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.