Fluoroscopy has significantly improved lead placement and decreased surgical time for implantable sacral neuromodulation. Despite the Food and Drug Administration public health advisory encouraging physicians to limit the use of fluoroscopy, there is a paucity of data regarding radiation and safety of fluoroscopy during sacral neuromodulation procedures. The aim of our study is to characterize fluoroscopy time and dose used during sacral neuromodulation surgery.

Electronic medical record was queried for sacral neuromodulation procedures (Stage 1 and full implant) between July 1, 2016 and July 1, 2021 at three academic institutions.  Demographic data including age, sex, weight, body mass index (BMI), tobacco use and perioperative data including procedural indications, procedure, surgeon, surgeon specialty, operative setting, presence of trainees, operative time, fluoroscopy time, and dosimetry were collected.  The data was entered into a centralized REDCap database. Statistical analyses were performed using STATA/BE 17.0.

524 procedures were performed across three institutions. 456 were Stage 1 lead placement and 68 were full implants. 358 (68.3%) procedures had fluoroscopy details recorded. Mean surgical time was 49.2 minutes +/- 16.8(Standard Deviation, SD).  The mean fluoroscopy time was 46.1 seconds +/- 48.9(SD) and mean dosimetry was 36.8mGy +/-  46.1(SD). Of all procedures, 80.5% were completed by general urologists and urology-trained Female Pelvic Medicine and Reconstructive Surgery (FPMRS) specialists. Surgical specialty was significantly predictive of time and dose with FPMRS-trained urologists utilizing the lowest of both (p<0.001, Table 1). The presence of trainees significantly increased fluoroscopy time. Bilateral lead placement also significantly increased both dose and time. On multivariate analysis for fluoroscopy time, both the placement of bilateral leads and FPMRS-trained urologists had a statistically significant impact (p<0.001).

Our data displays significant variation in both the radiation time and dose utilized among different specialties and among urogynecologists with different background training during sacral neuromodulation procedures. We also saw that the presence of trainees as well as bilateral lead placement significantly increased fluoroscopy time. Given the significant variation, there is room for improvement with radiation safety training and best practices guidelines to limit the usage of radiation during these frequently performed procedures. There are also future studies to be performed to analyze exactly where providers should stand during sacral neuromodulation procedures to best limit the radiation exposure.

Fluoroscopy practices in sacral neuromodulation procedures include significant variability in cumulative radiation dose and time based on multiple factors. These findings demonstrate the need for standardized radiation and fluoroscopy training across specialties who perform sacral neuromodulation procedures.

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Frane N, Bitterman A. Radiation Safety and Protection. In: StatPearls. StatPearls Publishing; 2022. Accessed March 14, 2022. http://www.ncbi.nlm.nih.gov/books/NBK557499/
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Continence 7S1 (2023) 100938
DOI: 10.1016/j.cont.2023.100938