Introduction: Intraoperative CT scan in a hybrid room environment during PCNL has been described internationally to aid in obtaining percutaneous access or to assess for residual stones. The initial description of using a robotic-armed fluoroscopy system (Artis Zeego, Siemens) to assess for residual stones, and then to confirm stone free status, was by Vincentini et al. in 2017. Van den Broek, et al. described the use of intraoperative CT scan during PCNL in a prospective study of 20 patients with a median intraoperative CT scan dose of 6.7 mSv. Our group is the first to report ultra-low-dose ( <2 mSv) intraoperative CT scans during PCNL/ECIRS.
Methods: This video demonstrates the technical factors involved in performing supine PCNL/ECIRS. We demonstrate how the Artis Zeego robotic biplane fluoroscopy platform was used to achieve ultra-low-dose intraoperative imaging in a hybrid operating room environment. Intraoperative CT scans are performed using a combination of low-dose protocols and imaging collimation to the level of the kidney to achieve extraordinarily low radiation exposures for patients and clinicians. PCNLs with intraoperative CT imaging are performed as part of an IRB-approved prospective QI study intended to maximize likelihood of complete stone treatment and to reduce radiation exposure.
Results: We have successfully ensured stone-free status in kidney stone patients undergoing PCNL/ECIRS by obtaining intraoperative CT imaging. In cases where residual stone is identified and successfully treated, a second scan is then routinely performed. This video demonstrates the first international experience with ultra-low dose intraoperative CT scan. Median intraoperative CT scan dose to date is only 1 mSv. This is 93% lower than the average post-PCNL CT scan performed at our facility (13.6 mSv). To date, we have achieved a total intraoperative effective dose (including standard fluoroscopy) as low as 1.11 mSv. This single-stage treatment of a 2.1 cm kidney stone included percutaneous access by the urologist, routine fluoroscopy, and an intraoperative CT scan that confirmed no residual fragments.
Conclusions: This video has documented the first international experience for ultra-low-dose intraoperative imaging during PCNL. Effective doses are sufficiently low that multiple scans can be obtained, while still achieving significantly lower total dosage than with standard post-operative imaging. Our study is ongoing with the intent to further decrease total radiation exposure related to stone surgery.
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