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Radiation exposure in urology
- 1. RADIATION EXPOSURE IN UROLOGY DR. PRAMESH PRASAD SHRESTHA FCPS RESIDENT DEPARTMENTOF UROLOGY
- 2. WHAT IS RADIATION? Emission or transmission of energy in the form of waves or particles through space or through a material medium.
- 4. SO,WHY AREWEWORRIED? Types of Radiation: Gravitational Radiation Acoustic Radiation Particle Radiation Electromagnetic radiation
- 5. SO,WHY AREWEWORRIED? Types of Radiation: Gravitational Radiation Acoustic Radiation Electromagnetic radiation Particle Radiation
- 6. SO,WHY AREWEWORRIED? Types of Radiation: Gravitational Radiation Acoustic Radiation Electromagnetic radiation Particle Radiation
- 7. SO,WHY AREWEWORRIED? Types of Radiation: Gravitational Radiation Acoustic Radiation Electromagnetic radiation Particle Radiation
- 8. SO,WHY AREWEWORRIED? Types of Radiation: Gravitational Radiation Acoustic Radiation Electromagnetic radiation Particle Radiation β
- 9. SO,WHY AREWEWORRIED? When exposed to Ionizing radiation Causes changes in the cell division process of the body by affecting DNA structure Damages protein structure of cells Direct damage to tissues The generic term for the detrimental effects of Radiation is termed as ACUTE RADIATION SYNDROME RADIATION SICKNESS
- 10. TERMINOLOGY Ionizing Radiation: Radiation from an source with enough energy to separate the subatomic particles and is a known Carcinogen Deterministic effect: Describes the cause and effect relationship of Ionizing Radiation Also known as Non-Stochastic Effect, Dependent upon dose, dose rate, dose fractionation, irradiated volume and type of radiation Skin Erythema 2-5 Gy Irreversible Skin Damage 20-40Gy Hair loss 2-5 Gy Sterility 2-3 Gy Cataracts 0.5 -5Gy Lethality 3-5GyWhole body Fetal Abnormality 0.1-0.5 Gy
- 11. TERMINOLOGY Stochastic Effect: Effect the occurs by chance No threshold, not dependent upon dose Caused by Mutational changes in cell DNA, Cell still remains viable after radiation effect Increased level of exposure does not effect severity of disease but affect the probability of development Example:Cancer Induction
- 12. TERMINOLOGY Absorbed Dose: Amount of radiation in theTissues Measured in Gray (Gy) Equivalent dose: Absorbed dose in a specific organ or tissue Exposure: Number of ions produced by X-rays per Kilogram of air Measured in Roentgen (R) Effective Dose: Reflects whole body exposure/Radiation present in the environment Measured in rem or Sievert (Sv) Dose area product (DAP): Radiation dose to air multipled by the are of X-ray field Measured in Gy*cm2
- 13. THRESHOLD European Union Effective Dose limit is 100mSv over 5 years No more than 50mSv in any one year United States of America Effective dose limit of 50mSv in one year Lifetime limit of 10mSv x Age (Years) International Commission on Radiological Protection No more than 20mSv/yr over 5 years No more than 50mSv in one year
- 14. BACKGROUND X rays has been used to diagnosed diseases in the kidney and urinary tract for about a century However, use of Fluoroscopy is relatively new Since the advent of Lithotripsy, use of CT has been increasing for mapping the anatomy, diagnosis of diseases A number of procedures, like PCNL, RIRS, Stent placement, ESWL,Tumor ablation require fluoroscopy or other form of ionizing radiation. In the United states; Per capita exposure to radiation has increased from 0.54mSv in 1980 TO 3.0mSv in 2006 600% increase
- 16. RISKS IN UROLOGY - PATIENTS Mainly in stone patients Ranging from 1.18 to 37.66 mSv Acute Stone episode patients undergo 1 – 4 radiographic studies in 1 year period after stone event Obesity increases mean Effective Dose by 177% BMI 30-39.9 Kg/m2 = twofold increase in Effective Dose BMI >40 kg/m2 =Threefold increase in Effective Dose ChenTT, et al. J Urol, 194:878; 2015.
- 17. SURGICAL MANAGEMENT - URS Non obese Males are exposed to a median 1.13 mSv Median Fluoroscopy time 46.95 Seconds Median Stone burden 5mm Preminger et al. J Urology. March 2012.
- 18. SURGICAL MANAGEMENT - PCNL Mean Effective Dose for Right PCNL: 7.63 mSv Mean Effective Dose for Left PCNL: 8.11 mSv Risks for increased Exposure: High BMI, Increased Stone Burden Increased number of access tracts Preminger et al. J Urology. March 2012.
- 19. SURGICAL MANAGEMENT - ESWL Mean total effective dose: 1.71 mSv in males Mean total effective dose: 1.82 mSv in females Lipkin et al. J Urol 2015; 194: 878 885
- 20. EXPOSURE FROM IMAGING IN UROLOGY Modality Exposure Conventional NCCT 10-20 mSv Stone Protocol NCCT 3.04 mSv Low dose CT 1.40-1.97 mSv Ultralow dose CT <1 mSv X-Ray KUB 0.63 – 1.1 mSv CT IVP 3.0 mSv DigitalTomosynthesis 0.83 mSv
- 21. RISKS IN UROLOGY - SURGEONS Radiation exposure: arises due to scatter from the beam, patient and operating table Lens of the eye is most radiosensitive >10mSv of exposure (cumulative) in 1 year increases lifetime risk of fatal cancer by 3% >20mSV of exposure in 1 year increases risk of fatal cancer between 1:1000 and 1: 10000 Risk of fatal malignancy in general population is 1:500000 Hanna L, et al. J Endo, 29: 526; 2015.
