title: Fluoroless ureteroscopy: zero-dose fluoroscopy during ureteroscopic treatment of urinary-tract calculi.
abstract: OBJECTIVE
  Fluoroscopy usage during endoscopic procedures exposes the patient and operating room staff to ionizing radiation. Pooled mean fluoroscopy usage time during ureteroscopy reported from recent literature is 144 seconds per case. The purpose of this study was to evaluate radiation exposure using a minimal-use fluoroscopy protocol during ureteroscopic treatment of urinary-tract calculi and determine patient and perioperative factors associated with increased fluoroscopy time.
  
  
  METHODS
  A protocol was developed to access the ureter with the ureteroscope without fluoroscopy usage, and minimize radiation utilization during each portion of the case. Over a 16-month period, fluoroscopy usage and radiation dose for all cases involving retrograde ureteroscopy for a single surgeon were prospectively recorded. A chart review was performed on patient factors and intraoperative events.
  
  
  RESULTS
  In 162 consecutive ureteroscopic procedures for nephrolithiasis, there were 156 renal units with fluoroscopic usage data, of which total mean and median fluoroscopy time, including stent placement, was 3.3 and 2.0 seconds (0-35 seconds), respectively. Excluding fluoroscopy usage to confirm ureteral stent placement, 75% of all cases did not require any fluoroscopy time (fluoroless), and 85% required 2 seconds or less. Of the 98 renal units with radiation dosage data, the total mean and median radiation dose measured as air kerma was estimated at 1.1 and 0.6 mGy (0.0-17.5 mGy), respectively. Reasons for utilization of total fluoroscopy time more than 5 seconds included stone impaction, ureteral tortuosity or narrowing, collecting system aberrant anatomy, and difficult ureteral stent placement.
  
  
  CONCLUSIONS
  The reduced fluoroscopy protocol resulted in minimal fluoroscopy time and radiation exposure, significantly lower than reported in the literature. Fluoroless ureteroscopy is safe and feasible in the majority of ureteroscopic cases and lessens exposure to patients and staff.
authors.affiliation: Department of Urology, University of Washington School of Medicine, Seattle, WA 98195, USA.
authors.forename: Ryan S
authors.initials: RS
authors.lastname: Hsi
authors.forename: Jonathan D
authors.initials: JD
authors.lastname: Harper
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004307:Dose-Response Relationship, Radiation; D005260:Female; D005471:Fluoroscopy / Q000379:methods*; D006801:Humans; D008297:Male; D008875:Middle Aged; D016896:Treatment Outcome; D014514:Ureteral Calculi / Q000000981:diagnostic imaging* / Q000628:therapy*; D018666:Ureteroscopy / Q000379:methods*; D055815:Young Adult