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Radiation Protection

Intraoperative fluoroscopy exposes the surgeon to scatter radiation, so every fluoroscopy case needs a planned staff-protection setup under the institution's radiation-safety program. Fluoroscopy is used in reconstructive practice for:

  • ureteral stent placement during or after ureteral reconstruction;
  • retrograde pyelography in complex ureteral cases;
  • antegrade nephrostomy work in the operating room;
  • C-arm guidance in pelvic fracture urethral injury reconstruction;
  • adjacent cases, such as percutaneous nephrolithotomy, for which the surgeon is in the room.

In a 2024 systematic review of 21 studies, urologists' radiation exposure varied widely between studies and was highest in prone percutaneous nephrolithotomy. Thyroid shield and lead apron reduced measured exposure by 94.1% to 100%.[2] A separate review of 16 observational studies found that lead apron and thyroid shield were used more consistently than lead eyeglasses and gloves, and that radiation-safety education was infrequent.[3] See Radiation Tissue Effects for the effects of radiation on patients.

Shielding​

The apron is the primary barrier. Coverage and attenuation are chosen with the radiation safety officer or medical physicist. A lead equivalence of 0.25 mm is the lowest commonly specified, and 0.35 to 0.5 mm is used when exposure is higher.

  • Wrap-around versus front-only. A wrap-around apron protects when the surgeon turns away from the C-arm, so it suits cases with position changes. It is heavier.
  • Two-piece (vest and skirt) versus one-piece. A two-piece apron carries weight on the hips instead of the shoulders, which is easier on the cervical spine in long cases.
  • Lead-free composites. Tungsten, antimony and bismuth are used in some composite aprons. A radiation-protection paper reports 20% to 30% lower weight for composite aprons than for lead-impregnated aprons.[4] Protection must be verified at the relevant X-ray energies.
  • Fit. An apron that rides up or shifts laterally leaves gaps and loads the shoulders and paraspinal muscles. Fit is checked on the individual.

A thyroid shield is worn with the apron for every fluoroscopy case. Typical lead equivalence is 0.25 to 0.5 mm, and it must fit under the scrub top without gaping when the surgeon turns. Protective glasses with lateral shielding reduce dose to the lens of the eye, which is sensitive to radiation and can develop dose-dependent cataract. Lateral exposure contributes a meaningful share of eye dose. Prescription inserts or prescription lenses are available. Room shields, including the under-table skirt and overhead panel, must be positioned correctly. Apron overlap, storage and periodic integrity testing are checked. Protective gloves do not make direct-beam hand exposure safe and can increase automatic exposure output.[1][2]

Dosimetry​

For interventional work, IAEA recommends two badges: one outside the apron at the collar on the exposed side, and one beneath it on the torso. An outside badge is not automatically whole-body effective dose. Use eye or ring monitoring when indicated, for example a ring dosimeter for a surgeon whose hands are near the beam, and follow the local wearing and return schedule.[1]

During Exposure​

The governing principle is ALARA (as low as reasonably achievable), applied through time, distance and shielding: minimize fluoroscopy-on time, increase distance from the source, and use lead garments, eyewear, thyroid shield and room shields. Reduce unnecessary imaging, step back when feasible and use shields. Dose from a point source falls with the square of distance, so doubling the distance cuts it to about a quarter, but scatter from the patient makes actual reductions geometry-dependent. The patient is the main scatter source; favor the detector side during lateral imaging. Keep hands outside the primary beam.[1]

See Also​

References​

1. IAEA and co-sponsoring organizations. Radiation Protection and Safety in Medical Uses of Ionizing Radiation. Specific Safety Guide SSG-46, 2018. Sections 3.79–3.99 and 3.104–3.121. Official guidance.

2. De Coninck V, Hendrickx L, Mortiers X, et al. Radiation exposure of urologists during endourological procedures: a systematic review. World J Urol. 2024;42(1):310. doi:10.1007/s00345-024-05023-z

3. Smith M, Thatcher MD, Davidovic F, et al. Radiation safety education and practices in urology: a review. J Endourol. 2024;38(1):88-100. doi:10.1089/end.2023.0327

4. Livingstone RS, Varghese A. "A simple quality control tool for assessing integrity of lead equivalent aprons." Indian J Radiol Imaging. 2018;28(2):258-262. doi:10.4103/ijri.IJRI_374_17