- 22. WHAT CANYOU DO? ALARA Protect yourself Know your equipment Procedural control Alternative imaging Adjunctive techniques
- 23. ALARA AS LOW AS REASONABLY ACHIEVABLE Reduce Radiation exposure Time: minimize “Beam-On”Time Distance: Double the distance from the source, exposure dose is 1/4th Shielding: lightweight, radioprotective clothing Scatter Affected by patient size, position, settings on the machine, shielding, filtration, angulation.
- 27. SCATTER
- 28. HELLAWELL ET AL. J OF UROL. 2005 4 months period, 18 ureteral procedures Average Fluoroscopy time: 78s Mobile C-arm unit with under table X-rayTube Dosimetry placed in 7 positions on body Forehead Little Finger B/L Anterior Legs B/L Upper aspect of foot/ankle B/L
- 29. HELLAWELL ET AL. J OF UROL. 2005 Average scattered radiation dose in μ Gy per case
- 30. PROTECTIONS Standard Lead jacket requires 0.35mm thickness Does not prevent absolutely But Reduces transmission by up to 100 fold 0.25mm allow 10% radiation transmission 0.5mm allows 2% of radiation transmission Leaded eyewear Leaded Gloves Wear Dosimeters Hellawell G, et al. J Urol 174, 948; 2005.
- 31. KNOWYOUR EQUIPMENT Low dose rate setting Minimize use of Cine mode Collimate the beam Use magnification as little as possible Image intensifier as close to patient as possible Keep field clean of radiodense objects, such as metallic objects, as these increases scatter by reflection.
- 32. Image Intensifier X ray Source Collimator Filter 4 Axis Direction Control Monitor Exposure Indicator Light X ray Generator Control Panels
- 35. PROCEDURAL CONTROL Mark Body surface forTargetting Coning of radiation field Radioprotective draping of patient Laser guided C-arm
- 36. ALTERNATIVE IMAGING Air Nephrogram V/S Contrast 50% decrease in radiation exposure Ultrasonography Less costs Sensitivity: 48% Specificity: 88% PCNL Guidance: reduced Fluoroscopy time from 28.6s to 14.4s BasiriA, et al. J Endourol , 22:281; Alan C, et al. Urol Res, 39:205; 2011.
- 37. TAKE HOME MESSAGE Urologist are at a significant risk of exposure to radiation But risks can be reduced by taking appropriate precautions Ionizing radiation mainly used in stone removing procedures Wearing lead jacket is just a part of preventive measures to be taken
Editor's Notes
- Gravitational radiation is generated, when a particle has enough energy be expelled form the source at the speed of light, and is able to change the fabric of time and space. This was previously though to be theoretical and was proposed by albert Einstein on 1916, and was only recently proven by the Hadron Collider and the discovery of the higgs boson particle. It is createdin small amounts by planets and star, and are largely created by black holes
- Acoustic Radiation includes Sound wave released by objects because of their specific vibration. Also included sound emitted by speakers, ultrasounds and seismic waves and requires a medium for transmission Particle radiation are formed when an object receives enough energy for breaking up of the atom and formation of subatomic particles. Includes Alpha waves, when 2 Neutron and 2 protons expelled from the atom. These are low energy radiation, which is even blocked by the cloth fabric, but may cause detrimental effects if it is inhaled or ingested. Beta waves are a type of particle radiation when an electron is expelled form an atom. These are high energy radiation, which is 8000 times higher than alpha particles, it is blocked by most solid objects, but travels through skin and may cause radiation sickness. Electromagnetic radiation are energy radiation, in forms of waves and includes a variety of forms.
- Electromagnetic radiation are energy radiation, in forms of waves and includes a variety of forms. These are divided into ionizing and non ionizing radiations.
- Particle radiation are a type of ionizing radiation, other than electromagnetic radiation formed when an object receives enough energy for breaking up of the atom and formation of subatomic particles. Includes Alpha waves, when 2 Neutron and 2 protons expelled from the atom. These are low energy radiation, which is even blocked by the cloth fabric, but may cause detrimental effects if it is inhaled or ingested. Beta waves are a type of particle radiation when an electron is expelled form an atom. These are high energy radiation, which is 8000 times higher than alpha particles, it is blocked by most solid objects, but travels through skin and may cause radiation sickness. Gamma Rays are a type of electromagnetic radiation, which propel in form of waves of Photons and does not have any mass therefore, is able to pass through most solid structure including the human body.
- So, to answer the Question, “Why are we worried?”
- This was an experiment was done in the mayo clinic to measure the exposure in relation to the distance from the source. At 50cm distance, exposure was found to be 220 milliroentgen per hour
- At 100cm distance, exposure was found to be reduced to 55 milliroentgen per hour
- At 200cm distance, exposure was found to be 12.8 milliroentgen per hour
- All beams of electromagnetic waves, including visible light and and lionizing radiation likewise, has 3 methods of scattering. Reflection: has the highest dose of ionizing radiation, which is present under the table Refraction: and lower than those reflected doses, as part of the refracted dose is absorbed by the patient and the operating table.