement were used to assess the differences between the two methods. All patients were evaluated by recording bladder diaries, postvoid residual volumes before and during the testing period. Permanent SNM implantation is acceptable if symptoms improve by at least 50%.

RESULTS

The operating time decreased from 87.1 ± 25.19 min in the X-ray group to 68.2 ± 25.20 min (p < 0.05) in the ultrasound group. The number of electrode contacts with stimulus responses, rate of standard lead electrode placement, and implantable pulse generator (IPG) placement rate were not significantly different between the two groups (p > 0.05). There was no radiation exposure during the operation in the ultrasound group. No incisional infections, hematomas, or other critical complications were reported in either groups.

CONCLUSION

Ultrasound can be applied to safely place lead electrode for sacral neuromodulation and leads to no radiation exposure to the patient, surgeon, and operating room staff and a shortened operating time while maintaining the same efficacy as X-ray.

[Effect of X-ray protective visors on the eye lens dose during ureteroscopy]

BACKGROUND AND OBJECTIVES

Eye lens radiation exposure during fluoroscopy-guided interventional procedures may result in occupational radiation-induced cataracts. We evaluated the eye lens radiation doses and the protective effect of X‑ray protective visors during ureteroscopic procedures.

MATERIALS AND METHODS

Eye lens doses were measured in front of and behind X‑ray protective visors using eye lens dosemeters during ureteroscopic procedures done by 4 different endourologic surgeons within a 12-week period. Background radiation dose, simultaneously measured with transport dosemeters, was subtracted. Measured eye lens doses below the detection limit of the eye lens dosemeters were adjusted to the detection limit of 0.028 mSv. Correlating the eye lens doses (ELD) to the dose-area-product (DAP) an ELD/DAP ratio was calculated. Applying this ELD/DAP ratio the potential reduction of the eye lens radiation dose was retrospectively calculated for all ureteroscopic procedures done within one year.

RESULTS

Within the 12-week period 76 ureteroscopies were done by the 4 endourologic surgeons. The accumulated eye lens radiation dose was 0.796 mSv in front of the X‑ray protective visors, and 0.338 mSv behind the X‑ray protective visors. Thus, the eye lens radiation exposure was reduced to at least 42% by using X‑ray protective visors. Considering the 215 documented ureteroscopies in our clinic in the year before starting the study, occupational radiation exposure to the eye lens would have been reduced by X‑ray protective visors from 4.090 to 1.737 mSv.

CONCLUSION

X‑ray protective visors can effectively reduce the radiation exposure to the eye lens during fluoroscopy-guided endourologic procedures and should be used especially by high-volume endourologic surgeons.

Assessment of Radiation Safety Knowledge Among Urology Residents in the United States

Introduction: Urologists are increasingly exposed to fluoroscopy, which can cause cellular damage. Appropriate awareness and safety precautions concerning fluoroscopy are necessary and likely should be a focus during training. We sought to assess radiation safety knowledge among Urology residents in the United States. Methods: A 19-question survey was constructed to assess radiation safety training, knowledge, behavior, and attitudes. The survey was sent through REDCap™ (Research Electronic Data Capture) to all Urology program directors and coordinators in the United States with a request to distribute to their residents. The survey was closed after 3 weeks. Results: One hundred thirty-six urology trainees responded during the study period. Thirteen percent learned fluoroscopic radiation safety formally, 46% informally, 35% both informally and formally, and 6% no education. Forty-six percent reported radiation safety being part of their curriculum. When asked about directional X-ray travel and exposure, only 54% answered correctly. Regarding conditions related to radiation exposure, 94% believe infertility is potentially related, 83% cataracts, 93% leukemia and lymphoma, 57% central nervous system tumors, 77% birth defects, and 4% diabetes. Regarding protection, 9% wear lead-lined glasses, 30% dosimeters, 99% thyroid shields, 0% lead gloves, 97% lead apron, 26% lead shield, and 0% nothing. Regarding fluoroscopy machine settings, 7% knew the machine used was set to continuous, 73% pulse, and 21% were unsure. Sixty-six percent had awareness of the directional travel of the machine routinely used. Regarding safety techniques, 99% knew decreasing time and 100% knew wearing protective materials decrease exposure. However, when asked about distance and exposure, 55% answered incorrectly. Most respondents believe radiation safety is important (89%) and desire more formal education (64%). Conclusions: Trainees lack sufficient knowledge in several key areas regarding radiation safety. Formal education may be considered during training and is desired by trainees. This education is likely needed to ensure trainees learn methods to keep them safe during their career.

Current status of radiological protection in endourological procedures in Spain

OBJECTIVE

To discover the extent of training in radiological protection (RP) of Spanish urologists who perform endourological procedures, and to analyse the use of on ionising radiation control and protection measures.

