Abstract
I
There are several interesting and important points illustrated by this article. First, these authors report very low fluoroscopy times during PCNL (mean of 120 sec) with excellent surgical outcomes. These low fluoroscopy times and good outcomes are even more impressive when you realize that PGY-4 and 5 residents are performing and assisting in significant portions of these cases. The residents were also the ones stepping on the fluoroscopy pedal and performing the initial puncture. Although in the univariate analysis the PGY-5 residents used less fluoroscopy than the PGY-4 residents (115 vs 130 sec, respectively), in the multivariate analysis, the difference was no longer significant.
One contributing factor to this lack of significance could be that 4 of the 10 PGY-4 residents had performed no PCNLs. Arguing against this explanation, however, is the fact that postgraduate trainees who had performed >9 PCNLs had similar fluoroscopy times to those who performed ≤9 PCNLs (116 vs 119 sec; P=0.6). Another possible explanation is that the annual lectures provided in this institution and the emphasis on radiation safety allowed residents of all levels to successfully perform PCNL with equally low fluoroscopy times.
In this center of excellence, there were three predictors of fluoroscopy time including number of punctures, estimated blood loss, and operative time. It is not surprising that the number of punctures affects fluoroscopy time because this portion of the procedure necessitates the most fluoroscopy for needle insertion and tract dilation. In addition, the correlation between fluoroscopy time and blood loss is not surprising because surgeons who are very skilled at reducing radiation exposure will substitute direct visual observation for many of the steps traditionally performed using fluoroscopy (such as renal mapping). When bleeding is significant, however, it is much harder to use direct endoscopic visualization. Finally, it is not surprising that the most complex cases needing the most operative time would also necessitate the most fluoroscopy.
This article demonstrates that dramatic reductions in radiation exposure to patients undergoing PCNL are possible, regardless of level of training. The initiative to reduce radiation exposure must come from the senior endourologic surgeon before it can be adopted by trainees and operating room staff. This article highlights how, with the right motivation and mentoring, resident surgeons can rapidly and successfully adopt techniques that reduce fluoroscopy.