A Randomized Trial of Surgeon vs. Technologist Control of Fluoroscopy During Pediatric Ureteroscopy
Caleb P. Nelson, MD, MPH1, Paul J. Kokorowski, MD, MPH2, Jeanne S. Chow, MD1, Bartley G. Cilento, Jr., MD, MPH1, Michael P. Kurtz, MD, MPH1, Don-Soo Kim, PhD1, Robert D. MacDougall, PhD1, Tanya Logvinenko, PhD1.
1Boston Children's Hospital, Boston, MA, USA, 2Children's Hospital Los Angeles, Los Angeles, CA, USA.
BACKGROUND:Fluoroscopy is commonly used during pediatric ureteroscopy (PURS) for urolithiasis, and the most important contributor to overall radiation exposure is fluoroscopy time (FT). One factor that may impact FT is who controls activation of the fluoroscope: the urologist (with a foot pedal) or the radiation technologist (as directed by the urologist). While there are plausible reasons to believe that one approach or the other may lead to reduced FT, there are no systematic investigations of this question. We sought to compare FT with surgeon-control vs. technologist control during PURS for urolithiasis.
METHODS: We conducted a randomized controlled trial of fluoroscopy control during PURS for presumed urolithiasis. Each patient (age 5-26 years) was randomized to surgeon- or technologist-controlled activation of the x-ray source. Block-randomization was stratified by surgeon. Allocation was concealed until the envelope was opened in the operating room at the start of the case. For technologist control, the surgeon verbally directed the technologist to activate and cease exposure using standard verbiage. For surgeon control, a foot pedal was used for activation by the surgeon. The technologist controlled c-arm positioning, settings, and movement. The primary outcome was total FT for the procedure. Secondary outcomes included radiation exposure measured as entrance surface air kerma [ESAK, mGy]. We also analyzed clinical and procedural predictors of FT and exposure. Mixed linear models accounting for clustering by surgeon were used for group comparisons and to assess association of other factors with outcomes.
RESULTS: A total of 73 procedures were included, performed by 5 different surgeons. Number of procedures performed by each surgeon ranged from 7 to 36. 43% of cases were pre-stented. 31 procedures were left-side, 35 were right-side, and 7 were bilateral. Stones were treated in 71% of procedures (21% laser, 13% basket and 65% laser and basket). Stone locations were distal ureter in 12%, proximal/mid ureter in 8%, renal in 69%, and ureteral/renal in 12%. Access sheath was used in 77%. Median stone size was 8.0mm (range: 2.0-20.0). Median FT in the surgeon-control group was 0.5 minutes (range: 0.01-6.10) versus 0.55 minutes (range: 0.10-5.50) in the technologist-control group (p=0.284). Median ESAK in the surgeon-control group was 46.02 mGy (range: 5.44-3236.80) versus 46.99 mGy (range: 0.17-1039.31) in the technologist-control group (p=0.362). Other factors associated with lower FT on univariate analysis included female sex (p=0.015), no prior urologic surgeries (p=0.041), shorter surgery (p=0.011), and no access sheath (p=0.006), although on multivariate analysis only female sex (p=0.017) and no access sheath (p=0.049) remained significant. There was significant variation among surgeons (p<0.0001); individual surgeon median FT ranged from 0.40 minutes to 2.95 minutes.
CONCLUSIONS: Fluoroscopy time and radiation exposure are similar whether the surgeon or technologist controls activation of the fluoroscope. Other strategies to reduce exposure might focus on surgeon-specific factors, given the significant variation between surgeons in fluoroscopy use.
| Measure | Tech Control (N=36) | Surgeon Control (N=37) | Overall (N=73) | P-value |
| Total Fluoro Time (min) | 0.2836 | |||
| Median (IQR) | 0.55 (0.65) | 0.50 (0.70) | 0.50 (0.70) | |
| Radiation ESAK (mGy) | 0.3616 | |||
| Median (IQR) | 46.99 (72.98) | 46.02 (86.18) | 46.50 (79.47) |
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