Tips and tricks for reducing radiation exposure during retrograde intrarenal surgery: A literature review by the European Association of Urology Section of Endourology

Fluoroscopy is an important component of retrograde intrarenal surgery (RIRS), since it facilitates safe and accurate access, guidance, and intraoperative navigation. Fluoroscopy during surgery exposes patients and medical personnel to the harmful effects of ionizing radiation. To reduce radiation exposure, multiple strategies have been proposed. The objective of this review is to analyze strategies for minimizing radiation exposure during RIRS and to provide recommendations for their implementation. A comprehensive literature review was performed by searching the PubMed, Cochrane Library, EMBASE, and Web of Science databases, as well as the ClinicalTrials.gov registry, for publications on strategies for reducing fluoroscopy use during RIRS, employing various combinations of the following Medical Subject Headings: “fluoroscopy”, “radiation safety”, “radiation exposure”, “urology”, “endourology”, “flexible ureterorenoscopy”, “FURS”, “retrograde intrarenal surgery”, and “RIRS”. A substantial corpus of evidence, encompassing original articles, clinical trials, and narrative and systematic reviews, was discovered. Several preoperative measures, including thorough analysis of available imaging studies and the application of quality checklists to guarantee optimal patient positioning, C-arm settings, and the use of radiation protection equipment, have been associated with a significant reduction in radiation exposure. Intraoperatively, the use of fluoroless or fluoroscopy-free RIRS, along with equipment optimization techniques such as intermittent fluoroscopy, collimation, and last image hold, has been identified as a promising approach for radiation reduction. The implementation of radiation safety and simulation-based training can further decrease radiation exposure. Minimizing radiation exposure during RIRS necessitates a comprehensive strategy that integrates careful preoperative planning, fluoroless or fluoroscopy-free techniques, equipment optimization, and radiation safety training and education. Current evidence suggests that the implementation of these approaches can be performed safely and effectively in appropriately selected patients. However, further high-quality randomized controlled trials are needed to confirm these findings and guide their broader adoption.