Background

The 2024 AUA meeting ushered in a cadre of exciting new advancements across the spectrum of urologic care. Additionally, for the first time, the plenary sessions provided a platform for a topic that has gained traction across many other surgical specialties: ergonomics and safety in the operating room (OR). With impending shortages of urologists of 12% to 46% projected by 2035, our specialty should embrace lessons in ergonomics to maximize longevity of existing surgeons.¹

Occupational risks for urologists can include exposure to bloodborne pathogens, chemotherapy, laser energy, ionizing radiation, and ergonomic hazards. Although many exposures have well-established hospital-based policies for mitigating their associated risks of injury, there are few guidelines that urologists can utilize to avoid ergonomic hazards in the OR. The goal of this plenary session was to provide urologists with a basic understanding of the scope of the work-related injury problem and provide a framework to address these risks without interrupting their clinical workflow.

Scope of the Problem

Work-related musculoskeletal (MSK) pain and injury are rampant among urologists, with recent estimates suggesting that 50% to 90% of urologists experience MSK pain attributed to performing surgery during their career.^2,3 Data from the 2018 AUA Census revealed that half of all urologists report work-related discomfort, and symptoms were worse among female surgeons under age 45.⁴ More than two-thirds of urologists endorse using NSAIDs to treat pain associated with operating, and 10% to 20% have sought medical evaluation due to a work-related injury.⁵ Work-related MSK pain can restrict range of motion, strength, and motor control, leading to impaired speed and performance. MSK pain can also decrease mental focus and negatively impact communication and OR team dynamics.⁶

What Drives Work-Related Pain and Injury

Many factors can drive work-related MSK pain among surgeons. Some factors are modifiable at the surgeon level, while others require systematic changes in OR policies or device design. The most common and modifiable risk factors of injury are awkward or static body postures and long periods of operating without breaks. Other key modifiable risk factors include the equipment we wear or interact with such as headlights, loupes, lead aprons, foot pedals, and choice of surgical devices (eg, instruments, staplers). There are also surgeon-specific factors such as inexperience, age, caseload, surgical approach (eg, robotic-assisted, open, endoscopic), extreme surgeon height (tall or short), small glove size, and female sex that cannot be modified but have also been associated with higher rates of work-related MSK pain.

How Urologists Can Optimize Surgical Ergonomics and Prevent Injury

Strategies to optimize ergonomics can be stratified into 3 broad categories: (1) OR layout adjustments, (2) perioperative surgeon and team activities, and (3) activities outside of the OR. Routine implementation of intraoperative strategies may be facilitated by incorporating a brief “ergonomics time-out” at the start of the case. Nonexhaustive lists of these factors are below.

Operating Room Layout Factors

• Place foot pedals close to surgeon in alignment with target anatomy to allow ease of pedal activation while minimizing need to place body weight on 1 foot; swap which foot is engaging the pedal.
• Adjust table height to accommodate the tallest surgeon; use broad-based steps for shorter surgeons.
• During endoscopic surgery and laparoscopy, the table height should be set such that the target working area (eg, urethral meatus, percutaneous access sheath) is between the level of the surgeon’s pubic symphysis and umbilicus while standing. During open surgery, the table height should be adjusted such that the target anatomy is roughly 2 to 4 inches below elbow height. Appropriate table height allows for the upper extremities to remain in a neutral position, with elbows forming a 90- to 120-degree angle with the biceps while limiting neck and back flexion to < 25 degrees (Figure).
• During endoscopic surgery, adjust monitor position directly in front of the surgeon, at least 2.5 to 4 feet away (larger screens can be farther away), with the top of the screen at eye level, to facilitate a slight “gaze-down” eye position.
• While seated at the robotics console, adjust chair height so thighs are parallel to the ground, forming a thigh-torso angle of roughly 90 degrees, knees extended at an angle of 90 degrees or greater, feet resting flat on the ground within several inches of the foot pedals, and forearms resting on the armrest such that the elbows form a 90- to 120-degree angle with the biceps. Use an adjustable chair with lockable wheels so you can keep your lumbar spine against the lumbar support. Save console settings for future procedures.^5,7

Figure. Open surgery upper body ergonomic positioning.

Perioperative Surgeon and Team Activities

• Wear supportive footwear and compression stockings.
• Sit while operating when feasible.
• Stand on antifatigue mats during long cases.
• Use self-retaining and/or lighted retractors when possible.
• Minimize time spent wearing lead aprons and distribute lead weight to hips with hip strap or wear 2-piece aprons.
• Ensure loupe working distance and focal length are appropriately fitted, select lightweight frames, and adjust declination angle based on operations that you typically perform (deep pelvic cases = maximize declination angle; perineal cases = minimize declination angle).
• For presbyopic surgeons wearing corrective lenses, consider surgery-specific lenses that include only near and intermediate working distances; this helps minimize static postures and excessive neck extension.⁸
• Targeted stretching routines either during (ie, intraoperative microbreaks) or between cases have been shown to decrease MSK discomfort without prolonging OR time.^9,10
• Partner with local ergonomics experts to evaluate your posture intraoperatively.
• Use postural resets to return to neutral and relaxed postures throughout cases.

Injury Prevention Strategies Beyond the OR

• Regular weekly exercise
• Physical therapy
• Massage therapy
• Seek care and report MSK injuries (eg, occupational health clinic)
• Partner with industry to improve surgical device design

Conclusions

As urologists, we can modify our activities and our OR environment to improve performance and reduce the risk of MSK pain/injury. We are encouraged by the AUA’s commitment to providing a voice for these issues and encourage urologists to find ways to incorporate ergonomics best practices into their workflows. After all, to optimally care for others, we must also learn to care for ourselves.