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Radiation Exposure During Percutaneous Nephrolithotomy: A Comparative Analysis of Single Specialty versus Multi-Specialty Procedures
Sanchita Bose, MD1, Priyanka Bearelly, MD1, Jerilyn M. Latini, MD2, Ruslan Korets, MD2.
1Boston Medical Center, Boston, MA, USA, 2Veterans Affairs Boston Healthcare System, Harvard Medical School, Boston, MA, USA.
Patient and personnel ionizing radiation doses during percutaneous nephrolithotomy (PCNL) can be significant, especially while obtaining percutaneous renal access. In the US the majority of renal access for PCNL is obtained by interventional radiologists with theoretical decrease in operative times and radiation exposure for the patient and operating room staff, especially if access is obtained prior to PCNL in a dedicated interventional radiology (IR) suite. The aim of this study was to assess if staging renal access may lead to shorter operative times and lower radiation dose during PCNL.
We performed a retrospective analysis of an endourology database of 66 adults undergoing PCNL between August 2013 to March 2017 at a single tertiary institution. Of these, 54 had complete information including fluoroscopy and radiation dosimetry times. Fluoroscopy time included the time for percutaneous access (IR suite or operating room), tract dilation, PCNL, and placement of postoperative drains. Patients were stratified into two groups: Group 1 (n=30) had single stage PCNL with renal access obtained in the operating room using fluoroscopic guidance by the urologist; Group 2 (n=24) had renal access obtained in the IR suite by the radiologist 1 day before or just prior to PCNL. Decision regarding timing/method of access was at the discretion of the operating surgeon. Data was collected regarding patient demographics, stone complexity, operative time, estimated blood loss (EBL), IR access time, and radiation exposure. The Mann-Whitney U and chi-square tests were used for statistical analysis.
The patients in Group 2 were older (65.9 vs 61.8 yrs, p=0.0476), but the two groups were similar in terms of existing co-morbidities, using American Association of Anesthesiologist (ASA) classification. Guy’s stone score, a metric of stone complexity, was comparable between the two groups (p=0.118). There was no difference in EBL between the two groups (p=0.34). Group 2 had longer mean total procedure times at 216.2 minutes than Group 1 at 133.2 minutes (p<0.001). However, when comparing OR times not including the IR access time, there was no difference in operative length (133.2 vs 124.9 minutes, p=0.52). For Group 1, total average fluoroscopy time was 224.1 seconds and total radiation dose was 4.3 mSv. Group 2 had a total average fluoroscopy time of 997.7 seconds and total average radiation dose of 7.7 mSv. When controlling for Guy’s stone score, total fluoroscopy time and total radiation dose were both significantly higher for the group with access obtained in the IR suite (p<0.001).
In the setting of multi-specialty involvement in PCNL, we found a significant increase in total radiation dose and fluoroscopy time for the patient, without identifying a significant reduction in operative room times. Although benefits exist in obtaining percutaneous renal access ahead of the operation and the decision to obtain access by IR versus the operating urologist may be surgeon- or institution-dependent, this study highlights important differences in operative length and radiation exposure between the two groups that warrant further investigation.
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