Studies Find Gaps in Radiation Protection for Urologists

Neil Osterweil

July 05, 2022

AMSTERDAM — Lead aprons alone may not be doing enough to protect urologists from workplace hazards such as cataracts or cancers.

That's the opinion of investigators in Spain, who found significantly lower exposures to radiation to the hands with the use of lead-lined surgical gloves and reduced doses to the eyes with the use of leaded eye shielding and a fluoroless (low/no radiation) protocol.

Hand Exposures

"The use of lead-lined gloves should be promoted in the urology community, especially in those who dedicate most of their practice to endourological surgery," said Alejandra Bravo-Balado, MD, from Fundació Puigvert and the Autonomous University of Barcelona, Spain, in an oral abstract presented at the European Association of Urology Congress 2022.

She noted that the authors of one study of radiation protection for the fluoroscopy operator and staff holds that attenuating materials, such as lead-lined gloves, don't offer sufficient protection and may in fact increase levels of scatter radiation.

Other studies, however, suggest that wearing shielded gloves when close to, but not within, the primary beam may reduce radiation exposures to the clinician's fingers by up to 58%.

To settle this issue, Bravo-Balado and colleagues conducted a prospective study in their center comparing radiation exposures between one surgeon who used lead-lined surgical gloves as well as a fluoroless protocol during part of the study and another surgeon who used regular latex gloves and did not use a fluoroless protocol.

They found that the surgeon with the lead-lined gloves had a mean annual radiation dose to the hands of 2.87 millisieverts (mSv) compared with 14.87 mSv per annum for the surgeon wearing only latex gloves (P = .027).

The mean radiation dose per procedure was 0.02 mSv and 0.1 mSv, respectively (P < .001).

In addition, lead-lined gloves were associated with numerically but not statistically lower levels of scatter radiation compared with latex gloves.

Finally, they compared radiation exposures between protocol types and found that for the surgeon who used lead-lined gloves and switched from a standard fluoroscopy protocol to a fluoroless protocol, the mean radiation dose per year to the extremities dropped from 3.88 mSv to 1.84 mSv, although this difference was not statistically significant.

Eye on Safer Procedures

In addition to the hands, eyes are also especially prone to damage from intraoperative radiation, with cataracts forming at doses below 0.1 Gy, which translates to approximately 100 mSv.

Bravo-Balado noted that Euratom, the European Atomic Energy Community, has reduced the annual limit of equivalent radiation dose to the lens from 150 mSv to 20 mSv, with the exception of 50 mSv in 1 year if the exposures do not exceed a total of 100 mSv within 5 years.

To estimate radiation exposures to the eye from endourologic procedures and to see whether surgeons were using eye protection as recommend, they conducted a multicenter study using prospective data to estimate radiation doses to the eyes at a depth of 0.3 mm.

Their sample included four endourologists, from four different European centers, who agreed to use an eye dosimeter during ureteroscopy, retrograde intrarenal surgery, and percutaneous nephrolithotomy.

Two of the surgeons wore leaded protective glasses, and one used a fluoroless protocol.

They found that the mean annual doses to the eye were lowest with the use of leaded glasses and with the fluoroless protocol.

Of interest, the surgeon with the highest mean annual exposure (3.70 mSv compared with 0.16, 1.18, and 1.41 mSv) performed the fewest endourologic procedures, suggesting that exposures were not related to the cumulative number of procedures.

"We recommend the use of ALARA protocols," Bravo-Balado said, using the acronym for "as low as reasonably achievable."

Cataracts and Cancers

A urologist who was not involved in the studies told Medscape Medical News that radiation exposure does not get the attention it deserves among urologists.

"During the last few years, there has been a lot of debate regarding this matter," said Lazaros Tzelves, MD, of Sismanogleio General Hospital in Athens, Greece, who co-moderated the session during which the abstracts were presented.

"There are studies saying that the total measured radiation is higher in cardiology, but the effective dose received by the urologist is maximal because we have the C-arm, which makes the radiation closer to us," Tzelves said. "And because we are close to the C-arm, we see many cataracts in urologists as they get older and, unfortunately, some malignancies which are presenting more and more."

He expressed the opinion that if most urologists at the meeting were polled, they would admit to not using protective glasses or gloves, partly because that type of protective equipment is often not reimbursed to clinicians and because gloves may impair the surgeon's dexterity.

The study was internally supported. Bravo-Balado and Tzelves reported no relevant financial conflicts of interest.

European Association of Urology (EAU) Congress 2022. Abstracts A0256 and A0257. Presented July 2, 2022.

Neil Osterweil, an award-winning medical journalist, is a long-standing and frequent contributor to Medscape.

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