The headlines are raising the alarm. Rising burnout rates among physicians and risk of personal injury due to the physical demands placed on surgeons are alarming. We must ask: “How can we take better care of ourselves?” This call to action is reflected in the revised modern Hippocratic oath: “I will attend to my own health, well-being, and abilities in order to provide care of the highest standard.”¹ The risks to urologists in the operating room include hazardous exposures such as radiation, bodily fluids, laser energy, as well as the physical demands of operating.

Radiation

Radiation exposure for the urologist is at present unavoidable. Fortunately, there has been a growing initiative to keep radiation usage during cases as low as reasonably achievable (ALARA). The risk of radiation to the urologist is difficult to quantify and varies widely in the literature. For stochastic effects, the linear no-threshold model proposes that any exposure can present a risk.

Techniques to lower this risk include proper shielding with the use of thyroid shield, 2-piece wraparound lead, and lead glasses. Recent studies have shown that up to 20% of urologists may not be using thyroid shields, and only 16% of urologists wear lead glasses.² The exposure to a urologist per percutaneous nephrolithotomy is low at around 0.05-0.21 mSv per case, but as mentioned previously, the linear no-threshold model suggests that any exposure can entail risk.³ Moreover, dosimeter use to track exposure among endourologists is poor, and doses likely vary significantly.

In addition to personal protection, radiation reduction protocols and adjusting fluoroscopy device settings can decrease total fluoroscopy time up to 80%.⁴ Education is also important, and implementing a curriculum for radiation safety training for physicians reduces fluoroscopy usage by over 50%.⁵ Switching device settings to low dose, collimating, and limiting pulses to 1 frame per second can decrease radiation exposure and total fluoroscopy time by over 50% with no significant effect on total operating time.^6,7 Other techniques that can be used to reduce exposure include using save-and-swap technology, using the laser guide to target the location without image exposure, marking the areas of interest on the drape and floor to allow for easy transition of the fluoroscope, and using visual and tactile cues before pedal depression.

Promising results of “fluoro-less” endourological procedures are emerging, and performing endourological procedures is feasible without the use of radiation.^8,9

Eyes

The eye is particularly exposed during endourological surgery to bodily fluids, radiation, and laser energy. During ureteroscopy eye exposure to blood droplets has been shown to occur in up to 50% of cases on a microscopic level, with gross blood exposure almost 10% of the time.¹⁰ Nearly 30% of urologists forgo use of any eyewear at all during ureteroscopy.¹¹ Fortunately, the risk of contracting a blood-borne infection from this exposure is low, but not zero.

Radiation exposure affects the eye as a deterministic effect, meaning there is a threshold cumulative dose that leads to cataract formation. It is estimated that to reach this threshold dose a urologist would have to perform 20 cases using fluoroscopy per month for 50 years.¹² This threshold, though high, is conceivable to reach within the career of a high-volume endourologist. Lead glasses have been shown to reduce eye exposure up to 95%; however, as mentioned previously, use among endourologists is low.²

Finally, with the use of laser energy, there is a theoretical risk of ocular injury. Thulium carries an increased risk of eye injury compared to holmium. Fortunately, for thulium, laser-specific safety goggles provide complete protection, and prescription glasses provide partial protection.¹³ For holmium, regular glasses appear sufficient to prevent injury at all distances.¹⁴

Ergonomics

Surgeons are by nature focused on the task at hand, which sometimes comes at the expense of proper ergonomics leading to biomechanical stresses. In a survey of endourologists around two-thirds reported orthopedic complaints with the most frequent being back, neck, hand, and knee issues.¹⁵ While these issues are common, awareness is low.¹⁶

To reduce risk of orthopedic issues the surgeon should ensure optimal ergonomics for each case. As detailed by Gabrielson et al, display monitors should be placed 80-120 cm away, directly in front of the operating surgeon to allow for less than 30° of neck flexion (see Figure). The upper body should be positioned with elbows bending between 90° and 120° with arms abducted no more than 30°. A finger grip rather than a palm grip of the ureteroscope is preferable. Surgeons should be primarily engaging the wrist and finger muscles to control the scope as opposed to large inefficient movements with the shoulders and elbows. The foot pedal should be placed such that dorsiflexion is less than 25°, and alternating which foot controls the pedal also decreases fatigue.¹⁷

Proper selection of equipment and instruments can also lessen physical strain. For example, wearing 2-piece lead aprons improves weight distribution compared with 1-piece aprons.¹⁸ Use of lighter ureteroscopes results in less muscle group activation and decreases surgeon fatigue.¹⁹

The Pregnant Endourologist

Lastly, one unique group that is at potentially higher risk in the operating room is the pregnant endourologist. Pregnancy should be declared to the radiation safety officer from the onset of pregnancy. A fetal dosimeter should be assigned for those with any radiation usage, and badge dose should be checked monthly. Dr Somani’s team recently looked at rules and regulations for a pregnant endourologist in 12 European countries, and found a lack of universal guidance and varied practices.²⁰ While no guidelines exist, some safety considerations specific to the operating room include fetal radiation exposure, additional shielding, lead gown specifications, and standing and lifting restrictions.

Conclusion

There are many potential safety concerns for the urologist during endourological surgery. Steps to mitigate the risks of occupational exposure include proper lead shielding, decreasing radiation usage, practicing sound ergonomics to limit orthopedic injury, and the use of eye protection. As urologists, we should ensure optimal self-care to promote career longevity.