Radiation Exposure in Robotic versus Conventional Ureterorenoscopy: Retrospective Clinical Data Analysis and Experimental Simulation Study

Radiation Exposure in Robotic versus Conventional Ureterorenoscopy: Retrospective Clinical Data Analysis and Experimental Simulation Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Radiation Exposure in Robotic versus Conventional Ureterorenoscopy: Retrospective Clinical Data Analysis and Experimental Simulation Study Rifat Burak Ergül, Şüheda Nur İnceoğlu, Büşra Özdemir, Arda Tunç Aydınoğlu, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9348429/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective: Fluoroscopy in urinary stone surgery poses significant ionizing radiation risks to patients and operating staff. This study compares surgeon radiation dose in robotic-assisted versus conventional ureteroscopy and evaluates the safety and ergonomic advantages of robotic systems. Methods: A retrospective analysis of 35 cases (August–October 2024) was performed. Fluoroscopy time was divided into robotic and non-robotic phases. Surgeon exposure was estimated using a three-stage simulation model at four positions: near the X-ray tube (A), 50 cm unshielded (B), 50 cm with lead protection (C), and 150 cm behind a mobile lead barrier (D). Exposure was calculated across five scenarios: Scenario 1 (Patient Mode, A), Scenario 2 (Conventional Unprotected Mode, B), Scenario 3 (Conventional Protected Mode, C), Scenario 4 (Robotic Partial Protection Mode, B non-robotic, D robotic), and Scenario 5 (Robotic Full Protection Mode, C non-robotic, D robotic). Data were analyzed using t-test, Mann-Whitney U, and chi-square tests, and presented as median (IQR) or n (%). Results: Among 35 patients (mean age 46.6 ± 15.0 years), mean total fluoroscopy time was 18.6 ± 10.1 s (5.2 ± 3.4 s robotic phase). Radiation exposure differed significantly across scenarios (p < 0.05), with median doses of 160,101.8 µSv (Scenario 1), 56.93 µSv (Scenario 2), 9.07 µSv (Scenario 3), 40.88 µSv (Scenario 4), and 6.97 µSv (Scenario 5). Conclusion: Robotic-assisted ureteroscopy significantly reduces surgeon radiation exposure. Specifically, the combination of increased distance and shielding minimizes dose levels while also improving surgeon ergonomics. Figures Figure 1 Figure 2 Introduction Urinary stone disease is a global health challenge, affecting 10% of the population and representing one of the most prevalent disorders of the urinary tract [ 1 ]. Management of urolithiasis primarily involves extracorporeal shockwave lithotripsy (SWL), ureterorenoscopy (URS) and percutaneous nephrolithotomy (PCNL), which have largely replaced traditional open and laparoscopic surgeries in routine clinical practice [ 2 , 3 ]. Among these approaches, URS has become one of the most commonly performed interventions [ 4 ]. More recently, robotic-assisted technologies have been introduced into the endourological practice, offering improved precision, ergonomics, and visualization [ 5 ]. Ionizing radiation is associated with both deterministic and stochastic effects. Deterministic effects, such as cataract formation and bone marrow suppression [ 6 ], manifest only when specific thresholds are surpassed [ 7 ], which are not normally reached in standard endourological procedures [ 8 ]. Conversely, stochastic effects lack a threshold value [ 9 ]; thus, cumulative exposure increases the risk of malignancies, including leukemia, multiple myeloma, and various solid tumors (thyroid, bladder, breast, lung, ovarian, and colon) [ 8 , 10 ]. This lack of a threshold is particularly relevant in endourology [ 11 ], where repetitive fluoroscopic guidance and multiple procedures contribute to cumulative radiation burdens. To mitigate these risks, the “As Low as Reasonably Achievable” (ALARA) principle advocates minimizing radiation exposure time, maximizing distance from the radiation source, and using appropriate protective shielding, underscoring the need to optimize urinary stone surgery techniques to reduce radiation exposure without compromising operative efficiency or procedural safety [ 12 , 13 ]. Robotic surgical systems improve surgical ergonomics and offer important potential advantages in terms of radiation safety by increasing the physical distance between the surgeon and the patient [ 14 ]. Although several studies in the current literature suggest that robotic systems may reduce radiation exposure [ 15 ], direct comparative data evaluating radiation exposure between robotic-assisted and conventional ureteroscopy are lacking. This study aims to quantitatively compare surgeon radiation exposure between robotic-assisted and conventional URS in an experimental setting and to evaluate the impact of robotic platforms on radiation safety. Methods Study Population A retrospective analysis was conducted on 35 patients who underwent URS at the Department of Urology, Istanbul Faculty of Medicine, between August and October 2024. Initially, 50 consecutive cases were identified through a systematic review of operating room records and fluoroscopy system archives. The following inclusion criteria were established: age > 18 years, treatment with robotic-assisted or conventional URS, availability of comprehensive fluoroscopic dose parameters, demographic characteristics, and clinical data. Consequently, 15 cases were excluded based on the following criteria: age < 18 years, alternative surgical techniques, the presence of non-opaque stones, or incomplete clinical/fluoroscopic documentation.This study was approved by the ethics committee of our university (Approval No: XXXX; Date: ) and conducted in accordance with the Declaration of Helsinki. All data were anonymized prior to analysis. Radiation Exposure Simulation A three-stage simulation model was developed to measure surgeon radiation exposure by integrating real clinical procedural durations with experimentally measured radiation dose rates. Stage 1: Retrospective Fluoroscopy Data Collection Fluoroscopy data were retrospectively extracted from 35 clinical cases to determine actual surgical durations. Fluoroscopy time was obtained directly from the C-arm system ( OEC One, GE Healthcare, Chicago, IL, USA) used in pulsed low-dose mode (70 kVp, 0.7 mA). Fluoroscopy time was categorized into two predefined procedural phases: Robotic and non-robotic. Robotic phase was defined as the interval beginning with the first fluoroscopic visualization of the flexible ureteroscope within the ureteral access sheath (UAS) and continuing until the final fluoroscopic image in which the UAS remains visible. Non-robotic phase was defined as all fluoroscopic imaging performed outside the defined robotic phase interval, including initial access, UAS placement, and imaging following UAS removal. These phase-specific durations provided the clinical time parameters required for the surgeon radiation exposure simulation. Stage 2: Experimental Measurement of Dose Rates In the second stage, an experimental simulation was conducted to determine the dose rates (µSv/s) at four reference positions, representing the surgeon's radiation exposure. Measurements were performed in a vacant operating room using a personal dosimeter (AT1123, Atomtex, Belarus) at a fixed height of 100 cm above the floor. The fluoroscopy system was operated using 2–3 second exposure pulses. For each position, five independent replicates were recorded; these were averaged and normalized to a per-second dose rate. The following measurement positions were defined: Position A: Measurement at the position closest to the X-ray tube Position B: Measurement at 50 cm from the X-ray tube without shielding Position C: Measurement at 50 cm from the X-ray tube behind a lead apron (Model No: 373, Aktif X-Ray, Istanbul, Turkey; Lightweight Lead, 0.50 mm Pb frontal equivalence, certified according to IEC 61331-3:2014) Position D: 150 cm from the X-ray tube behind a mobile lead barrier (Aktif X-Ray, Istanbul, Turkey; 100x200 cm, 2.00 mm Pb lead equivalence) Stage 3: Integration and Total Radiation Dose Calculation In this stage, the previously calculated dose rates defined in Stage 2 were combined with the phase-specific fluoroscopy times for each patient to calculate total surgeon radiation exposure for each scenario. For each patient, the total exposure was calculated as follows: Scenario 1 (Patient Mode): Total fluoroscopy time × Dose Rate at Position A Scenario 2 (Conventional Unprotected Mode): Total fluoroscopy time × Dose Rate at Position B Scenario 3 (Conventional Protected Mode): Total fluoroscopy time × Dose Rate at Position C Scenario 4 (Robotic Partial Protection Mode): (Non-robotic phase time × Dose Rate at Position B) + (Robotic phase time × Dose Rate at Position