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Sener TE, Tanidir Y, Ketenci S, Kutukoglu U, Dorucu D, Cayir H, Pietropaolo A, Emiliani E, Somani B. Radiation exposure during different percutaneous renal puncture techniques: A YAU endourology & urolithiasis study. Investig Clin Urol 2023; 64:474-479. [PMID: 37668203 PMCID: PMC10482668 DOI: 10.4111/icu.20220395] [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: 12/11/2022] [Revised: 03/05/2023] [Accepted: 06/07/2023] [Indexed: 09/06/2023] Open
Abstract
PURPOSE Radiation exposure is affected by C-arm fluoroscopy device positioning during percutaneous renal puncture. Our aim was to compare the exposure of surgeon's lens, hand and chest with a fluoroscopy protocol replicated in different C-arm positions. MATERIALS AND METHODS A standardized fluoroscopy protocol was created using water-equivalent solid phantoms to replicate a surgeon and patient. 111 mGy radiation (360 s) was applied in standard fluoroscopy mode (91 kVp, 2.7 mA/mAs). Dosimeters were placed on lens, chest and hand of surgeon and patient phantom models. 7 different C-arm positions were created: 0°, mediolateral (ML) +90°, ML -90°, ML +30°, ML -15°, craniocaudal (CC) +30°, CC +15°. Measurements were evaluated separately for different positions. RESULTS The highest radiation exposure was measured on patient dosimeter (2.97 mSv). The highest exposure on surgeon was recorded on finger dosimeter in all C-arm positions; highest dose was recorded in ML +90° position (2.88 mSv). In finger dosimeters, lowest exposure was recorded in 0° position (0.51 mSv). The lowest exposure of all positions was measured in chest dosimeter in ML -90° position (0.24 mSv). CONCLUSIONS In positions where X-ray generator of the C-arm was facing towards the surgeon, radiation exposure measured in all dosimeters was higher compared to positions where the generator was facing away. The hand radiation exposure in all positions was higher than chest and lens. Special care must be taken to avoid facing the X-ray generator tube and hands should be as well-protected as chest and eyes with special protective gear.
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Affiliation(s)
- Tarik Emre Sener
- Department of Urology, Marmara University, School of Medicine, Istanbul, Türkiye
- Young Academic Urologists, Endourology and Urolithiasis Working Party, European Association of Urology, Arnhem, Netherlands.
| | - Yiloren Tanidir
- Department of Urology, Marmara University, School of Medicine, Istanbul, Türkiye
| | - Serap Ketenci
- Department of Radiation Oncology, Unit of Radiation Health, Marmara University Pendik Training and Research Hospital, Istanbul, Türkiye
| | - Umut Kutukoglu
- Department of Urology, Marmara University, School of Medicine, Istanbul, Türkiye
| | - Dogancan Dorucu
- Department of Urology, Marmara University, School of Medicine, Istanbul, Türkiye
| | - Huseyin Cayir
- Department of Radiology, Unit of Radiation Health, Marmara University Pendik Training and Research Hospital, Istanbul, Türkiye
| | - Amelia Pietropaolo
- Young Academic Urologists, Endourology and Urolithiasis Working Party, European Association of Urology, Arnhem, Netherlands
- Department of Urology, NHS Foundation Trust, Southampton University Hospital, Southampton, UK
| | - Esteban Emiliani
- Young Academic Urologists, Endourology and Urolithiasis Working Party, European Association of Urology, Arnhem, Netherlands
- Department of Urology, Fundación Puigvert. Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Bhaskar Somani
- Department of Urology, NHS Foundation Trust, Southampton University Hospital, Southampton, UK
- European Association of Urology Section of Uro-Technology, Arnhem, Netherlands
- European Association of Urology Section of Urolithiasis (EULIS), Arnhem, Netherlands
- European School of Urology (ESU), Arnhem, Netherlands
