Brad Schwartz, DO, FACS

 Can you discuss fluoroscopic tables, where we are, and where we are going?

There are numerous fluoroscopic tables out there. They are quite expensive, but you are getting a very large piece of medical equipment, so it is a capitol purchase for these hospitals or surgery centers. A lot of people are moving toward cheaper, smaller alternatives, like these mobile cystoscopy tables. Those are also very good, but you do potentially decrease your imaging quality when you move to that table.

There are permanent cysto-tables that are firmly secured in the room. They are great. The things you can do with them are amazing: the variability, the surgeon independence that you have, the image control, and the table control. They are really fantastic. The image quality that we are getting with these tables is just amazing. You could do virtually any procedures on them. You can do percutaneous treatments, cystoscopies, and ureteroscopies on them. You can make it multidisciplinary. You can have GI [gastrointestinal] procedures; gastroenterology can do things on that table. They are a staple for us as urologists. We use them every single day in our practice.

 In your experience, where would you particularly use the fluoroscopic tables?

I use a fluoroscopic table during 100% of my ureteroscopy procedures. We use them for probably 30% to 40% of our percutaneous dome procedures.

 Do you have any last thoughts on the state of urological imaging and the industry as a whole?

I am excited to see what comes next. For those of us who are in the clinical world, and certainly those who dabble in the research world, this is an exciting time. We never know what is going to come out next and what is out there. All of us are always excited to see the next level of technology and the next breakthrough. We will just sit on the sideline and wait for things to happen. I am really excited to see what comes out.

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The rationale for utilizing fluoroscopic imaging as well as other evolving technologies that are currently being developed and explored in urology.

Fluoroscopic Imaging and Other Developments in Urology

: To help bring everything together, what do you see as the trends in imaging for men’s health?

Things keep getting better. They keep getting smaller. It is important to keep the footprints in the operating room small and to maintain room in the operating room. The image quality, with the advanced technology of imaging and optics, is becoming quite incredible. Patient safety is paramount, so we need to decrease the risk of radiation exposure to patients; anything we can do to lower radiation doses while maintaining the high quality of the imaging is crucial. Artificial intelligence [AI] might be a key component in the future. Planning—preoperative planning—might be an exciting area to track developments. The overall push toward better and keener technology is exciting. Also important is more safety introductions, more safety education, to be put in place for patients and the staff. All those things are exciting and are part of current trends.

 Can you share your thoughts on the potential impact on image quality as it relates to patients with prostate cancer?

 I do not treat a lot of patients with prostate cancer. I am not really sure what is coming down the line in regard to that, to be truthful with you. The area of prostate cancer is a moving target and a very hot topic in reference to technological breakthroughs. As I said, AI is really going to have a huge role in our treatments in the future. I know technology is being developed to better diagnose prostate cancer, improve grading, and provide better information in regard to how serious that prostate cancer is. It will be a huge breakthrough for those people who do treat it.

Reactions to advances in the quality and safety of newer imaging tests used in prostate cancer.

Advances in Imaging in Prostate Cancer

 In your experience, how important is image quality?

Realistically, it is probably the single most important component of all the imaging systems. The image quality is what you use to make a diagnosis. When you look at the impact of clinical outcomes and the medical care of the patients that we are treating, image quality could mean the difference between success and failure. It could mean the difference between seeing a defect and not seeing a defect.

High image quality could mean the difference between tracking the wire up into the kidney and actually having successful placement of the wire vs failing and then not being able to perform a retrograde approach. We would then have to convert it to an antegrade approach, thereby changing the entire outcome of that patient’s disease process. The quality of the imaging is key. You have to see what you are doing and you have to be able to track the course of the procedure to make sure it is going in the direction you want it to go. It is very crucial.

: How satisfied are you with the image quality of your current system in your workflow? What features are you most satisfied with?

We have the most current system, and of course I’m very happy with it. One of the beauties of the system that I use—which is a Liebel-Flarsheim system—is the independence the surgeon has when employing the system. We can control almost everything with foot pedals. We do not need anyone in the room to push buttons. We do not need the circulators to get involved and adjust settings. We can do virtually everything we want with just our foot pedals: we can magnify, do spot films, fluoroscopies, cone in, and cone out.

As surgeons, we can really have complete independence when dealing with these systems. That gives us real-time information and actually has been shown, in the literature, to decrease the amount of fluoroscopy that we use when we control that. The surgical independence is fantastic. The image quality is fantastic, and we can make some very high-level treatment decisions based on what we are seeing real time.

Dr Brad Schwartz comments on his satisfaction with current imaging systems used in urology and the impact of image quality on treatment decisions and clinical outcomes.

Urology Testing: Image Quality and Clinical Outcomes

 It sounds a little quaint, but I started my residency in 1990. I was in the Army. The military contracts at the time were with Liebel-Flarsheim Urology tables and cysto tables. Since 1990, virtually in every location where I have been and I have practiced, we have had a Liebel-Flarsheim cysto table. For 30 years, I have used their tables in every location I have ever worked. I do find them extremely reliable. Their service is very dependable. The quality of their image is good. They keep up with technology, and they try to push the edge of image quality while we are working intraoperatively. Their image quality is far superior to others on the market.

How concerned are you with the radiation dose at your practice?

 Very. There have been a number of articles that have addressed the need for minimal exposure and maximum protection during radiation imaging. Some studies indicate that it may not be as serious as we originally thought. However, the bottom line is that radiation safety within our environment is extremely important.

In your experience, have you found that some imaging systems use less radiation?

 I am not aware of what the differences in radiation exposure is with the different systems on the market. I know that all companies are moving toward trying to minimize exposure and risk. They can do that through a number of technological advances in the system itself. Also, through radiation education, we can reduce exposure. At our institution [Southern Illinois University School of Medicine], we have to take a yearly radiation safety course. That is a yearly, required training that is very good. It is very much needed, and it does result in decreased radiation exposure to the staff and the patients.

How do you address patients’ concerns when it comes to radiation risk?

 With our chronic stone formers, that is a real potential issue. They come to the ER [emergency department], and they get CT scans. They go to different ERs in different regions of the state. They might get more CT scans at different locations because they are unaware of where they were just were 5 days ago. I try to let them know, very carefully, that there is an inherent amount of radiation that everyone gets just by going outside or flying in an airplane—just from the environmental sources. The technology that we have has minimized the risk of exposure to the greatest extent possible. We have ultra-low dose CT scans that we can use. We use shielding for many patients during these scans. We try to use ultrasound and MRI when feasible to limit the radiation dose. In the operating room, we try to maintain our distance from the radiation source. We all wear lead aprons and lead thyroid shields. Most of the surgeons have lead glasses that we use. We all are required to do the radiation safety courses. We do as much as we can to limit the amount of radiation exposure to the patient; we do so by employing less radiation and being careful and sensible about their exposure.

Right. Absolutely. How do you track radiation dose?

 We are required by state regulation to wear dosimetry badges. We wear them based on the guidelines, and we turn those in monthly. We get reports back. So far, we have been responsible. We do a good job. We have never really been flagged for excessive radiation exposure. That is a fairly typical method of tracking radiation doses—through these badges required by the state.

Brad Schwartz, DO, FACS, comments on radiation exposure associated with imaging assessments used in urology and explains what he and colleagues are doing to minimize exposure and address patient concerns.

Brad Schwartz, DO, FACS

Articles

Fluoroscopic Imaging and Other Developments in Urology

Advances in Imaging in Prostate Cancer

Urology Testing: Image Quality and Clinical Outcomes

Radiation Exposure From Imaging Assessments in Urology