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Novel Use of an Image Enhancement Device to Reduce Fluoroscopic Radiation Exposure during Ureteroscopic Lithotripsy: A Randomized, Prospective Clinical Evaluation of Lessray™ Ashley J. Brandon, Michael D. Fabrizio, Arjun Poddar and Shaun E.L. Wason Department of Urology, Eastern Virginia Medical School, Norfolk, Virginia Introduction Patients and Methods Intraoperative exposure to ionizing radiation is a growing concern for the safety of both patient and OR staff Efforts to reduce the amount of radiation during fluoroscopic procedures often result in decreased image quality LessRay™ is a device used to digitally enhance images obtained from a C-arm using a low-dose pulse setting allowing for reduction in radiation dose while maintaining image quality After IRB approval, a randomized prospective trial of 23 patients undergoing ureteroscopic lithotripsy for unilateral obstructing ureteral stones was performed comparing standard fluoroscopy to LessRay™ Inclusion criteria: • Adult, non-pregnant patients • No anatomic GU abnormalities • BMI <45 Patient demographics, stone parameters and operative characteristics were recorded in addition to total radiation dose, total fluoroscopy time and images obtained Dosimetry badges worn by OR personnel estimated radiation exposure to operating room staff Lessray™ Technology The Lessray™ system is a standalone computer display system interfaced to a fluoroscope with a video cable and combines the current image with a prior baseline image of the same anatomy An algorithm provides for digitally enhanced images (higher resolution) using the low dose-pulse setting snf incorporates tracking and alternating features Used exclusively in orthopedic surgery to date Results Discussion Average patient radiation dose was decreased from 1003 to 373 mRAD (p = 0.008) per case, along with total fluoroscopy time (43.32 vs. 16.2 sec, p= 0.006) and average dose per image (23.6 vs. 10.3 mRAD/image, p= 0.002) using LessRay™ compared to standard fluoroscopy intraoperatively (table 2) A statistically significant reduction in radiation exposure to the surgeon was also noted (p= 0.03). Image quality was not compromised substantively and no conversion from low radiation imaging to standard fluoroscopy was needed in any case due to inadequate visualization A 63% reduction in average patient radiation exposure was achieved using the LessRay™ device compared to standard fluoroscopy in ureteroscopic procedures performed for solitary obstructing ureteral stones LessRay™ allowed for a greater than 4x reduction in the amount of radiation to the urologist during a single procedure A significant limitation of this study includes the inability to blind the surgeon to the intervention due to the nature of the device which may have introduced a bias Conclusion LessRay™ offers an innovative and novel technique for significantly reducing intraoperative radiation exposure from fluoroscopic imaging for both patients and surgeons. It has never been previously described in the urologic literature Image resolution is superior to low-dose pulse fluoroscopy and additional features enhance standard fluoroscopy. In addition to ureteroscopy, future applications in urology may include PCNL or any procedure where fluoroscopy is utilized Shaun E. L. Wason, MD: [email protected]