MATERIAL AND METHODS

A survey conducted through the Plataforma de Investigación de Estudios Multicéntricos (PIEM) (Multicentre Study Research Platform) on the 1,894 associates of the Spanish Association of Urology, between April and October 2015. The questionnaire comprised 21 questions on endourological activity undertaken, RP training, and the use of protective measures, and personal dosimetry. Seventeen percent responded, and 238 surveys were eventually validated for study.

RESULTS

Sixty-three percent of the respondents had received no type of RP training, 25% had first level accreditation, and only 12% second level. Fifty-seven percent, 27%, and 2% of the urologists used flap, wrist and crystalline dosimetry respectively. Use of radiation protection measures was insufficient. Fifty-three percent of the urologists at greatest risk of exposure had had no training in RP, 30% did not use flap dosimetry, and 40% used neither an apron or thyroid collar during the endourological procedures.

CONCLUSIONS

RP training, dosis monitoring, and the use of ionising radiation protective measures are insufficient, even by practitioners most exposed to radiation. It is essential that these serious shortcomings in RP are corrected, at the level of the individual, in urology departments, scientific societies, and the health authorities.

Perceptions and Practice Patterns of Holmium Laser Goggles in Endourological Procedures: An Unnecessary Evil?

PURPOSE

The holmium laser is used increasingly for a wide array of urological procedures. Laser safety goggles are mandatory at many centers for individuals within the nominal hazard zone, as set out by the institution. Recent ex vivo studies suggest standard eye wear may be equally as protective. We sought to evaluate the perceptions and practice patterns of laser safety goggles in urology.

MATERIALS AND METHODS

A 24-question survey was sent out through e-mail to an international e-mail list of ∼2000 urologists that were members of the Endourological Society. Data were collected anonymously using Survey Monkey.

RESULTS

A total of 264 (14%) urologists completed the survey. Thirty-four percent worked in the community, whereas 63% worked at an academic institution. Ninety-seven percent routinely used the holmium laser. The most common uses were lithotripsy (99%), tissue incision (71%), tumor ablation (58%), and prostate ablation (26%). Formal laser training and institutional laser safety policies were reported in 76% and 64%, respectively. Forty percent of respondents routinely wore laser safety goggles. Laser adverse events were witnessed by 19%, but there were no eye injuries reported. Seventy percent of surgeons felt that laser safety goggles may impair their vision. When presented with the information that regular eye glasses may be as effective as laser goggles for preventing harm, the majority (86%) would opt for regular eye wear.

CONCLUSIONS

Laser safety eyewear practice patterns vary greatly. Many centers have adopted policies for universal mandatory laser goggles in the operating room. With over two thirds of surgeons suggesting laser goggles impair their vision, and recent literature suggesting regular eye wear is equivalent in preventing laser-associated eye injuries, laser goggle safety policies should be updated to better match the potential hazards inherent to the device.

Risk of radiation-induced lens opacities among surgeons and interventional medical staff

The main effect of ionizing radiation on the eyes is the onset of posterior cortical and subcapsular cataracts. Recent studies have raised questions about the mechanism of ocular damage and the threshold dose for the onset of such effects. Currently, operators may be exposed to ionizing radiation during surgical procedures. It has been estimated that urologists can be exposed to an annual dose close to or above 20 mSv/year. The aim of our study was to evaluate the frequency of cataracts in a group of professional radiological operators to verify their possible association with the radiation dose to the crystalline lens and the tasks performed. The records of 73 health workers exposed to ionizing radiation were reviewed. The average annual dose to the crystalline lens, the number of years of exposure, and the presence of radiation-compatible opacities were assessed for all operators. Lenticular opacities were observed in 16.4% of subjects. The presence of alterations was associated with exposure doses below 10 mSv and > 10 years' experience in fluoroscopically guided procedures. Based on our results, protection of the crystalline lens against exposure to ionizing radiation by means of goggles is recommended. In addition, examination of the lens via slit lamp examination is recommended for all operators involved in interventional procedures with the current levels of radiation exposure.

Compliance With Radiation Protection Practices Among Radiologists

BACKGROUND

Radiologists are at higher risk of adverse health effects due to their occupational radiation exposure; therefore, applying protection techniques is imperative. Studies on radiologists' compliance in this regard are scarce. We aimed to assess compliance with radiation safety practices among radiologists.

METHODS

Questionnaires were distributed to radiologists in tertiary hospitals. The questionnaire was designed to assess compliance in three domains: using personal protective devices, using exposure-reduction techniques during fluoroscopic exposures, and using personal dose-monitoring devices. Descriptive analysis of the compliance was performed.

