Discussion
In Turkey, students who complete the formal six-years medical school education receive the title of medical doctor. They are then subjected to a nationwide central examination to be able to receive specialist training in a branch. Those who are successful in the exams receive training their residency in university hospitals or training and research hospitals for a period of time that varies according to each department. In our study, which evaluated the tendency of urology residents studying in different institutions in Turkey to use fluoroscopy in urological operations; interestingly, it was concluded that, even though all of them are at similar education levels on radiation exposure, the residents training in university hospitals had more anxiety about using fluoroscopy, than their colleagues in training and research hospitals. Similarly, it is seen that unlike their colleagues in training and research hospitals, the residents in university hospitals prefer to operate a case with a different method without using fluoroscopy in more sessions, than a single session with using fluoroscopy. The reason for this may be that the residents in university hospitals have higher awareness of the harmful effects of ionizing radiation exposure under the mentorship of senior urologists who provide medical education as well as their specialty education. In addition, it is seen that auxiliary healthcare staff much more avoid the cases in which fluoroscopy is used than urology residents. This can be explained by the fact that residents with concern of training in their occupation, ignoring ionizing radiation exposure. There are many studies in the literature about the awareness of urology residents to radiation exposure.1,6,8-10 However, this is the first study to evaluate residents’ tendencies to use fluoroscopy according to their educational institutions.
Ionizing radiation is an serious health problem, faced by practitioners when they apply it during medical diagnosis and treatment. While applying these procedures, the harmful effects of radiation must be taken into account. Especially in recent years, the increase in endourological interventions and the parallel increase in exposure to radiation impose an important responsibility on urologists in order to protect themselves, auxiliary healthcare staff and their patients.11 Radiation exposure causes serious morbidity and mortality. While causing cellular damage with its cumulative effect, it causes leukemia, lymphoma, thyroid cancer, bladder cancer, liver cancer, esophageal cancer, breast cancer, skin cancer, cataracts and central nervous system cancers and also it has a deterministic effect by causing cell death at high doses.6 For this purpose, the use of a lead apron, thyroid shield, radiation protective glasses and gloves is recommended in cases where fluoroscopy is used, and it is known that these protective equipment prevent the harmful effects of ionizing radiation.1 However, many studies have shown that most urologists do not have sufficient knowledge about the harmful effects of radiation and do not take adequate precautions against radiation.1,4,12 In a study which Harris et al. evaluated 136 urology residents in the United States, it was shown that almost half of the residents did not receive a formal radiation safety training. In the same study, it was reported that 99% of the residents used a thyroid shield, 97% of them regularly wore a lead apron, but only 9% of the residents used radiation protective glasses. Besides, it has been shown that none of the assistants wore radiation protective gloves.6 In another survey study conducted on urology residents in Canada, it was stated that although the rate of thyroid shield use was 96% but 24% of them used it irregularly. While the rate of use of radiation protective lead apron is 13%, it has been shown that almost no residents use radiation protective gloves. In this study, it was also emphasized that 70% of the residents did not use dosimetry.10 Similar results are also observed in studies conducted in Europe.9 In our study, it is seen that while the use of lead aprons and thyroid shields is quite high among urology residents in Turkey, almost none of the residents use radiation protective glasses and gloves. Additionally, 68.1% of the residents never used dosimetry and only 5.3% stated that they received training on radiation safety. Another striking result is that the vast majority of urology residents do not believe that protective equipment is regularly checked for effectiveness.
Fluoroscopy is used in many operations in urology. In the study conducted by Altıntas et al., 53.9% of the participants answered the question ”In which case do you need fluoroscopy device the most” as PNL.8 In our study, it is also understood that fluoroscopy is almost used in all PNL cases. In operations of RIRS and nephrostomy/DJ insertion, fluoroscopy was preferred in one of three patients. We think that this difference may have arisen due to studies showing the effectiveness and reliability of the non-fluoroscopic RIRS technique.13
There are some limitations of our study. First of all, this study is a survey-based study and only those who preferred to participate in the survey via ”WhatsApp®” were included in the study. Apart from this, the low number of participants is another handicap. In addition, the status of the auxiliary healthcare staff to avoid cases using fluoroscopy was evaluated according to their responses to urology residents. Nevertheless, it is the first study to be conducted due to the tendencies of urology residents training in different institutions in Turkey about the use of fluoroscopy and making a social evaluation from a different perspective makes our study valuable.