ALARA in Urology: Steps to Minimise Radiation Exposure During All Parts of the Endourological Journey

Abstract

Purpose of the Review The global burden of kidney stone disease (KSD) and its management relies on ionising radiation. This includes the diagnosis, treatment and follow-up of KSD patients. The concept ‘As Low As Reasonably Achievable’ (ALARA) developed in response to the radiation risks and the key principles include optimisation, justification and limitation of radiation. This article provides an overview of the topic including background to the risks and steps that can be taken during all stages of endourological management. Recent Findings Our review suggests that ionising radiation is an invaluable tool in delineating the anatomy, localising disease, guiding manoeuvres and monitoring treatment in patients with KSD. It therefore plays an integral role in many stages of patient care; preoperatively, intraoperatively and postoperatively. The reduction of radiation pre- and post-surgical intervention relies on the use of low-radiation CT scan and ultrasound scan. It can also be achieved through various intraoperative techniques or fluoroless techniques in selected patients/procedures, customised to the patients and procedural complexity. Summary There are many parts of the patient journey where exposure to radiation can take place. Urologists must be diligent to minimise and mitigate this wherever possible as they too face exposure risks. Implementation of strategies such as teaching programmes, fluoroscopy checklists and judicious use of CT imaging among other things is a step towards improving practice in this area.

Training ultrasound-guided percutaneous nephrostomy technique with porcine model

“…It is well-known that 50 mSv is the maximum annual occupational exposure suggested by The International Commission on Radiological Protection [ 13 ]. Nevertheless, because there is no definite threshold dose for stochastic effects, even low levels of radiation exposure are potentially hazardous and capable of promoting cancer development [ 14 ]. Therefore, EAU guidelines on urolithiasis underscore the significance of minimizing radiation exposure by emphasizing the importance of implementing protective measures and adhering to the “as low as reasonably achievable” principle.…”

Radiation exposure in emergency ureteric stenting: A subgroup analysis by operator

“… 19 Non‐technical skills can affect radiation use, as effective communication and teamwork with the radiographer are essential to efficiently coordinate fluoroscopy usage 20 irrespective of the primary fluoroscopy controller, being the radiographer or surgeon. 21 Suggestions to reduce radiation exposure include education and fluoroscopy protocols, 22 and also formal feedback to surgeons, which has been demonstrated to reduce FT by 24%. 23 Comparisons between urology and general surgery registrars have been examined in the context of the acute scrotum for emergency cross‐cover of surgical specialties 24 but not for emergency stenting.…”

Radiation exposure during different percutaneous renal puncture techniques: A YAU endourology & urolithiasis study

“…There are strategies such as teaching programmes, fluoroscopy checklists and judicious use of radiation protection devices to decrease X-ray exposure during surgeries but when PCNL is discussed, perhaps the most important step to minimize exposure is the use of ultrasound for percutaneous access [ 8 9 ].…”