RESULTS

Sixty-two radiologists were included in the analysis. Use of leaded aprons and thyroid shields was commonplace, whereas only 3.2% ever use leaded eyeglasses. About half of the radiologists always considered reducing the time of exposure and avoided exposure by the primary beam, and the other half did that sometimes. Most of the radiologists (66.1%) always complied with reducing the number of unnecessary exposures, and the rest only complied sometimes. Most of the radiologists (93.5%) always used single personal dose-monitoring devices, most commonly at the neck level over the collar. There was no difference in compliance between different sexes, position descriptions, hospital types, hospital sizes, or years of experience.

CONCLUSION

Future compliance improvement strategies for radiologists should focus on use of thyroid shields and leaded eyeglasses and use of exposure-reduction techniques during fluoroscopic operations.

Risk of Radiation-Induced Cataracts: Investigation of Radiation Exposure to the Eye Lens During Endourologic Procedures

BACKGROUND

Due to new radiobiologic data, the International Commission on Radiological Protection recommends a dose limit of 20 mSv per year to the eye lens. Therefore, the IAEA International Basic Safety Standard and the European council directive 2013/59/EURATOM require a reduction of the annual dose limit from 150 to 20 mSv. Urologists are exposed to an elevated radiation exposure in the head region during fluoroscopic interventions, due to the commonly used overtable X-ray tubes and the rarely used radiation protection for the head. Aim of the study was to analyze real radiation exposure to the eye lens of the urologist during various interventions, during which the patient is in the lithotomy position.

MATERIALS AND METHODS

The partial body doses (forehead and apron collar) of the urologists and surgical staff were measured over a period of 2 months. 95 interventions were performed on Uroskop Omnia Max workplaces (Siemens Healthineers, Erlangen, Germany). Interventions were class-divided in less (stage I) and more complex (stage II) interventions. Two dosimeter-types were applied, well-calibrated electronic personal dosimeter Mk2 and self-calibrated thermoluminescent dosimeter-100H (both Thermo Fisher Scientific, Waltham, MA). The radiation exposure parameters were documented using the dose area product (DAP) and the fluoroscopy time.

RESULTS

The correlation between DAP and the apron dose of the urologist was in average 0.07 μSv per 1 μGym². The more experienced urologists yielded a mean DAP of 166 μGym² for stage I and 415 μGym² for stage II procedures. The interventionist was exposed with 10 μSv in mean outside the lead apron collar. The mean dose value of the eye lenses per intervention was ascertained to 20 μSv (mean DAP: 233 μGym²).

CONCLUSIONS

The study setup allows a differentiated and time-resolved measurement of the radiation exposure, which was found heterogeneous depending on intervention and surgeon. In this setting, ∼1000 interventions can be performed until the annual eye lens dose limit is achieved.

Prospective randomized study evaluating ultrasound versus fluoroscopy guided sacral InterStim® lead placement: A pilot study

OBJECTIVE

To investigate the use of intraoperative ultrasound during stage I InterStim® sacral lead placement.

METHODS

A total of 40 patients were randomly assigned to undergo InterStim® lead placement utilizing fluoroscopy or ultrasound guidance. Patients were blinded for the duration of the study. The surgeon and staff were blinded until after induction of anesthesia. Patients met criteria for refractory overactive bladder, fecal incontinence, or both. The ICIQ-OABqol, OABSS, and FIQL validated questionnaires were used pre- and post-operatively. Primary endpoint was total fluoroscopy time. Secondary endpoints were total radiation exposure and total number of foramen needle skin punctures.

RESULTS

Forty patients were enrolled, twenty in the ultrasound and twenty in the fluoroscopy only arm. Mean age was 60 (SD = 14.4) and mean BMI 32 (SD = 7.2). Twenty-seven patients (67.5%) had urinary symptoms, four (10%) fecal incontinence, and nine (22.5%) had mixed symptoms. Radiation exposure time was reduced by 70.5 s (P = 0.002), radiation exposure was decreased by 42.3 mGy (P = 0.017), and the number of needle skin punctures decreased by 3.6 (P = 0.035) with use of ultrasound. Mean OR time in minutes was 55.5 in ultrasound and 58.2 in fluoroscopy group (P = 0.53). There were no statistically significant differences in questionnaire scores between groups.

CONCLUSION

Ultrasound guided placement of foramen needle during Stage I sacral neuromodulation results in reduction of radiation exposure to the patient, surgeon, and operating room staff. Further studies are necessary to determine the learning curve and efficacy of this technique.