D) Scenario 5 (Robotic Full Protection Mode): (Non-robotic phase time Dose Rate at Position C) + (Robotic phase time × Dose Rate at Position D) Finally for each scenario, median values along with the first and third quartiles were calculated. This approach allowed for the estimation of surgeon radiation exposure for each patient, enabling a comparison across different protection strategies. Statistical Analysis Categorical variables were presented as frequencies and percentages [n (%)]. Between-group comparisons of categorical variables were performed using the chi-square test or Fisher’s exact test where appropriate. Continuous variables were reported as mean ± standard deviation or median and interquartile range (Q1–Q3), depending on the normality of distribution. Normality was assessed using the Shapiro–Wilk test and visual inspection of histograms and Q–Q plots. For comparisons between two groups, continuous variables were analyzed using the Student’s t-test for normally distributed data and the Mann–Whitney U test for non-normally distributed data. All statistical analyses were performed using R software. A two-sided p-value < 0.05 was considered statistically significant. Results A total of 50 patients who underwent URS were initially assessed for eligibility. Of these, 13 patients were excluded due to incomplete fluoroscopic dose parameters or missing clinical data. One patient was excluded for being under 18 years of age, and one patient was excluded due to significant renal anatomical variation that interfered with standardized radiation measurements. Consequently, 35 patients met the inclusion criteria and were included in the final analysis. Conventional URS was performed in 23 patients (65.7%), whereas 12 patients (34.3%) underwent robotic-assisted URS. The mean age of the study population was 46.6 ± 15.0 years. The study population included 25 male patients (71.4%) and 10 female patients (28.6%). Baseline demographic and stone-related characteristics are presented in Table 1. Fluoroscopy usage was evaluated both as total exposure and according to predefined procedural phases. The mean total fluoroscopy time was 18.6 ± 10.1 seconds, with 5.2 ± 3.4 seconds attributed to the robotic phase. The mean total number of fluoroscopic frames was 33.2 ± 16.1, of which 9.3 ± 5.6 frames were acquired during the robotic phase (Table 1). Radiation dose measurements obtained using the simulation-based dosimetry model differed significantly across the five predefined measurement scenarios. The highest radiation dose was observed in Scenario 1 (Patient Mode [Figure 2a]), with a median value of 160,101.8 µSv (Q1–Q3: 99,841.41–218,163.3). In Scenario 2 (Conventional Unprotected Mode [Figure 2b]), the median radiation dose was 56.93 µSv (Q1–Q3: 35.505–77.575). In Scenario 3 (Conventional Protected Mode [Figure 2c]), the median radiation dose was 9.07 µSv (Q1–Q3: 5.655–12.355) (Table 1). Radiation dose measurements obtained during robotic workflow scenarios are presented in Scenarios 4 and 5 (Fig. 2d-2e). In Scenario 4 (Robotic Partial Protection Mode), the median radiation dose was 40.88 µSv (Q1–Q3: 25.815–56.66). The lowest radiation dose among all scenarios was observed in Scenario 5 (Robotic Full Protection Mode), with a median value of 6.97 µSv (Q1–Q3: 4.33–9.56) (Table 1). Overall, differences in radiation dose across the five scenarios were statistically significant (all p < 0.05) (Table 2 ). Figure 2. Experimental scenarios and radiation protection configurations: (a) Patient Mode, (b) Conventional Unprotected Mode, (c) Conventional Protected Mode, (d) Robotic Partial Protection Mode, (e) Robotic Full Protection Mode Table 1. Demographic and clinical characteristics of the study population Variable Value (n = 35) Age (years), mean ± SD 46.63 ± 14.97 Gender, n (%) Male 25 (71.4%) Female 10 (28.6%) BMI (kg/m2), mean ± SD 28.29 ± 5.82 Type of Surgery, n (%) Robotic URS 12 (34.3%) Conventional URS 23 (65.7%) Side, n (%) Right 13 (37.1%) Left 22 (62.9%) Preoperative JJ Stent, n (%) Absent 19 (54.3%) Present 16 (45.7%) Stone Localization, n (%) Upper Pole 3 (8.6%) Middle Pole 5 (14.3%) Lower Pole 6 (17.1%) Renal Pelvis 8 (22.9%) Multiple 8 (22.9%) Proximal Ureter 5 (14.3%) Fluoroscopy Parameters Total number of frames, mean ± SD 33.17 ± 16.14 Robotic phase frames, mean ± SD 9.26 ± 5.56 Non-Robotic phase frames, mean ± SD 23,91 ± 11,31 Total fluoroscopy time (sec), mean ± SD 18.62 ± 10.07 Robotic phase time (sec), mean ± SD 5.22 ± 3.44 Non-Robotic phase time (sec), mean ± SD 13,40 ± 6,96 Measured Radiation Dose, median (IQR) µSv Scenario 1 (Patient Mode) 160,101.8 (99,841.41–218,163.3) µSv Scenario 2 (Conventional Unprotected Mode) 56.93 (35.505–77.575) µSv Scenario 3 (Conventional Protected Mode) 9.07 (5.655–12.355) µSv Scenario 4 (Robotic Partial Protection Mode) 40.88 (25.815–56.66) µSv Scenario 5 (Robotic Full Protection Mode) 6.97 (4.33–9.56) µSv µSv: Mikrosievert Table 2 Statistical comparison of radiation doses between different scenarios Comparison p-value Scenario 1 vs. Scenario 2 <0.001 Scenario 1 vs. Scenario 3 <0.001 Scenario 1 vs. Scenario 4 <0.001 Scenario 1 vs. Scenario 5 <0.001 Scenario 2 vs. Scenario 3 <0.001 Scenario 2 vs. Scenario 4 0,018 Scenario 2 vs. Scenario 5 <0.001 Scenario 3 vs. Scenario 4 <0.001 Scenario 3 vs. Scenario 5 0,045 Scenario 4 vs. Scenario 5 <0.001 Discussion In this study, robotic-assisted URS was associated with significantly lower surgeon radiation exposure compared with conventional URS under experimental conditions. Radiation exposure decreased with increasing distance from the fluoroscopy source and the application of protective shielding, with the lowest levels observed in robotic-assisted full-protection settings. Taken together, these findings suggest that robotic-assisted URS may provide an advantage in occupational radiation safety. Given the widespread use of URS in contemporary stone management, fluoroscopy represents a major source of occupational radiation exposure for the operating surgeon, making radiation exposure an important consideration in urinary stone disease [ 16 , 17 ]. Supporting this concern, Rajaraman et al. [ 18 ] reported a 35% increase in stroke incidence among radiologic technologists who had performed fluoroscopically guided interventional procedures compared with those who had not. Similarly, in a prospective cohort of U.S. radiologic technologists, occupational exposure to such procedures was associated with a more than two-fold increase in brain cancer mortality (hazard ratio [HR] 2.55, 95% confidence interval [CI] 1.48–4.40), as well as increased incidence of female breast cancer (HR 1.16, 95% CI 1.02–1.32) and melanoma (HR 1.30, 95% CI 1.05–1.61) [ 19 ]. Within this context, identifying strategies that reduce radiation exposure without disrupting procedural workflow is of particular clinical relevance. Fluoroscopy-guided endourological procedures are associated with occupational radiation exposure for the operating surgeon in the range of < 10 to 55 µSv per case [ 20 ]. Operator radiation exposure in our study reached a value slightly above the reported range during conventional unprotected URS (56.93 µSv), decreased to 40.88 µSv with robotic-assisted procedures, and was reduced to the lowest observed level of 6.97 µSv under robotic full protection. In conventional practice, surgeons typically operate in close proximity to the radiation source. In contrast, robotic-assisted URS enables greater physical distance from the fluoroscopy unit and allows the use of radiation shielding barriers, which may contribute to reduced occupational radiation exposure [ 21 ]. Several studies have investigated occupational radiation exposure during endourological procedures. Deininger et al. [ 22 ] reported median radiation exposures of 38.81 µSv for the chest and 17.2 µSv for the head of the surgeon, despite the routine use of lead aprons and thyroid shields in the endourology operating theatre. Park et al. [ 23 ] measured per-case radiation doses during RIRS, reporting 290 µSv for the eye, 10–310 µSv for the thyroid shield (inside vs outside), 10–580 µSv for the lead apron (inside vs outside), and 550–730 µSv for the extremities, highlighting that even with standard protective equipment, substantial exposure can occur. Furthermore, Inoue et al. [ 24 ] demonstrated that adding a protective lead curtain (LC) significantly mitigates risk, reducing mean doses outside the apron at the neck from 2.22 µSv to 0.84 µSv and at the waist from 5.48 µSv to 0.76 µSv. Building upon these benchmarks, our study shows that while a standard Conventional Protected Mode (Scenario 3) yields a median waist dose of 9.07 µSv, transitioning to a Robotic Full Protection Mode (Scenario 5) further