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Birowo P, Rustandi R, Risky Raharja PA, Putra HW, Rasyid N, Atmoko W. The learning curve for a single surgeon using ultrasonography to guide supine percutaneous nephrolithotomy with an alken metal telescopic dilator. Heliyon 2022; 8:e12524. [PMID: 36590495 PMCID: PMC9801132 DOI: 10.1016/j.heliyon.2022.e12524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 10/04/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022] Open
Abstract
Ultrasound (US) has three advantages over fluoroscopy for guiding percutaneous nephrolithotomy (PNCL): it provides an assessment of adjacent structures and real-time puncture adjustment, and is radiation free. This study aimed to define the number of procedures that should be performed to achieve competence in US-guided PCNL using an Alken metal telescopic dilator. A non-randomised retrospective study with consecutive sampling was used for the study design. A total of 50 patients above 18 years of age with the largest diameter of renal stone ≥20 mm were included. They were divided into five groups based on timing of the surgery to evaluate and visualise improvements based on primary outcomes within the groups. Line charts were used, and statistical analysis was performed to evaluate the learning curve. Most of the base characteristics between the groups were similar. Tract dilatation time decreased significantly after 20 PCNLs were performed (p < 0.001). Stone-free status markedly increased after 20 PCNLs were performed (p < 0.001). Postoperative fever (10%) and need for blood transfusion (26%) were the only complications. Basic competency was achievable after 20 PCNL procedures were performed, and further improvements in outcomes were achieved after 40 PCNLs with an acceptable rate of non-severe complications.
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Tzelves L, Juliebø-Jones P, Manolitsis I, Bellos T, Mykoniatis I, Berdempes M, Markopoulos T, Lardas M, Zeeshan Hameed BM, Aggelopoulos P, Pietropaolo A, Somani B, Varkarakis I, Skolarikos A. Radiation protection measures during endourological therapies. Asian J Urol 2022. [PMID: 37538154 PMCID: PMC10394289 DOI: 10.1016/j.ajur.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
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.
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Zampini AM, Bamberger JN, Gupta KR, Gallante B, Atallah W, Gupta M. FACTORS AFFECTING PATIENT RADIATION EXPOSURE DURING PRONE AND SUPINE PERCUTANEOUS NEPHROLITHOTOMY. J Endourol 2021; 35:1448-1453. [PMID: 33847176 DOI: 10.1089/end.2020.0870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Purpose Radiation exposure from fluoroscopy poses risks to patients and surgeons. Percutaneous Nephrolithotomy (PCNL) has traditionally required fluoroscopy, however the use of ultrasound (US) has decreased radiation exposure. US-guidance in supine PCNL may further reduce radiation exposure. In this study we investigate patient and operative factors affecting fluoroscopy time (s), total radiation dose (mGy) and effective radiation dose (ERD) (mSv) in patients undergoing US-guided supine or prone PCNL. Methods: We performed a retrospective study of patients undergoing US-guided PCNL in prone position and supine position. Patients with multiple access tracts, pre-existing renal access or fluoroscopic renal access were excluded. Patient demographic, radiologic and operative data were collected, and compared between the two groups. Results: 99 patients were included: 45 prone (P-PCNL) and 54 supine (S-PCNL). There were no significant demographic differences between the two groups. Operative time, access location, tract length and total radiation dose (mGy) also did not differ. S-PCNL was associated with lower ERD (2.92mSv ± 0.32 vs 5.3mSv ± 0.7, p=0.0014) despite increased fluoroscopy time (86.32s ± 7.7 vs. 51.00s ± 5.1, p=0.004), and was more likely a mini-PCNL (35.2‰ vs 15.9‰, p=0.032). In multivariate analysis, supine PCNL remained associated with reduced ERD compared to prone (p=0.002), whereas BMI (p<0.001) and staghorn calculi (p<0.001) were independently associated with increased ERD.