Staff lens doses in interventional urology. A comparison with interventional radiology, cardiology and vascular surgery values

The purpose of this work is to evaluate radiation doses to the lens of urologists during interventional procedures and to compare them with values measured during interventional radiology, cardiology and vascular surgery. The measurements were carried out in a surgical theatre using a mobile C-arm system and electronic occupational dosimeters (worn over the lead apron). Patient and staff dose measurements were collected in a sample of 34 urology interventions (nephrolithotomies). The same dosimetry system was used in other medical specialties for comparison purposes. Median and 3rd quartile values for urology procedures were: patient doses 30 and 40 Gy cm(2); personal dose equivalent Hp(10) over the apron (μSv/procedure): 393 and 848 (for urologists); 21 and 39 (for nurses). Median values of over apron dose per procedure for urologists resulted 18.7 times higher than those measured for radiologists and cardiologists working with proper protection (using ceiling suspended screens) in catheterisation laboratories, and 4.2 times higher than the values measured for vascular surgeons at the same hospital. Comparison with passive dosimeters worn near the eyes suggests that dosimeters worn over the apron could be a reasonable conservative estimate for ocular doses for interventional urology. Authors recommend that at least the main surgeon uses protective eyewear during interventional urology procedures.

Do We Really Need to Wear Proper Eye Protection When Using Holmium:YAG Laser During Endourologic Procedures? Results from an Ex Vivo Animal Model on Pig Eyes

PURPOSE

We sought to evaluate the effect of holmium:yttrium-aluminum-garnet (Ho:YAG) laser exposure on ex vivo pig eyes and to test the protective action of different glasses in preventing eye lesions in case of accident.

MATERIALS AND METHODS

We pointed the tip of a Ho:YAG laser fiber from different distances (0, 3, 5, 8, 10, and 20 cm, respectively) toward the center of the pupil of the pig eye. The Ho:YAG laser was activated for 1 or 5 seconds at three different settings (0.5 J-20 Hz, 1 J-10 Hz, and 2 J-10 Hz, respectively). The experiment was repeated using laser safety glasses and eyeglasses. A total of 78 pig eyes were used. The effects of the Ho:YAG laser on pig eyes were assessed by histopathology. Comparable laser emission experiments were performed on thermal paper at different distances using different pulse energies.

RESULTS

Ho:YAG laser-induced corneal lesions were observed in unprotected eyes, ranging from superficial burning lesions to full-thickness necrotic areas, and were directly related to pulse energy and time of exposure and inversely related to the distance from the eye. When the laser was placed 5 cm or more, no corneal damage was observed regardless of the laser setting and the time of exposure. Similar distance/energy level relationships were observed on thermal paper. No damage was observed to the lens or the retina in any of the Ho-YAG laser-treated eyes or in any of the eyes protected by laser safety and eyeglasses.

CONCLUSIONS

Ho:YAG lasers can cause damage when set to high energy, but only to the cornea, from close distances (0-5 cm) and in the absence of eye protection. Eyeglasses are equally effective in preventing laser damage as laser safety glasses.

[Eye lens radiation exposure during ureteroscopy with and without a face protection shield: Investigations on a phantom model]

BACKGROUND AND OBJECTIVES

Eye lens radiation exposure during radiologically-guided endoscopic procedures may result in radiation-induced cataracts; therefore, we investigated the ocular radiation exposure during ureteroscopy on a phantom model.

MATERIALS AND METHODS

Using an Alderson phantom model and eye lens dosimeters, we measured the ocular radiation exposure depending on the number of X-ray images and on the duration of fluoroscopic imaging. The measurements were done with and without using a face protection shield.

RESULTS

We could demonstrate that a significant ocular radiation exposure can occur, depending on the number of X-ray images and on the duration time of fluoroscopy. Eye lens doses up to 0.025 mSv were recorded even using modern digital X-ray systems. Using face protection shields this ocular radiation exposure can be reduced to a minimum.

CONCLUSION

The International Commission on Radiological Protection (ICRP) recommendations of a mean eye lens dosage of 20 mSv/year may be exceeded during repeated ureteroscopy by a high volume surgeon. Using a face protection shield, the eye lens dose during ureteroscopy could be reduced to a minimum in a phantom model. Further investigations will show whether these results can be transferred to real life ureteroscopic procedures.

Ureteroscopy for treatment of upper urinary tract stones in children: technical considerations

The incidence of pediatric urolithiasis is increasing. While many smaller stones may pass spontaneously, surgical therapy is sometimes warranted. Surgical options include shock wave lithotripsy, ureteroscopy, percutaneous nephrolithotomy, and open surgery. Ureteroscopy represents a minimally invasive approach, and it is increasingly being used to treat pediatric upper tract calculi. Ureteroscopy is performed under anesthesia and fluoroscopic guidance, with basket extraction or lithotripsy of the calculi. Technical considerations include active or passive ureteral dilatation, the use of ureteral access sheaths for larger stone burdens, and post-operative stent placement. The current pediatric literature suggests high success rates (equal to or surpassing shock wave lithotripsy) and low complication rates. However, concerns remain regarding feasibility in patients with variant anatomies and risk due to intra-operative radiation exposure.