minimizes exposure to just 6.97 µSv. This represents a nearly 60% reduction compared to the head doses reported by Deininger et al. and is lower than the internal apron doses observed by Park et al., suggesting that the integration of robotic workflows provides a superior radiation safety profile over conventional setups by optimizing operator distance and shielding. Radiation-free URS has been described in several studies, while its routine implementation remains limited by inherent selection bias, as favorable outcomes are typically reported in carefully selected patients with normal anatomy and procedures performed by highly experienced surgeons [ 25 ]. In real-world practice, particularly in training centers like ours, fluoroscopy continues to play an integral role in supporting safe procedural teaching. Furthermore, fluoroscopy remains the recommended standard in complex situations including ureteral strictures, renal anomalies, and impacted stones where precise image guidance is critical [ 26 ]. Patient-related factors also challenge imaging-restricted approaches, as a 5-unit increase in BMI has been associated with 30% higher odds of severe complications during ultrasound-guided procedures [ 27 ]. Consequently, rather than a complete abandonment of fluoroscopy, minimizing radiation exposure in accordance with the ALARA principle represents a more pragmatic and generalizable strategy for ensuring surgical safety in routine practice. The International Commission on Radiological Protection (ICRP) has established an annual occupational equivalent dose limit of 20 mSv for the lens of the eye and 500 mSv for the skin and extremities. In addition, cumulative exposures in the range of 500 mSv have been associated with an increased risk of cataract formation and potential long-term cardiovascular and cerebrovascular effects [ 28 ]. Based on the per-procedure median surgeon doses measured in our study, extrapolation to a high-volume training center setting such as ours suggests that a surgeon performing approximately 300 URS procedures each year would accumulate an estimated annual dose of ~ 17 mSv with conventional unprotected techniques, ~ 12 mSv with robotic-assisted positioning without shielding, ~ 2.7 mSv with conventional techniques using lead apron protection, and ~ 2.1 mSv under robotic full protection. In contrast to conventional and partially protected techniques that approach the ICRP-recommended annual dose limit, at which cumulative radiation risks may become clinically relevant, robotic assisted techniques with full protection maintain occupational exposure well below this threshold. Conventional URS has been associated with musculoskeletal strain and postural discomfort among urologists due to prolonged standing and constrained operative conditions [ 29 , 30 ]. This strain commonly progresses to work-related musculoskeletal disorders (WMSDs), with nearly 90% of urologists reporting annual pain and one-third experiencing discomfort more than once per week [ 31 , 32 ]. 10% of urologists eventually require corrective surgery [ 33 ], while nearly 70% rely on NSAIDs to manage pain during practice [ 32 ]. The ergonomic advantage of robotic platforms addresses these challenges; for instance, Bagrodia et al. [ 34 ] demonstrated that the prevalence of neck and back pain is substantially lower in robotic procedures (23%) compared to open (50%) and laparoscopic (56%) approaches. These findings are further corroborated by Plerhoples et al. [ 35 ], who identified laparoscopy as the most frequent cause of physical symptoms (55%) in a survey of over 1,000 surgeons, while robotic surgery was implicated in only 8% of cases. Lundon et al. [ 36 ] reported a significant disparity between surgical workload and physical strain in a high-volume center. Although laparoscopic procedures represent only 2% of the total surgical volume, they are associated with post-operative discomfort in 87% of urologists. In contrast, robotic-assisted surgery accounts for 79% of the surgical volume yet offers an improved ergonomic profile. Robotic-assisted URS may further enhance the ergonomic profile for the urologist by eliminating the need for lead aprons, which are responsible for neck and back pain, a condition sometimes referred to as “interventionalist’s disc disease” [ 37 , 38 ]. Consequently, robotic-assisted URS provides a dual advantage by optimizing surgeon ergonomics and minimizing radiation exposure, ensuring long-term professional sustainability [ 5 , 14 ]. Several studies have suggested that the use of robotic platforms may be associated with lower occupational radiation exposure during URS For instance, the Roboflex Avicenna® system utilizes a remote workstation that allows the surgeon to operate from a seated position outside the immediate radiation field [ 39 ], while the ILY® system functions as a telemanipulated holder, enabling the surgeon to remain behind protective shielding at a greater distance from the fluoroscopy unit [ 15 ]. However, despite these proposed advantages, no studies to date have performed a direct, objective comparison of occupational radiation exposure between these approaches using quantitative dosimetric measurements. Accordingly, the present study provides an objective, quantitative evaluation of occupational radiation exposure under different procedural workflows, addressing an important gap in the literature. This study has several limitations that should be acknowledged. First, its retrospective nature may introduce selection bias. Second, while the experimental simulation model provided standardized data, it may not fully replicate the dynamic variables of a live operating room, such as patient-specific anatomy or surgeon movement. Furthermore, our findings rely on simulation rather than real-time intraoperative dosimetry on a live clinical cohort, which would be necessary to validate these results in a non-simulated environment. Finally, the relatively small sample size from a single institution may limit the generalizability of the findings. Future prospective studies with real-time measurements are needed to confirm the radiation safety advantages of robotic-assisted URS. Conclusion This study demonstrates that robotic-assisted URS results in lower radiation exposure for the operating surgeon compared with conventional URS, using an experimental simulation model. A combination of increased distance from the radiation source and the use of lead shielding during robotic-assisted URS was associated with a substantial reduction in radiation dose. Furthermore, reduced dependence on continuous lead apron use may enhance surgeon ergonomics and physical comfort. These findings support the role of robotic-assisted URS in improving radiation safety while also optimizing the ergonomic working environment for the surgeon. Declarations Author Contribution R.B.E. conceived and designed the study. S.N.İ., B.Ö., and A.G. performed the data collection and clinical data acquisition. R.B.E., A.T.A., Ö.A., and B.D. conducted the experimental dosimetry measurements and technical setup. Ö.A. and B.D. were responsible for the radiation dose analysis and calculations. F.E. and A.T. contributed to the clinical validation and data interpretation. S.N.İ. wrote the first draft of the manuscript. 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J Urol 187(4 Suppl):e614–e615 Ayoub EM, Bourgi A, Alsouki J, Merhej S, Conort P (2021) Fluoroless endourological surgery for high burden renal and proximal ureteric stones: A safe technique for experienced surgeons. Arab J Urol 19(4):438–444 Ross AM, Segal J, Borenstein D, Jenkins E, Cho S (1997) Prevalence of spinal disc disease among interventional cardiologists. Am J Cardiol 79(1):68–70 Saglam R, Muslumanoglu AY, Tokatli Z, Caskurlu T, Sarica K, Tasci AI et al (2014) A new robot for flexible ureteroscopy: development and early clinical results (IDEAL stage 1-2b). Eur Urol 66(6):1092–1100 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9348429","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":624458748,"identity":"eaf06b76-fe07-4391-989c-5fe41e44d5b3","order_by":0,"name":"Rifat Burak 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Klina","correspondingAuthor":false,"prefix":"","firstName":"Vincent","middleName":"","lastName":"Coninck","suffix":""},{"id":624458756,"identity":"70b7692f-657b-42b0-9932-f41354095662","order_by":8,"name":"Francesco Esperto","email":"","orcid":"","institution":"Fondazione Policlinico Universitario Campus Bio-Medico of Rome","correspondingAuthor":false,"prefix":"","firstName":"Francesco","middleName":"","lastName":"Esperto","suffix":""},{"id":624458757,"identity":"6b98351b-b473-4858-adc7-6c9af57a569f","order_by":9,"name":"Arman