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Increasing Stone Complexity Does Not Affect Fluoroscopy Time in Percutaneous Nephrolithotomy
Annah J. Vollstedt, MD, Johann Ingimarsson, MD, Lawrence Dagrosa, MD, Vernon Pais, MD.
Dartmouth Hitchcock Medical Center, Lebanon, NH, USA.

BACKGROUND: It has been previously suggested that increasing stone complexity is associated with increasing fluoroscopy time (FT) and radiation exposure to patient and OR staff. However, with widespread adoption of the as low as reasonably achievable (ALARA) radiation protocols, radiation doses have decreased. We have adopted ALARA strategies and sought to assess whether stone complexity is still associated with increased intraoperative absorbed radiation dose.
METHODS: We retrospectively reviewed records of 261 consecutive patients undergoing PCNL between February 2007 and October 2015. Of these, 203 had both preoperative CT for accurate staging and full intraoperative fluoroscopy and radiation dosimetry data available. Stone complexity was assessed using Guy’s stone score (GSS), which has undergone prior internal and external validity testing. Correlation between FT, radiation exposure, and GSS was assessed in a univariate and multivariate fashion, including parameters such as age, sex, BMI, and number of accesses.
RESULTS: Overall mean FT was 3.69 minutes (SD 2.77). Overall mean GSS was 2.5 (SD 1). There was a statistically significant correlation between operative time and FT (r = 0.34, p <0.0001). There was a trend towards increasing operative time with increasing GSS (r= 0.12, p = 0.08), but no there was no statistically significant correlation. In addition, there was no correlation between FT and GSS (r = 0.04, p = 0.55). There was also no correlation between mGy and GSS (r = 0.11, p = 0.13). On multivariable regression, accounting for gender, BMI, age, and singular versus multiple accesses, there was no significant correlation between stone complexity and FT (p = 0.893).
CONCLUSIONS: In the setting of conscious efforts to reduce intraoperative radiation exposure, increasing stone complexity did not correlate with fluoroscopy time or radiation exposure on univariate or multivariate analysis. Thus, complex stones may be treated without concern of significant additional radiation risks to the patient or operating room staff. However, the routine practice of obtaining a mapping pyelogram, a fluoroscopic antegrade stent placement and a chest fluoroscopy, all of which likely cause similar amount of radiation to each patient, could potentially have diluted out the differences in radiation incurred by difficulty in obtaining access.


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