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.