Tsaturyan","email":"","orcid":"","institution":"Erebuni","correspondingAuthor":false,"prefix":"","firstName":"Arman","middleName":"","lastName":"Tsaturyan","suffix":""},{"id":624458758,"identity":"9fd2dbd0-5a78-45e8-8646-2e41048c1421","order_by":10,"name":"Begona Ballesta Martinez","email":"","orcid":"","institution":"Hospital Universitario del Vinalopó","correspondingAuthor":false,"prefix":"","firstName":"Begona","middleName":"Ballesta","lastName":"Martinez","suffix":""},{"id":624458759,"identity":"cbbb804e-31a3-4b9b-8a8e-902b583f62cf","order_by":11,"name":"Tzevat Tefik","email":"","orcid":"","institution":"Istanbul University","correspondingAuthor":false,"prefix":"","firstName":"Tzevat","middleName":"","lastName":"Tefik","suffix":""}],"badges":[],"createdAt":"2026-04-07 18:08:47","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9348429/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9348429/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107323549,"identity":"49b4c20c-c48a-4807-a3f2-9231338a7c69","added_by":"auto","created_at":"2026-04-20 10:58:53","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":612091,"visible":true,"origin":"","legend":"\u003cp\u003eExperimental setup and measurement positions: (a) Position A, (b) Position B, (c) Position C, (d) Position D\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9348429/v1/d36060b8683832c540a007b8.png"},{"id":107484967,"identity":"fea07552-0727-4ab0-8df0-359de499fb36","added_by":"auto","created_at":"2026-04-22 02:33:24","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":441648,"visible":true,"origin":"","legend":"\u003cp\u003eExperimental scenarios and radiation protection configurations: (a) Patient Mode, (b) Conventional Unprotected Mode, (c) Conventional Protected Mode, (d) Robotic Partial Protection Mode, (e) Robotic Full Protection Mode\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9348429/v1/47704b31e3b7d14e6302da20.png"},{"id":107707955,"identity":"a0dc4fd5-6966-4eab-b489-f46ae10854f2","added_by":"auto","created_at":"2026-04-24 09:21:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1580079,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9348429/v1/b638e674-df98-47d7-a925-a00c0c6677bd.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Radiation Exposure in Robotic versus Conventional Ureterorenoscopy: Retrospective Clinical Data Analysis and Experimental Simulation Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eUrinary stone disease is a global health challenge, affecting 10% of the population and representing one of the most prevalent disorders of the urinary tract [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Management of urolithiasis primarily involves extracorporeal shockwave lithotripsy (SWL), ureterorenoscopy (URS) and percutaneous nephrolithotomy (PCNL), which have largely replaced traditional open and laparoscopic surgeries in routine clinical practice [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Among these approaches, URS has become one of the most commonly performed interventions [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. More recently, robotic-assisted technologies have been introduced into the endourological practice, offering improved precision, ergonomics, and visualization [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIonizing radiation is associated with both deterministic and stochastic effects. Deterministic effects, such as cataract formation and bone marrow suppression [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], manifest only when specific thresholds are surpassed [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], which are not normally reached in standard endourological procedures [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Conversely, stochastic effects lack a threshold value [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]; thus, cumulative exposure increases the risk of malignancies, including leukemia, multiple myeloma, and various solid tumors (thyroid, bladder, breast, lung, ovarian, and colon) [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. This lack of a threshold is particularly relevant in endourology [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], where repetitive fluoroscopic guidance and multiple procedures contribute to cumulative radiation burdens. To mitigate these risks, the \u0026ldquo;As Low as Reasonably Achievable\u0026rdquo; (ALARA) principle advocates minimizing radiation exposure time, maximizing distance from the radiation source, and using appropriate protective shielding, underscoring the need to optimize urinary stone surgery techniques to reduce radiation exposure without compromising operative efficiency or procedural safety [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRobotic surgical systems improve surgical ergonomics and offer important potential advantages in terms of radiation safety by increasing the physical distance between the surgeon and the patient [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Although several studies in the current literature suggest that robotic systems may reduce radiation exposure [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], direct comparative data evaluating radiation exposure between robotic-assisted and conventional ureteroscopy are lacking. This study aims to quantitatively compare surgeon radiation exposure between robotic-assisted and conventional URS in an experimental setting and to evaluate the impact of robotic platforms on radiation safety.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Population\u003c/h2\u003e \u003cp\u003eA retrospective analysis was conducted on 35 patients who underwent URS at the Department of Urology, Istanbul Faculty of Medicine, between August and October 2024. Initially, 50 consecutive cases were identified through a systematic review of operating room records and fluoroscopy system archives. The following inclusion criteria were established: age\u0026thinsp;\u0026gt;\u0026thinsp;18 years, treatment with robotic-assisted or conventional URS, availability of comprehensive fluoroscopic dose parameters, demographic characteristics, and clinical data. Consequently, 15 cases were excluded based on the following criteria: age\u0026thinsp;\u0026lt;\u0026thinsp;18 years, alternative surgical techniques, the presence of non-opaque stones, or incomplete clinical/fluoroscopic documentation.This study was approved by the ethics committee of our university (Approval No: XXXX; Date: ) and conducted in accordance with the Declaration of Helsinki. All data were anonymized prior to analysis.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eRadiation Exposure Simulation\u003c/h3\u003e\n\u003cp\u003eA three-stage simulation model was developed to measure surgeon radiation exposure by integrating real clinical procedural durations with experimentally measured radiation dose rates.\u003c/p\u003e \u003cp\u003eStage 1: Retrospective Fluoroscopy Data Collection\u003c/p\u003e \u003cp\u003eFluoroscopy data were retrospectively extracted from 35 clinical cases to determine actual surgical durations. Fluoroscopy time was obtained directly from the C-arm system ( OEC One, GE Healthcare, Chicago, IL, USA) used in pulsed low-dose mode (70 kVp, 0.7 mA). Fluoroscopy time was categorized into two predefined procedural phases: Robotic and non-robotic. Robotic phase was defined as the interval beginning with the first fluoroscopic visualization of the flexible ureteroscope within the ureteral access sheath (UAS) and continuing until the final fluoroscopic image in which the UAS remains visible. Non-robotic phase was defined as all fluoroscopic imaging performed outside the defined robotic phase interval, including initial access, UAS placement, and imaging following UAS removal. These phase-specific durations provided the clinical time parameters required for the surgeon radiation exposure simulation.\u003c/p\u003e \u003cp\u003eStage 2: Experimental Measurement of Dose Rates\u003c/p\u003e \u003cp\u003eIn the second stage, an experimental simulation was conducted to determine the dose rates (\u0026micro;Sv/s) at four reference positions, representing the surgeon's radiation exposure. Measurements were performed in a vacant operating room using a personal dosimeter (AT1123, Atomtex, Belarus) at a fixed height of 100 cm above the floor. The fluoroscopy system was operated using 2\u0026ndash;3 second exposure pulses. For each position, five independent replicates were recorded; these were averaged and normalized to a per-second dose rate.