Reducing Radiation Exposure in Endourology: Practical Recommendations for the Urologist.

Abstract

Radiation exposure remains an unavoidable part of modern stone management. Patients with urolithiasis may receive ionising radiation during diagnosis, surgical treatment and follow-up, particularly when computed tomography, plain radiography and intraoperative fluoroscopy are repeatedly used. In parallel, urologists and operating room staff are exposed to scattered radiation during endourological procedures, especially in complex or prolonged cases. Although the individual risk of radiation-induced malignancy in this setting is difficult to quantify and should not be overstated, cumulative exposure should be actively reduced whenever this can be achieved without compromising safety or surgical efficacy. This narrative review provides practical recommendations for reducing radiation exposure in endourology, with a focus on ureteroscopy, retrograde intrarenal surgery, percutaneous nephrolithotomy and endoscopic combined intrarenal surgery. It is based on current European Association of Urology guidance on urolithiasis and radiation protection in endourology, together with the relevant clinical literature on fluoroscopy use, occupational exposure, low-dose protocols, ultrasound-guided access and fluoroscopy-sparing techniques. The core principles include appropriate justification for imaging, adherence to the as low as reasonably achievable principle, minimisation of fluoroscopy time, maximisation of distance from the radiation source, adequate shielding, collimation, pulsed fluoroscopy, low-dose settings, avoidance of unnecessary magnification and systematic use of last-image hold. Radiation reduction in endourology should be viewed as part of good surgical technique rather than as an administrative requirement. Simple measures, consistently applied, can reduce exposure for both patients and staff. Ultrasound-guided and fluoroscopy-sparing approaches offer additional opportunities, particularly in percutaneous stone surgery, but require training, case selection and awareness of their limitations. A structured radiation safety culture, led by the urologist and shared by the whole operating room team, is essential for safer and more sustainable endourological practice.