In January of 1896, the New York Times wrote: “Men of science in this city are awaiting with the utmost impatience the arrival of English technical journals which will give them the full particulars of Professor Roentgen’s discovery of a method of photographing opaque bodies."
Wilhem Roentgen, a German physicist, had just captured the first ever x-ray of his wife’s hand and of a ring on her finger, consequently unraveling one of the greatest discoveries in the history of science. Over a century later, medical imaging has made dramatic advances in the diagnosis and treatment of a variety of diseases. Unfortunately many of these advances have been accompanied by an increase in radiation exposure. Radiation exposure from medical imaging currently contributes to greater than half of the effective radiation dose exposure in the US population. With advances in imaging technology, there has also been developing awareness into the potential harmful effects of radiation exposure. The FDA has recently issued a white paper calling for a reduction in radiation exposure due to CT, fluoroscopy, and nuclear medicine. In an attempt to comply with this mandate, we have developed a technique for performing ureteroscopy without fluoroscopy.
Using only tactile feedback, direct visualization, and external visual cues, the surgeon is able to perform each step of this procedure safely without employing any image guidance. In this study we also demonstrated that patients treated with fluoroless ureteroscopy have equivalent outcomes compared to patients that undergo conventional fluoroscopic-guided ureteroscopy. Both groups showed similar stone free rates, operative times, complication rates, and number of repeat procedures.
This technique is a departure from what has always been considered an image-guided procedure. Subsequently, it is not surprising that our initial presentations of this information at scientific meetings generated significant discussion. Some surgeons were delighted to have a technique available that could reduce radiation exposure to the patients, the staff and themselves. In contrast, other surgeons felt that the technique represented such a significant departure from conventional techniques that it was cavalier and potentially risky.
The adoption of reduced fluoroscopy techniques does not have to be abrupt or stressful for the surgeon. The skills necessary for this procedure are easily mastered by residents and fellows graduating from our institution. In addition, some outside physicians who have observed two or three fluoroless ureteroscopies have successfully added this technique to their surgical armamentarium.
A very simple way to reduce radiation exposure to patients is by using a slow gradual adoption of a few simple modifications to the conventional technique. In our own institution, we began by implementing a simple radiation reduction protocol for ureteroscopy.(1) The protocol included a detailed review of prior imaging, use of single pulse fluoroscopy, use of visual and tactile cues for guidewire/stent placement, and direct visualization of stone location and the stent bladder curl. These simple measures led to an 82% reduction in fluoroscopy time compared to cases performed prior to implementation of this protocol. The next step was to develop a technique to place ureteral stents without fluoroscopy. This technique was performed and validated in uncomplicated ureteroscopic lithotripsy cases and used tactile feedback, anatomic markers, and external visual cues to facilitate accurate stent placement.(2) In this previous paper we showed that stent placement using the fluoroless technique was actually better than stent placement using fluoroscopy because it was more precise and the ureteral stent was inserted based on precise ureteral measurements. The wire used to insert the stent is the safety wire routinely used during ureteroscopy and has been endoscopically confirmed to be in the kidney prior to removal of the ureteroscope. The stent will follow the wire into the kidney. To date we have had no ureteral perforation or injury resulting from poor stent placement. As we became more experienced with reduced fluoroscopy techniques we slowly transitioned to less and less fluoroscopy until we realized that in many cases no fluoroscopy was required at all. Avoidance of fluoroscopy allows the surgeon to avoid the heavy lead gown thereby avoiding musculoskeletal problems and the “interventionalist’s disc disease”.(3) The use of this technique also simplified ureteroscopy in children and in pregnant patients.
Certainly, the experience that our institution has gained over the years with radiation reduction protocols has led to a much easier transition and better level of comfort with this technique. In some complicated stone patients fluoroscopy may aid in locating stone fragments, guidewire and ureteroscope placement and for these patients we recommend the use of a low-dose technique. As this procedure is being adopted, surgeons should always do what is safe in their hands. If there is any question regarding the position of guidewires, scopes, or stents, fluoroscopy should be readily employed. However, surgeons should not hesitate to employ these low-dose techniques out of fear since they are easily and safely adopted.
Today, we are using a fluoroless technique in about half of our ureteroscopies, and even in those complicated cases requiring fluoroscopy our mean fluoroscopy time is 6.1 seconds for the past 100 patients. Thomas Edison’s invention of fluoroscopy remains a major advance in modern medicine, but as the risks of excessive radiation exposure become more well known, we feel that techniques like those outlined in this paper can allow us to more appropriately utilize this amazing invention in accordance with the ALARA principles.
1. Greene DJ, Tenggadjaja CF, Bowman RJ, Agarwal G, Ebrahimi KY, Baldwin DD. Comparison of a reduced radiation fluoroscopy protocol to conventional fluoroscopy during uncomplicated ureteroscopy. Urology. 2011;78(2):286-90.
2. Brisbane W, Smith D, Schlaifer A, Anderson K, Baldwin DD. Fluoro-less ureteral stent placement following uncomplicated ureteroscopic stone removal: a feasibility study. Urology. 2012;80(4):766-70.
3. Ross AM, Segal J, Borenstein D, Jenkins E, Cho S. Prevalence of spinal disc disease among interventional cardiologists. The American journal of cardiology. 1997;79(1):68-70.
Muhannad Alsyouf, MD, Ruth Belay, BS, D. Duane Baldwin, MD
Department of Urology, Loma Linda University School of Medicine, Loma Linda, California.