In this month’s BJUI, Armas‐Phan et al.  report on a prospective observational trial of fluoroscopic vs ultrasound (US)‐guided tract dilatation during percutaneous nephrolithotomy (PCNL). A total of 176 patients underwent successful initial US‐only guided puncture; of these patients, 138 had US‐only dilatation, while in 38 fluoroscopy was required. The authors found no difference in patient factors (e.g. age, gender, body mass index [BMI]) or stone factors (hydronephrosis, stone burden, number of tracts or puncture location). On multivariate analysis, US dilatation was more likely to be performed in the modified dorsal lithotomy position (compared to prone), but there was no significant difference in important outcomes such as stone clearance, complication rates or blood loss.
Whilst only reporting on access (and not necessarily dilatation), the Clinical Research Office of the Endourological Society PCNL Global Study shows us that worldwide fluoroscopic access is by far the most common (88.3% of cases)  and there are relatively few reports of US‐guided dilatation in the literature. The technique does produce technical challenges as the surgeon needs to confidently identify the depth of the dilators or balloon and be sure of its location relative to calyceal anatomy. Whilst dilating short is not usually a problem as simply re‐dilating can be done, dilating too far carries serious risk of perforation of the pelvicalyceal system and vascular injury. The authors’ described technique does rely on good kidney and guidewire visualisation, and if this is not possible then fluoroscopy is used instead. Thus, even in this series with experts at this technique, 38 (22%) underwent fluoroscopic dilatation after US‐guided puncture, and of the 138 with intended US dilatation, seven (5%) were converted to fluoroscopy. Furthermore, 115 patients never entered this series as they underwent initial fluoroscopic‐guided puncture. Thus, it is important to realise that this is a series of select patients being treated by expert enthusiasts of this technique and fluoroscopy should be available in the operating theatre, as it is not possible to do this technique for all patients. In particular, obesity limits the visualisation under US and the authors have previously shown that renal access drops from 76.9% of normal‐weight patients (BMI <25 kg/m2) to 45.6% for those classified as obese (BMI >30 kg/m2) . An alternative strategy to avoid radiation is to use endoscopic combined intrarenal surgery (ECIRS), as the depth of dilatation can be monitored by direct visualisation via the flexible ureteroscope.
Patients and healthcare professionals are increasingly aware of the risks posed by ionising radiation. Ferrandino et al.  analysed radiation exposure of patients presenting with acute stone episodes in an American setting. The mean dose was a staggering 29.7 mSv and 20% of patients received >50 mSV. There is also awareness of risk to the operating staff from endourological procedures and although doses are relatively low , these can accumulate during a lifetime of operating, with risks of not only malignancy but also cataract formation . Whilst I am sure we all wear protective lead gowns in the operating theatre, how many people wear lead glasses? A recent study showed that, at typical workload, the annual dose to the lens of the eye was 29 mSv in interventional endourology .
As urologists, we should all be aware of these risks and follow the ALARA (As Low As Reasonably Achievable) principals of keeping doses to a minimum. Thus, this paper  is particularly welcome and shows zero‐radiation procedures can be safely performed. The authors now attempt this technique for all PCNL procedures and achieve US‐only puncture and dilatation in over half of their patients. Hopefully, this paper will inspire us all to look at reducing or eliminating radiation usage in our stone procedures and this will be good for patients and surgeons alike.
by Matt Bultitude
- Ultrasound guidance can be used safely for renal tract dilatation during percutaneous nephrolithotomy. BJUI 2019; 125: 284-91 , , et al.
- The Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study: indications, complications, and outcomes in 5803 patients. J Endourol 2011; 25: 11– 7 , , et al.
- Ultrasound guidance to assist percutaneous nephrolithotomy reduces radiation exposure in obese patients. Urology 2016; 98: 32– 8 , , , , .
- Radiation exposure in the acute and short‐term management of urolithiasis at 2 academic centers. J Urol 2009; 181: 668– 72 , , et al.
- Surgical staff radiation protection during fluoroscopy‐guided urologic interventions. J Endourol 2016; 30: 638– 43 , , et al.
- Risk of radiation‐induced cataracts: investigation of radiation exposure to the eye lens during endourologic procedures. J Endourol 2018; 32: 897– 903 , , et al.
- Risk of radiation exposure to medical staff involved in interventional endourology. Radiat Prot Dosimetry 2015; 165: 268– 71 , , et al.