\u003c/p\u003e \u003cp\u003eThe following measurement positions were defined:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003ePosition A: Measurement at the position closest to the X-ray tube\u003c/p\u003e\u003cp\u003ePosition B: Measurement at 50 cm from the X-ray tube without shielding\u003c/p\u003e\u003cp\u003ePosition C: Measurement at 50 cm from the X-ray tube behind a lead apron (Model No: 373, Aktif X-Ray, Istanbul, Turkey; Lightweight Lead, 0.50 mm Pb frontal equivalence, certified according to IEC 61331-3:2014)\u003c/p\u003e\u003cp\u003ePosition D: 150 cm from the X-ray tube behind a mobile lead barrier (Aktif X-Ray, Istanbul, Turkey; 100x200 cm, 2.00 mm Pb lead equivalence)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eStage 3: Integration and Total Radiation Dose Calculation\u003c/p\u003e \u003cp\u003eIn this stage, the previously calculated dose rates defined in Stage 2 were combined with the phase-specific fluoroscopy times for each patient to calculate total surgeon radiation exposure for each scenario. For each patient, the total exposure was calculated as follows:\u003c/p\u003e \u003cp\u003eScenario 1 (Patient Mode): Total fluoroscopy time \u0026times; Dose Rate at Position A\u003c/p\u003e \u003cp\u003eScenario 2 (Conventional Unprotected Mode): Total fluoroscopy time \u0026times; Dose Rate at Position B\u003c/p\u003e \u003cp\u003eScenario 3 (Conventional Protected Mode): Total fluoroscopy time \u0026times; Dose Rate at Position C\u003c/p\u003e \u003cp\u003eScenario 4 (Robotic Partial Protection Mode): (Non-robotic phase time \u0026times; Dose Rate at Position B) + (Robotic phase time \u0026times; Dose Rate at Position D)\u003c/p\u003e \u003cp\u003eScenario 5 (Robotic Full Protection Mode): (Non-robotic phase time Dose Rate at Position C) + (Robotic phase time \u0026times; Dose Rate at Position D)\u003c/p\u003e \u003cp\u003eFinally for each scenario, median values along with the first and third quartiles were calculated. This approach allowed for the estimation of surgeon radiation exposure for each patient, enabling a comparison across different protection strategies.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eCategorical variables were presented as frequencies and percentages [n (%)]. Between-group comparisons of categorical variables were performed using the chi-square test or Fisher\u0026rsquo;s exact test where appropriate. Continuous variables were reported as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation or median and interquartile range (Q1\u0026ndash;Q3), depending on the normality of distribution. Normality was assessed using the Shapiro\u0026ndash;Wilk test and visual inspection of histograms and Q\u0026ndash;Q plots. For comparisons between two groups, continuous variables were analyzed using the Student\u0026rsquo;s t-test for normally distributed data and the Mann\u0026ndash;Whitney U test for non-normally distributed data. All statistical analyses were performed using R software. A two-sided p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 50 patients who underwent URS were initially assessed for eligibility. Of these, 13 patients were excluded due to incomplete fluoroscopic dose parameters or missing clinical data. One patient was excluded for being under 18 years of age, and one patient was excluded due to significant renal anatomical variation that interfered with standardized radiation measurements. Consequently, 35 patients met the inclusion criteria and were included in the final analysis.\u003c/p\u003e \u003cp\u003eConventional URS was performed in 23 patients (65.7%), whereas 12 patients (34.3%) underwent robotic-assisted URS. The mean age of the study population was 46.6\u0026thinsp;\u0026plusmn;\u0026thinsp;15.0 years. The study population included 25 male patients (71.4%) and 10 female patients (28.6%). Baseline demographic and stone-related characteristics are presented in Table\u0026nbsp;1.\u003c/p\u003e \u003cp\u003eFluoroscopy usage was evaluated both as total exposure and according to predefined procedural phases. The mean total fluoroscopy time was 18.6\u0026thinsp;\u0026plusmn;\u0026thinsp;10.1 seconds, with 5.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.4 seconds attributed to the robotic phase. The mean total number of fluoroscopic frames was 33.2\u0026thinsp;\u0026plusmn;\u0026thinsp;16.1, of which 9.3\u0026thinsp;\u0026plusmn;\u0026thinsp;5.6 frames were acquired during the robotic phase (Table\u0026nbsp;1).\u003c/p\u003e \u003cp\u003eRadiation dose measurements obtained using the simulation-based dosimetry model differed significantly across the five predefined measurement scenarios. The highest radiation dose was observed in Scenario 1 (Patient Mode [Figure 2a]), with a median value of 160,101.8 \u0026micro;Sv (Q1\u0026ndash;Q3: 99,841.41\u0026ndash;218,163.3). In Scenario 2 (Conventional Unprotected Mode [Figure 2b]), the median radiation dose was 56.93 \u0026micro;Sv (Q1\u0026ndash;Q3: 35.505\u0026ndash;77.575). In Scenario 3 (Conventional Protected Mode [Figure 2c]), the median radiation dose was 9.07 \u0026micro;Sv (Q1\u0026ndash;Q3: 5.655\u0026ndash;12.355) (Table\u0026nbsp;1). Radiation dose measurements obtained during robotic workflow scenarios are presented in Scenarios 4 and 5 (Fig.\u0026nbsp;2d-2e). In Scenario 4 (Robotic Partial Protection Mode), the median radiation dose was 40.88 \u0026micro;Sv (Q1\u0026ndash;Q3: 25.815\u0026ndash;56.66). The lowest radiation dose among all scenarios was observed in Scenario 5 (Robotic Full Protection Mode), with a median value of 6.97 \u0026micro;Sv (Q1\u0026ndash;Q3: 4.33\u0026ndash;9.56) (Table\u0026nbsp;1). Overall, differences in radiation dose across the five scenarios were statistically significant (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFigure 2. Experimental scenarios and radiation protection configurations: (a) Patient Mode, (b) Conventional Unprotected Mode, (c) Conventional Protected Mode, (d) Robotic Partial Protection Mode, (e) Robotic Full Protection Mode\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;1. Demographic and clinical characteristics of the study population\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValue (n\u0026thinsp;=\u0026thinsp;35)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46.63\u0026thinsp;\u0026plusmn;\u0026thinsp;14.97\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (71.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (28.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg/m2), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28.29\u0026thinsp;\u0026plusmn;\u0026thinsp;5.82\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of Surgery, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRobotic URS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (34.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConventional URS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (65.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSide, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (37.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (62.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative JJ Stent, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbsent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (54.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePresent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (45.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStone Localization, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUpper Pole\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (8.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle Pole\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (14.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLower Pole\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (17.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRenal Pelvis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (22.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMultiple\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (22.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProximal Ureter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (14.