DISCUSSION
The harmful effects of radiation should be taken into account because
ionizing radiation, to which personnel are exposed during diagnosis and
treatment, can pose a serious health problem, especially in recent
years, because of increased endourological procedures. Therefore, for
urologists, other health care professionals, and patients, controlling
ionizing radiation exposure has utmost importance [13]. However,
clinicians are unaware or underestimate the radiation levels to which
they or their patients expose [14-16].
Time, distance, and protective equipment (a lead vest, neck collar,
gloves, glasses) are important measures to protect people from
radiation. In two studies by Soylemez et al. [11,17], urologists’
use of lead gowns was found common, although, the use of safety glasses,
gloves, and dosimeters was rare. In a study by Bagley and Cubler-Godman,
the radiation dose in the neck of the urologists performing
ureterorenoscopy was 0.3 mSV while the radiation dose in the hands was
12.7 mSV, while those in the hands was 12.7 mSV [9]. In another
study by Elkhousy et al., demonstrated that 97% of urologists used lead
gowns, and 68% used thyroid shields, while protective gloves and
glasses were used by 9.7% and 17.2%, respectively [18]. Another
study revealed that 75% of urologists used lead gowns, while other
protective equipment was rarely used [17]. In our study, the number
of participants using glasses and gloves was very low Although the dose
handled in surgeries using fluoroscopy was high [9], as in our
study, the rate of urologists using gloves and glasses was rare. A small
number of urologists reported that they did not use protectives during
surgeries due to their heavy structure and non-ergonomic design. The
reasons for not using protectives in another study were similar
[17]. One interesting finding is that almost 35% of the urologists
did not trust their protection although they took protective measures.
One of the primary measures of radiation protection is that the amount
of annual dose exposed should not be exceeded [19]. Therefore, it is
necessary for urologists, like radiologists, to use dosimeters. In a
previous study, the dosimeter usage rate of all staff working in the
urology theater was found to be 46.5% [1]. In another study, the
proportion of urologists who never used dosimeters was reported as 56%
[13] In our study, the proportion of those who used dosimeters was
around 20%, lower than the reported rates in literature. In general, it
can be deduced that using dosimeters among urologist low. This issue
might be explained by that either urologists are underestimating the
dose of radiation exposure or they are under-trained on the importance
of using a dosimeter.
Shortening the duration of fluoroscopy use (especially in endourological
procedures) is one of the most effective methods to reduce the radiation
dose exposed in the operation room [20]. To shorten the usage
period, measures such as intermittent fluoroscopy, distance and location
of the image intensifier, retention of the last image on the screen, and
the timer alarm are important [9,21] With the use of intermittent
compression (pulse compression), the exposure dose can be reduced by
64% and the exposure time by 74% [22]. In a study involving 40
patients who underwent percutaneous nephrolithotomy, the mean duration
of fluoroscopy was 33.7 sec in the patient group, where a specific
intermittent protocol was applied for fluoroscopy, while it was 175.6
sec in the non-protocol group [23]. In our study, there was no
difference between the groups in terms of mean fluoroscopy time per
case, but the duration of fluoroscopy use by experts was higher. More
than 60% of the participants reported that there was no need for
additional surgical interventions in surgeries requiring fluoroscopy
where the fluoroscopy was not used. This finding showed that the
shortening of fluoroscopy time is mostly in the hands of the operator.
In our study, the majority of both academicians and experts stated that
they shoot in motion and the use of intermittent shooting is relatively
low among urologists. Routine use of measures such as keeping the first
image on the screen, intermittent shooting, and the alarm method can
reduce the radiation exposure to the surgeon and the operation team.
Another way to reduce radiation exposure is to increase the distance
before pressing the shooting button because as the distance increases
(inverse square rule), radiation exposure decreases [24]. In a
study, although participants knew that the radiation exposure increased
as the duration of fluoroscopy increased, more than half of the
participants did not know the effect of distance on the exposure dose
[25]. A study by Harris et al. demonstrated that the over couch
systems (body dose 3.63 mSV, limb dose 3.72 mSv) caused more radiation
exposure in the body and extremities than the under couch systems (body
dose 0.31 mSv and limb dose 0.35 mSv), suggesting the importance of the
placement of X-ray tube [26]. In this study we questioned the
awareness of distance and radiation relationship with two questions
(question 12 and 13). Interestingly less than half of the respondents
answered these questions correctly. The reason for the wrong positioning
of the fluoroscopy device may be that the device placed before or during
the surgery is being positioned randomly. The fact that the urologist or
technical team has insufficient information about radiation may be the
major contributor to this issue. Thus, all personnel in the operation
room, especially urologists, should be trained accordingly.
Many studies have highlighted the lack of awareness of radiation, the
importance of training for radiation exposure and the use of protective
equipment for healthcare professionals [27-32]. In a study performed
in Europe, urologists had little knowledge of the effects of radiation
exposure; half of them were unaware of the risk of malignancy, and only
28% used dosimeters [17]. Soye and Peterson found that physicians
trained for radiation increased their awareness of radiation doses and
protective equipment that occur during radiological procedures [33].
The question of how to adjust the fluoroscopy dose in the study revealed
that 20,5% of academics, 9.6% of experts and 4,5% of assistants are
determining the radiation doses themselves. The majority of the
responders stated that they either shoot in automatic mode or do not
know how to determine it. Besides, almost 50% of academics and experts
stated that they have not read the literature about the harm of
radiation. On the other hand, this rate was much higher in assistants
(86.4%). However, it is clearly seen in our study that urologists do
not have sufficient information and follow the literature about the
negative effects of radiation.
Fluoroscopy use may cause acute adverse effects. In a study evaluating
the adverse effects of fluoroscopy use on orthopedic surgeons, headache
and fatigue were the most common complained symptoms [34]. However,
36% of the surgeons did not report any side effect after fluoroscopy
use. More severe injuries such as skin erythema and edema can also be
seen after a higher dose of radiation exposure such as percutaneous
angioplasty, embolization, and stent placement [35]. In our study,
although we did not observe any severe injuries among urologists, the
rate of adverse effects was high (Figure 2). Only 23% of the
participants did not report any adverse effects. In the long term,
chronic exposure may lead to more fatal complications such as cancer
[36]. Another continuing debate on this topic is that whether the
radiation exposure can affect the sex offspring proportion. Although we
observed female offspring dominancy in our study, further studies are
required to confirm this effect of radiation [37]
The limitations of our study were as follows. Since an internet-based
survey was conducted, the level of knowledge may not have been
objectively measured in the responses. This situation paradoxically
suggests that the awareness of urologists may have increased while
investigating the answers to the questions. Although the correct answers
of the survey results were shared, it was not observed whether the
clinical habits of urologists changed. Finally, since we thought that
independent variables, such as age, study area, and the number and
variety of endourological interventions, were affected, multiple
regression analysis was not performed.