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Affiliation(s)
- Anna M Zampini
- Icahn School of Medicine at Mount Sinai, 5925, Department of Urology, New York, New York, United States.,Cleveland Clinic, 2569, Glickman Urological and Kidney Institute, Cleveland, Ohio, United States;
| | - Jacob N Bamberger
- Icahn School of Medicine at Mount Sinai, 5925, Department of Urology, 425 W 59th St, Suite 4F, New York, New York, United States, 10029-6574;
| | - Kasmira R Gupta
- Northwestern University, 3270, No, Evanston, Illinois, United States;
| | - Blair Gallante
- Icahn School of Medicine at Mount Sinai, 5925, Department of Urology, 425 W. 59th Street, Suite 9F, New York, New York, United States, 10019;
| | - William Atallah
- Icahn School of Medicine at Mount Sinai, 5925, Department of Urology, New York, New York, United States;
| | - Mantu Gupta
- Icahn School of Medicine at Mount Sinai, 5925, Department of Urology, New York, New York, United States;
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Keller EX, DE Coninck V, Proietti S, Talso M, Emiliani E, Ploumidis A, Mantica G, Somani B, Traxer O, Scarpa RM, Esperto F. Prone versus supine percutaneous nephrolithotomy: a systematic review and meta-analysis of current literature. Minerva Urol Nephrol 2020; 73:50-58. [PMID: 33016031 DOI: 10.23736/s2724-6051.20.03960-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Percutaneous nephrolithotomy (PNL) can be performed either in prone or supine position. This study aimed at gathering together randomized controlled trials (RCTs) comparing efficacy and safety between prone and supine PNL. EVIDENCE ACQUISITION Systematic review of literature was conducted using the Scopus, Medline and Web of Science databases. Study selection, data extraction and quality assessment were independently assessed by two authors. Meta-analysis was performed with Review Manager 5.3. Sensitivity analyses were performed to exclude studies with high risk of bias. EVIDENCE SYNTHESIS Pooled data from 12 studies including 1290 patients were available for analysis. Only one study was found to have overall low risk of bias. Significantly shorter operative time was found in favor of supine PNL (mean difference 13 minutes, 95% confidence interval [CI]: 3.4-22.7; P<0.01). Stone-free rate (SFR)≥14 days after surgery was significantly higher in prone PNL (odds ratio [OR]=2.15, 95% CI: 1.07-4.34; P=0.03). Significantly higher fever rate was found in prone PNL (OR=1.60, 95% CI: 1.03-2.47; P=0.04). Overall SFR, hospital stay length, complications rate, transfusions rate and blood loss, as well as non-lower calyx puncture rate, puncture attempts and tubeless intervention rate did not differ between prone and supine PNL (P>0.05). CONCLUSIONS Efficacy of PNL seems balanced between prone and supine position, with comparable overall SFR and shorter operative time in favor of supine PNL. Safety of PNL appears in favor of supine PNL, with lower fever rate. Because of study heterogeneity and possible risks of outcome bias, results from this study should be interpreted with caution. Altogether, both prone and supine PNL account for appropriate therapy options.
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Affiliation(s)
- Etienne X Keller
- Department of Urology, University Hospital Zurich, University of Zurich, Zurich, Switzerland -
| | | | - Silvia Proietti
- Department of Urology, Ville Turro Division, European Training Center for Endourology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Michele Talso
- Department of Urology, Hospital of Vimercate, Vimercate, Monza-Brianza, Italy
| | - Esteban Emiliani
- Department of Urology, Fundació Puigvert, Autonomous University of Barcelona, Barcelona, Spain
| | | | - Guglielmo Mantica
- Department of Urology, IRCCS San Martino University Hospital, University of Genoa, Genoa, Italy
| | - Bhaskar Somani
- University Hospital Southampton NHS Trust, University of Southampton, Southampton, UK
| | - Olivier Traxer
- Department of Urology, Sorbonne University, GRC N. 20 Lithiase Urinaire, Hospital Tenon AP-HP, Paris, France
| | - Roberto M Scarpa
- Department of Urology, Campus Bio-Medico University, Rome, Italy
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Emiliani E, Kanashiro A, Chi T, Pérez-Fentes DA, Manzo BO, Angerri O, Somani BK. Fluoroless Endourological Surgery for Stone Disease: a Review of the Literature—Tips and Tricks. Curr Urol Rep 2020; 21:27. [DOI: 10.1007/s11934-020-00979-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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