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFluoroscopy Parameters\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal number of frames, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33.17\u0026thinsp;\u0026plusmn;\u0026thinsp;16.14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRobotic phase frames, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.26\u0026thinsp;\u0026plusmn;\u0026thinsp;5.56\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-Robotic phase frames, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23,91\u0026thinsp;\u0026plusmn;\u0026thinsp;11,31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal fluoroscopy time (sec), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18.62\u0026thinsp;\u0026plusmn;\u0026thinsp;10.07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRobotic phase time (sec), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.22\u0026thinsp;\u0026plusmn;\u0026thinsp;3.44\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-Robotic phase time (sec), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13,40\u0026thinsp;\u0026plusmn;\u0026thinsp;6,96\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeasured Radiation Dose, median (IQR) \u0026micro;Sv\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScenario 1 (Patient Mode)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e160,101.8 (99,841.41\u0026ndash;218,163.3) \u0026micro;Sv\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScenario 2 (Conventional Unprotected Mode)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56.93 (35.505\u0026ndash;77.575) \u0026micro;Sv\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScenario 3 (Conventional Protected Mode)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.07 (5.655\u0026ndash;12.355) \u0026micro;Sv\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScenario 4 (Robotic Partial Protection Mode)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40.88 (25.815\u0026ndash;56.66) \u0026micro;Sv\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScenario 5 (Robotic Full Protection Mode)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.97 (4.33\u0026ndash;9.56) \u0026micro;Sv\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e\u0026micro;Sv: Mikrosievert\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStatistical comparison of radiation doses between different scenarios\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComparison\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScenario 1 vs. Scenario 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScenario 1 vs. Scenario 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScenario 1 vs. Scenario 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScenario 1 vs. Scenario 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScenario 2 vs. Scenario 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScenario 2 vs. Scenario 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0,018\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScenario 2 vs. Scenario 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScenario 3 vs. Scenario 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScenario 3 vs. Scenario 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0,045\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScenario 4 vs. Scenario 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, robotic-assisted URS was associated with significantly lower surgeon radiation exposure compared with conventional URS under experimental conditions. Radiation exposure decreased with increasing distance from the fluoroscopy source and the application of protective shielding, with the lowest levels observed in robotic-assisted full-protection settings. Taken together, these findings suggest that robotic-assisted URS may provide an advantage in occupational radiation safety.\u003c/p\u003e \u003cp\u003eGiven the widespread use of URS in contemporary stone management, fluoroscopy represents a major source of occupational radiation exposure for the operating surgeon, making radiation exposure an important consideration in urinary stone disease [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Supporting this concern, Rajaraman et al. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] reported a 35% increase in stroke incidence among radiologic technologists who had performed fluoroscopically guided interventional procedures compared with those who had not. Similarly, in a prospective cohort of U.S. radiologic technologists, occupational exposure to such procedures was associated with a more than two-fold increase in brain cancer mortality (hazard ratio [HR] 2.55, 95% confidence interval [CI] 1.48\u0026ndash;4.40), as well as increased incidence of female breast cancer (HR 1.16, 95% CI 1.02\u0026ndash;1.32) and melanoma (HR 1.30, 95% CI 1.05\u0026ndash;1.61) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Within this context, identifying strategies that reduce radiation exposure without disrupting procedural workflow is of particular clinical relevance.\u003c/p\u003e \u003cp\u003eFluoroscopy-guided endourological procedures are associated with occupational radiation exposure for the operating surgeon in the range of \u0026lt;\u0026thinsp;10 to 55 \u0026micro;Sv per case [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Operator radiation exposure in our study reached a value slightly above the reported range during conventional unprotected URS (56.93 \u0026micro;Sv), decreased to 40.88 \u0026micro;Sv with robotic-assisted procedures, and was reduced to the lowest observed level of 6.97 \u0026micro;Sv under robotic full protection. In conventional practice, surgeons typically operate in close proximity to the radiation source. In contrast, robotic-assisted URS enables greater physical distance from the fluoroscopy unit and allows the use of radiation shielding barriers, which may contribute to reduced occupational radiation exposure [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSeveral studies have investigated occupational radiation exposure during endourological procedures. Deininger et al. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] reported median radiation exposures of 38.81 \u0026micro;Sv for the chest and 17.2 \u0026micro;Sv for the head of the surgeon, despite the routine use of lead aprons and thyroid shields in the endourology operating theatre. Park et al. [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] measured per-case radiation doses during RIRS, reporting 290 \u0026micro;Sv for the eye, 10\u0026ndash;310 \u0026micro;Sv for the thyroid shield (inside vs outside), 10\u0026ndash;580 \u0026micro;Sv for the lead apron (inside vs outside), and 550\u0026ndash;730 \u0026micro;Sv for the extremities, highlighting that even with standard protective equipment, substantial exposure can occur. Furthermore, Inoue et al. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] demonstrated that adding a protective lead curtain (LC) significantly mitigates risk, reducing mean doses outside the apron at the neck from 2.22 \u0026micro;Sv to 0.84 \u0026micro;Sv and at the waist from 5.48 \u0026micro;Sv to 0.76 \u0026micro;Sv. Building upon these benchmarks, our study shows that while a standard Conventional Protected Mode (Scenario 3) yields a median waist dose of 9.07 \u0026micro;Sv, transitioning to a Robotic Full Protection Mode (Scenario 5) further minimizes exposure to just 6.97 \u0026micro;Sv. This represents a nearly 60% reduction compared to the head doses reported by Deininger et al. and is lower than the internal apron doses observed by Park et al., suggesting that the integration of robotic workflows provides a superior radiation safety profile over conventional setups by optimizing operator distance and shielding.\u003c/p\u003e \u003cp\u003eRadiation-free URS has been described in several studies, while its routine implementation remains limited by inherent selection bias, as favorable outcomes are typically reported in carefully selected patients with normal anatomy and procedures performed by highly experienced surgeons [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. In real-world practice, particularly in training centers like ours, fluoroscopy continues to play an integral role in supporting safe procedural teaching. Furthermore, fluoroscopy remains the recommended standard in complex situations including ureteral strictures, renal anomalies, and impacted stones where precise image guidance is critical [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Patient-related factors also challenge imaging-restricted approaches, as a 5-unit increase in BMI has been associated with 30% higher odds of severe complications during ultrasound-guided procedures [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Consequently, rather than a complete abandonment of fluoroscopy, minimizing radiation exposure in accordance with the ALARA principle represents a more pragmatic and generalizable strategy for ensuring surgical safety in routine practice.