Re: Aboutaleb H, Sultan M, Zaghloul A, Farahat Y, Gawish M, Zanaty F. Is fluoroscopy-free single-use flexible ureteroscopy a feasible treatment for kidney stones with abnormal renal anatomy? Asian J Urol 2024;11:591–5. Fluoroscopic-free procedures: Is this the future of endourology?

Dear Editor,

We read with great interest the article by Aboutaleb et al. [1] titled “Is fluoroscopy-free single-use flexible ureteroscopy a feasible treatment for kidney stones with abnormal renal anatomy?” and would like to commend the authors for their insightful study on the feasibility of fluoroscopy-free single-use flexible ureteroscopy in the treatment of kidney stones, particularly in patients with abnormal renal anatomy. This area of research is highly relevant, given the increasing concerns about radiation exposure to both patients and healthcare providers. The increasing attention to fluoroscopy-free procedures in recent years is justified, as we seek to minimize the risks associated with prolonged radiation use [2].

In our own clinical practice, we have successfully performed fluoroscopy-free ureteroscopy procedures in selected patients, and we have observed that, in most cases, there were no significant complications or difficulties. This aligns with the results of the study by Aboutaleb et al. [1], which found that the majority of procedures were completed without fluoroscopy, and that both the stone-free rates and perioperative complication rates were comparable between the fluoroscopy-free and fluoroscopy-guided approaches.

That said, the study raises several important questions that need further discussion and exploration.

One concern is the emphasis on the fluoroscopy-free aspect of the procedure. While it is certainly a significant advancement, I believe that rather than focusing solely on fluoroscopy-free procedures, it might be more practical and productive to establish clear guidelines on the minimum levels of radiation exposure [3] that are considered acceptable for various procedures (retrograde intrarenal surgery, percutaneous nephrolithotomy, and ureteroscopy) and various stone sizes [[4], [5], [6], [7]]. Setting these thresholds would allow clinicians to better balance the risks and benefits of using fluoroscopy, ensuring that radiation exposure remains as low as possible while still providing necessary guidance during surgery. This approach would allow us to reduce the use of fluoroscopy when possible, but still rely on it when needed, without neglecting patient safety.

Another issue that arises from this study is the question of the expertise required for endourologists to safely perform fluoroscopy-free procedures. The study suggests that when performed by expert urologists, fluoroscopy-free single-use flexible ureteroscopy is a feasible treatment for kidney stones. However, the level of expertise required to successfully transition from fluoroscopic to fluoroscopy-free procedures remains somewhat unclear. Endourologists vary in their experience, and some may face challenges in mastering this new technique without adequate guidance. This variability in skill levels raises the question of how to ensure that fluoroscopy-free procedures are performed safely across the board.

Given these concerns, one possible solution would be the establishment of standardized training programs for endourologists who are looking to adopt fluoroscopy-free techniques. Such programs could help ensure that clinicians have the necessary skills and experience before performing these procedures in a clinical setting. Standardized training would provide a structured approach to mastering the technique, helping to mitigate the learning curve associated with fluoroscopy-free ureteroscopy and ensuring that patient outcomes are not compromised as a result of insufficient experience.

Furthermore, the authors have provided valuable insights regarding the stone size and the feasibility of fluoroscopy-free ureteroscopy in patients with abnormal renal anatomy [1]. It is clear from the study that the technique is more effective in patients with stones of up to 15 mm in size, with lower success rates observed in larger stones. However, further research is needed to understand how this technique might be applied in cases involving larger stones, complex anatomy, or other challenging scenarios. Understanding the full range of conditions in which fluoroscopy-free ureteroscopy can be used successfully will be essential in expanding its clinical application. In conclusion, while the authors have demonstrated that fluoroscopy-free single-use flexible ureteroscopy is a promising and feasible technique for treating kidney stones in patients with normal and abnormal renal anatomy, there are still several critical issues that need to be addressed. Establishing acceptable radiation thresholds, defining the required expertise for clinicians, and implementing standardized training programs are key steps that will ensure the safe and effective use of fluoroscopy-free procedures in the future. We look forward to further studies that address these questions and contribute to the ongoing development of this important field.

Conflicts of interest

The authors declare no conflict of interest.