SummaryBackground-Sacral agenesis (SA) is a rare congenital condition that refers to the absence of part or all of two or more lower sacral vertebral bodies. It can be associated with neurogenic bladder dysfunction that does not necessarily correlate with the level of spinal or skeletal defect. Patients with SA should undergo urodynamic studies (UDS) to guide lower urinary tract (LUT) management.

Objective Little data have been reported regarding radiation exposure during pediatric endourologic procedures, including ureteroscopy (URS). We sought to measure radiation exposure during pediatric URS and identify opportunities for exposure reduction. Methods We prospectively observed URS procedures as part of a quality improvement initiative. Pre-operative patient characteristics, operative factors, fluoroscopy settings and radiation exposure were recorded. Our outcomes were entrance skin dose (ESD, in mGy) and midline dose (MLD, in mGy). Specific modifiable factors were identified as targets for potential quality improvement. Results Direct observation was performed on 56 consecutive URS procedures. Mean patient age was 14.8 ± 3.8 years (range 7.4 to 19.2); 9 children were under age 12 years. Mean ESD was 46.4 ± 48 mGy. Mean MLD was 6.2 ± 5.0 mGy. The most important major determinant of radiation dose was total fluoroscopy time (mean 2.68 ± 1.8 min) followed by dose rate setting, child anterior-posterior (AP) diameter, and source to skin distance (all p<0.01). The analysis of factors affecting exposure levels found that the use of ureteral access sheaths (p=0.01) and retrograde pyelography (p=0.04) were significantly associated with fluoroscopy time. We also found that dose rate settings were higher than recommended in up to 43% of cases and ideal C-arm positioning could have reduced exposure 14% (up to 49% in some cases). Conclusions Children receive biologically significant radiation doses during URS procedures. Several modifiable factors contribute to dose and could be targeted in efforts to implement dose reduction strategies.

Purpose After prospective measurement of radiation exposure during pediatric ureteroscopy (URS) for urolithiasis, we identified targets for intervention. Our objective was to systematically reduce radiation exposure during pediatric URS. Materials and Methods We designed and implemented a pre-fluoroscopy quality checklist for patients undergoing URS at our institution as part of a quality improvement initiative. Pre-operative patient characteristics, operative factors, fluoroscopy settings and radiation exposure were recorded. Primary outcomes were entrance skin dose (ESD, in mGy) and midline dose (MLD, in mGy) before and after implementation of the checklist. Results Direct observation was performed on 32 consecutive URS procedures using the safety checklist, 27 of whom were pediatric patients meeting inclusion criterion. Outcomes were compared to 37 patients from the pre-checklist phase. Pre- and post-checklist groups were similar with regard to patient age, total surgical time, or patient thickness. Mean ESD was reduced by 88% (p<0.01) and mean MLD by 87% (p<0.01). Significant improvements were noted among the major determinants of radiation dose including the total fluoroscopy time (reduced by 67%, p<0.01), dose rate setting (appropriate reduced dose setting in 93% vs 51%, p<0.01), and excess skin to intensifier distance (reduced by 78%, p<0.01). Conclusions After systematic evaluation of our practices and implementation of a fluoroscopy quality checklist, there were dramatic reductions in the radiation doses to children during URS procedures.