\u003c/p\u003e \u003cp\u003eThe International Commission on Radiological Protection (ICRP) has established an annual occupational equivalent dose limit of 20 mSv for the lens of the eye and 500 mSv for the skin and extremities. In addition, cumulative exposures in the range of 500 mSv have been associated with an increased risk of cataract formation and potential long-term cardiovascular and cerebrovascular effects [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Based on the per-procedure median surgeon doses measured in our study, extrapolation to a high-volume training center setting such as ours suggests that a surgeon performing approximately 300 URS procedures each year would accumulate an estimated annual dose of ~\u0026thinsp;17 mSv with conventional unprotected techniques, ~\u0026thinsp;12 mSv with robotic-assisted positioning without shielding, ~\u0026thinsp;2.7 mSv with conventional techniques using lead apron protection, and ~\u0026thinsp;2.1 mSv under robotic full protection. In contrast to conventional and partially protected techniques that approach the ICRP-recommended annual dose limit, at which cumulative radiation risks may become clinically relevant, robotic assisted techniques with full protection maintain occupational exposure well below this threshold.\u003c/p\u003e \u003cp\u003eConventional URS has been associated with musculoskeletal strain and postural discomfort among urologists due to prolonged standing and constrained operative conditions [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. This strain commonly progresses to work-related musculoskeletal disorders (WMSDs), with nearly 90% of urologists reporting annual pain and one-third experiencing discomfort more than once per week [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. 10% of urologists eventually require corrective surgery [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], while nearly 70% rely on NSAIDs to manage pain during practice [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. The ergonomic advantage of robotic platforms addresses these challenges; for instance, Bagrodia et al. [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] demonstrated that the prevalence of neck and back pain is substantially lower in robotic procedures (23%) compared to open (50%) and laparoscopic (56%) approaches. These findings are further corroborated by Plerhoples et al. [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], who identified laparoscopy as the most frequent cause of physical symptoms (55%) in a survey of over 1,000 surgeons, while robotic surgery was implicated in only 8% of cases. Lundon et al. [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] reported a significant disparity between surgical workload and physical strain in a high-volume center. Although laparoscopic procedures represent only 2% of the total surgical volume, they are associated with post-operative discomfort in 87% of urologists. In contrast, robotic-assisted surgery accounts for 79% of the surgical volume yet offers an improved ergonomic profile. Robotic-assisted URS may further enhance the ergonomic profile for the urologist by eliminating the need for lead aprons, which are responsible for neck and back pain, a condition sometimes referred to as \u0026ldquo;interventionalist\u0026rsquo;s disc disease\u0026rdquo; [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Consequently, robotic-assisted URS provides a dual advantage by optimizing surgeon ergonomics and minimizing radiation exposure, ensuring long-term professional sustainability [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSeveral studies have suggested that the use of robotic platforms may be associated with lower occupational radiation exposure during URS For instance, the Roboflex Avicenna\u0026reg; system utilizes a remote workstation that allows the surgeon to operate from a seated position outside the immediate radiation field [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e], while the ILY\u0026reg; system functions as a telemanipulated holder, enabling the surgeon to remain behind protective shielding at a greater distance from the fluoroscopy unit [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. However, despite these proposed advantages, no studies to date have performed a direct, objective comparison of occupational radiation exposure between these approaches using quantitative dosimetric measurements. Accordingly, the present study provides an objective, quantitative evaluation of occupational radiation exposure under different procedural workflows, addressing an important gap in the literature.\u003c/p\u003e \u003cp\u003eThis study has several limitations that should be acknowledged. First, its retrospective nature may introduce selection bias. Second, while the experimental simulation model provided standardized data, it may not fully replicate the dynamic variables of a live operating room, such as patient-specific anatomy or surgeon movement. Furthermore, our findings rely on simulation rather than real-time intraoperative dosimetry on a live clinical cohort, which would be necessary to validate these results in a non-simulated environment. Finally, the relatively small sample size from a single institution may limit the generalizability of the findings. Future prospective studies with real-time measurements are needed to confirm the radiation safety advantages of robotic-assisted URS.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study demonstrates that robotic-assisted URS results in lower radiation exposure for the operating surgeon compared with conventional URS, using an experimental simulation model. A combination of increased distance from the radiation source and the use of lead shielding during robotic-assisted URS was associated with a substantial reduction in radiation dose. Furthermore, reduced dependence on continuous lead apron use may enhance surgeon ergonomics and physical comfort. These findings support the role of robotic-assisted URS in improving radiation safety while also optimizing the ergonomic working environment for the surgeon.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eR.B.E. conceived and designed the study. S.N.İ., B.\u0026Ouml;., and A.G. performed the data collection and clinical data acquisition. R.B.E., A.T.A., \u0026Ouml;.A., and B.D. conducted the experimental dosimetry measurements and technical setup. \u0026Ouml;.A. and B.D. were responsible for the radiation dose analysis and calculations. F.E. and A.T. contributed to the clinical validation and data interpretation. S.N.İ. wrote the first draft of the manuscript. R.B.E., V.D.C., B.B.M., and T.T. critically revised the manuscript for important intellectual content. T.T. supervised the project. All authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSorokin I, Mamoulakis C, Miyazawa K, Rodgers A, Talati J, Lotan Y (2017) Epidemiology of stone disease across the world. World J Urol 35(9):1301\u0026ndash;1320\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWales R, Munshi F, Penukonda S, Sanford D, Pareek G. The Surgical Management of Urolithiasis: A Review of the Literature. R I, Med J (2013) 2023;106(11):36\u0026ndash;40\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eErgul RB, Ozervarli MF, Panthier F, Nedbal C, Tsaturyan A, Pietropaolo A et al (2025) Surgical outcomes of robotic surgery for kidney stones: a systematic review and meta-analysis from section of YAU and EAU endourology. World J Urol 43(1):364\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMuller PF, Schlager D, Hein S, Bach C, Miernik A, Schoeb DS (2018) Robotic stone surgery - Current state and future prospects: A systematic review. Arab J Urol 16(3):357\u0026ndash;364\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGamal A, Moschovas MC, Jaber AR, Saikali S, Perera R, Headley C et al (2024) Clinical applications of robotic surgery platforms: a comprehensive review. J Robot Surg 18(1):29\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBhanot R, Hameed ZBM, Shah M, Juliebo-Jones P, Skolarikos A, Somani B (2022) ALARA in Urology: Steps to Minimise Radiation Exposure During All Parts of the Endourological Journey. Curr Urol Rep 23(10):255\u0026ndash;259\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Coninck V, Mortiers X, Hendrickx L, De Wachter S, Traxer O, Keller EX (2024) Radiation exposure of patients during endourological procedures. World J Urol 42(1):266\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Coninck V, Hendrickx L, Mortiers X, Somani B, Emiliani E, Sener ET et al (2024) Radiation exposure of urologists during endourological procedures: a systematic review. World J Urol 42(1):310\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFontanet Soler S, Bravo-Balado A, Skolarikos A, Seitz C, Traxer O, Talso M et al (2024) Trends in the use of radiation protection and radiation exposure of European endourologists: a prospective trial from the EULIS-YAU Endourology Group. World J Urol 42(1):163\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePreston DL, Ron E, Tokuoka S, Funamoto S, Nishi N, Soda M et al (2007) Solid cancer incidence in atomic bomb survivors: 1958\u0026ndash;1998. Radiat Res 168(1):1\u0026ndash;64\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiller DT, Semins MJ (2021) Safety During Ureteroscopy: Radiation, Eyes, and Ergonomics. 