Reducing hand radiation during renal access for percutaneous nephrolithotomy: a comparison of radiation reduction techniques

Abstract

Percutaneous nephrolithotomy confers the highest radiation to the urologist's hands compared to other urologic procedures. This study compares radiation exposure to the surgeon's hand and patient's body when utilizing three different techniques for needle insertion during renal access. Simulated percutaneous renal access was performed using a cadaveric patient and separate cadaveric forearm representing the surgeon's hand. Three different needle-holding techniques were compared: conventional glove (control), a radiation-attenuating glove, and a novel needle holder. Five 300-s fluoroscopy trials were performed per treatment arm. The primary outcome was radiation dose (mSv) to the surgeon's hand. The secondary outcome was radiation dose to the patient. One-way ANOVA and Tukey's B post-hoc tests were performed with p < 0.05 considered significant. Compared to the control (3.92 mSv), both the radiation-attenuating glove (2.48 mSv) and the needle holder (1.37 mSv) reduced hand radiation exposure (p < 0.001). The needle holder reduced hand radiation compared to the radiation-attenuating glove (p < 0.001). The radiation-attenuating glove resulted in greater radiation produced by the C-arm compared to the needle holder (83.49 vs 69.22 mGy; p = 0.019). Patient radiation exposure was significantly higher with the radiation-attenuating glove compared to the needle holder (8.43 vs 7.03 mSv; p = 0.027). Though radiation-attenuating gloves decreased hand radiation dose by 37%, this came at the price of a 3% increase in patient exposure. In contrast, the needle holder reduced exposure to both the surgeon's hand by 65% and the patient by 14%. Thus, a well-designed low-density needle holder could optimize radiation safety for both surgeon and patient.

Keywords: Fluoroscopy; Percutaneous nephrolithotomy; Protective gloves; Radiation exposure; Radiation protection.

Fig. 1

Cadaver hand representing a surgeon’s hand positioning and respective fluoroscopic images obtained during simulated percutaneous renal access on a cadaver patient model using A a surgical glove, B radiation-attenuating glove, and C needle holder

Fig. 2

Optically stimulated luminescence dosimeter (OSLD) chips (red boxes) were fixed on A four locations of the surgeon hand model: the lateral distal phalanx of the first digit, ventral distal phalanx of the third digit, hypothenar eminence, and forearm 5 cm proximal to the anterior surface of the radiocarpal joint; B two OSLD chips were fixed on the patient model: the ventral and dorsal surface of the skin directly in line with the right kidney

Fig. 3

Mean equivalent dose of the first digit, third digit, hypothenar eminence, forearm, and overall average dose to the surgeon’s hand during simulated percutaneous renal access. Error bars represent one standard deviation. *p < 0.05 for all pairwise comparisons between arms except for the 3rd digit between the radiation-attenuating glove versus needle holder arms

Fig. 4

Mean equivalent dose of A the dorsal and B ventral surface of the patient with either the control, radiation-attenuating glove, or needle holder experimental arms during renal access for percutaneous nephrolithotomy. *p < 0.05

Fig. 5

Mean radiation dose produced by fluoroscopy machine during the control, radiation-attenuating glove, and needle holder experimental arms for the surgeon hand model during simulated renal access for percutaneous nephrolithotomy