Defining a national reference level for intraoperative radiation exposure in urological procedures: FLASH, a retrospective multicentre UK study.

OBJECTIVES: To define reference levels for intraoperative radiation during stent insertion, ureteroscopy (URS), and percutaneous nephrolithotomy (PCNL); to identify variation in radiation exposure between individual hospitals across the UK, between low- and high-volume PCNL centres, and between grade of lead surgeon. PATIENTS/SUBJECTS AND METHODS: In all, 3651 patients were identified retrospectively across 12 UK hospitals over a 1-year period. Radiation exposure was defined in terms of total fluoroscopy time (FT) and dose area product (DAP). The 75th percentiles of median values for each hospital were used to define reference levels for each procedure. RESULTS: Reference levels: ureteric stent insertion/replacement (DAP, 2.3 Gy/cm2 ; FT, 49 s); URS (DAP, 2.8 Gy/cm2 ; FT, 57 s); PCNL (DAP, 24.1 Gy/cm2 ; FT, 431 s). Significant variations in the median DAP and FT were identified between individual centres for all procedures (P < 0.001). For PCNL, there was a statistically significant difference between DAP for low- (<50 cases/annum) and high-volume centres (>50 cases/annum), at a median DAP of 15.0 Gy/cm2 vs 4.2 Gy/cm2 (P < 0.001). For stent procedures, the median DAP and FT differed significantly between grade of lead surgeon: Consultant (DAP, 2.17 Gy/cm2 ; FT, 41 s) vs Registrar (DAP, 1.38 Gy/cm2 ; FT, 26 s; P < 0.001). CONCLUSION: This multicentre study is the largest of its kind. It provides the first national reference level to guide fluoroscopy use in urological procedures, thereby adding a quantitative and objective value to complement the principles of keeping radiation exposure 'as low as reasonably achievable'. This snapshot of real-time data shows significant variation around the country, as well as significant differences between low- and high-volume centres for PCNL, and grade of lead surgeon for stent procedures.

Recurrent torsion after previous testicular fixation.

BACKGROUND: Occasionally patients present with acute testicular pain having undergone a previous testicular fixation for torsion. The aim of this article is to review the literature and determine whether recurrent torsion of the testis is possible and whether the technique used at initial fixation is relevant. METHODS: A literature search was performed using MEDLINE, Pre-MEDLINE, EMBASE and CIANHL databases using the terms 'spermatic cord torsion' and 'testicular torsion' in combination with 'treatment failure', 're-operation' or 'recurrence'. RESULTS: Twenty cases of recurrent testicular torsion after fixation are described. Fifteen of the 17 that specified the type of suture used at initial fixation had used absorbable suture. Animal models suggest that to produce dense adhesions at testicular fixation, the tunica vaginalis must be everted behind the testis with or without fixation, before the testis is returned to the scrotum. Without this eversion, the adhesions around the testis are fine and only located at the site of fixation suture. The use of non-absorbable suture led to abscess formation in 30% of testes in animal models. CONCLUSIONS: The higher incidence of recurrent torsion after fixation using absorbable rather than non-absorbable sutures in the literature may be caused by a greater number of fixations being carried out using absorbable suture. Use of non-absorbable suture is limited by the high rate of abscess formation. The most important factor for adhesion formation would appear to be the eversion of the tunica vaginalis and it is recommended that this is carried out at all testicular fixations.