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Occup Environ Med 73(1):21\u0026ndash;27\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRajaraman P, Doody MM, Yu CL, Preston DL, Miller JS, Sigurdson AJ et al (2016) Cancer Risks in U.S. Radiologic Technologists Working With Fluoroscopically Guided Interventional Procedures, 1994\u0026ndash;2008. AJR Am J Roentgenol 206(5):1101\u0026ndash;1108 quiz 9\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVassileva J, Zagorska A, Karagiannis A, Petkova K, Sabuncu K, Saltirov I et al (2021) Radiation Exposure of Surgical Team During Endourological Procedures: International Atomic Energy Agency-South-Eastern European Group for Urolithiasis Research Study. J Endourol 35(5):574\u0026ndash;582\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim J, Park H, Kwon DS, Lee JY, Cho SY (2025) Robotic flexible ureteroscopy system, Zamenix R, demonstrates efficacy and safety in initial clinical evaluation for retrograde intrarenal surgery. Sci Rep 15(1):17366\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDeininger S, Nairz O, Dieplinger AM, Deininger C, Lusuardi L, Ramesmayer C et al (2024) Real-Time Dosimetry in Endourology: Tracking Staff Radiation Risks. Diagnostics (Basel). ;14(16)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePark IW, Kim SJ, Shin D, Shim SR, Chang HK, Kim CH (2021) Radiation exposure to the urology surgeon during retrograde intrarenal surgery. PLoS ONE 16(3):e0247833\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInoue T, Komemushi A, Murota T, Yoshida T, Taguchi M, Kinoshita H et al (2017) Effect of Protective Lead Curtains on Scattered Radiation Exposure to the Operator During Ureteroscopy for Stone Disease: A Controlled Trial. Urology 109:60\u0026ndash;66\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDavis NF, Tzelves L, Geraghty R, Lombardo R, Yuan C, Petrik A et al (2023) Comparison of Treatment Outcomes for Fluoroscopic and Fluoroscopy-free Endourological Procedures: A Systematic Review on Behalf of the European Association of Urology Urolithiasis Guidelines Panel. Eur Urol Focus 9(6):938\u0026ndash;953\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAkram M, Somani B (2025) Radiation-free RIRS and setting a new standard: redefining safety and efficacy in stone surgery. Transl Androl Urol 14(3):485\u0026ndash;488\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArmas-Phan M, Tzou DT, Bayne DB, Wiener SV, Stoller ML, Chi T (2020) Ultrasound guidance can be used safely for renal tract dilatation during percutaneous nephrolithotomy. BJU Int 125(2):284\u0026ndash;291\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAuthors on behalf of I, Stewart FA, Akleyev AV, Hauer-Jensen M, Hendry JH, Kleiman NJ et al (2012) ICRP publication 118: ICRP statement on tissue reactions and early and late effects of radiation in normal tissues and organs\u0026ndash;threshold doses for tissue reactions in a radiation protection context. Ann ICRP 41(1\u0026ndash;2):1\u0026ndash;322\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGabrielson AT, Clifton MM, Pavlovich CP, Biles MJ, Huang M, Agnew J et al (2021) Surgical ergonomics for urologists: a practical guide. Nat Rev Urol 18(3):160\u0026ndash;169\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGabrielson AT, Tanidir Y, Castellani D, Ragoori D, Jean LE, Corrales M et al (2022) A Global Survey of Ergonomics Practice Patterns and Rates of Musculoskeletal Pain Among Urologists Performing Retrograde Intrarenal Surgery. J Endourol 36(9):1168\u0026ndash;1176\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEpstein S, Sparer EH, Tran BN, Ruan QZ, Dennerlein JT, Singhal D et al (2018) Prevalence of Work-Related Musculoskeletal Disorders Among Surgeons and Interventionalists: A Systematic Review and Meta-analysis. JAMA Surg 153(2):e174947\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGillespie AM, Wang C, Movassaghi M (2023) Ergonomic Considerations in Urologic Surgery. Curr Urol Rep 24(3):143\u0026ndash;155\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLloyd GL, Chung ASJ, Steinberg S, Sawyer M, Williams DH, Overbey D (2019) Is Your Career Hurting You? The Ergonomic Consequences of Surgery in 701 Urologists Worldwide. J Endourol 33(12):1037\u0026ndash;1042\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBagrodia A, Raman JD (2009) Ergonomics considerations of radical prostatectomy: physician perspective of open, laparoscopic, and robot-assisted techniques. J Endourol 23(4):627\u0026ndash;633\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePlerhoples TA, Hernandez-Boussard T, Wren SM (2012) The aching surgeon: a survey of physical discomfort and symptoms following open, laparoscopic, and robotic surgery. J Robot Surg 6(1):65\u0026ndash;72\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLundon D, Kelly B, Bouchier-Hayes D (2012) 1518 Surgeon morbidity does robot-assisted really cause less trauma to the operator? An international multiple surgeons\u0026rsquo; opinion from experience of over 3,000 cases. J Urol 187(4 Suppl):e614\u0026ndash;e615\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAyoub EM, Bourgi A, Alsouki J, Merhej S, Conort P (2021) Fluoroless endourological surgery for high burden renal and proximal ureteric stones: A safe technique for experienced surgeons. Arab J Urol 19(4):438\u0026ndash;444\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoss AM, Segal J, Borenstein D, Jenkins E, Cho S (1997) Prevalence of spinal disc disease among interventional cardiologists. Am J Cardiol 79(1):68\u0026ndash;70\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaglam R, Muslumanoglu AY, Tokatli Z, Caskurlu T, Sarica K, Tasci AI et al (2014) A new robot for flexible ureteroscopy: development and early clinical results (IDEAL stage 1-2b). Eur Urol 66(6):1092\u0026ndash;1100\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-9348429/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9348429/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003eFluoroscopy in urinary stone surgery poses significant ionizing radiation risks to patients and operating staff. This study compares surgeon radiation dose in robotic-assisted versus conventional ureteroscopy and evaluates the safety and ergonomic advantages of robotic systems.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003eA retrospective analysis of 35 cases (August–October 2024) was performed. Fluoroscopy time was divided into robotic and non-robotic phases. Surgeon exposure was estimated using a three-stage simulation model at four positions: near the X-ray tube (A), 50 cm unshielded (B), 50 cm with lead protection (C), and 150 cm behind a mobile lead barrier (D). Exposure was calculated across five scenarios: Scenario 1 (Patient Mode, A), Scenario 2 (Conventional Unprotected Mode, B), Scenario 3 (Conventional Protected Mode, C), Scenario 4 (Robotic Partial Protection Mode, B non-robotic, D robotic), and Scenario 5 (Robotic Full Protection Mode, C non-robotic, D robotic). Data were analyzed using t-test, Mann-Whitney U, and chi-square tests, and presented as median (IQR) or n (%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003eAmong 35 patients (mean age 46.6 ± 15.0 years), mean total fluoroscopy time was 18.6 ± 10.1 s (5.2 ± 3.4 s robotic phase). Radiation exposure differed significantly across scenarios (p \u0026lt; 0.05), with median doses of 160,101.8 µSv (Scenario 1), 56.93 µSv (Scenario 2), 9.07 µSv (Scenario 3), 40.88 µSv (Scenario 4), and 6.97 µSv (Scenario 5).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Robotic-assisted ureteroscopy significantly reduces surgeon radiation exposure. Specifically, the combination of increased distance and shielding minimizes dose levels while also improving surgeon ergonomics.\u003c/p\u003e","manuscriptTitle":"Radiation Exposure in Robotic versus Conventional Ureterorenoscopy: Retrospective Clinical Data Analysis and Experimental Simulation Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-20 10:58:49","doi":"10.21203/rs.3.rs-9348429/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"18929861-c8b7-4ed5-a1af-8d99195804f2","owner":[],"postedDate":"April 20th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-15T11:24:19+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-20 10:58:49","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9348429","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9348429","identity":"rs-9348429","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}