Intraoperative X-Ray Guidance for Endourological Stone Surgery: Fluoroscopic Workflow, Radiation Dose Optimization, and Emerging Image-Guided Technologies

Endourological stone surgery frequently relies on intraoperative X-ray fluoroscopy for guidewire and access sheath placement, retrograde pyelography, stent positioning, and percutaneous renal access. Although radiation exposure from an uncomplicated procedure is usually limited, recurrent imaging and interventions contribute to cumulative patient exposure, and repeated procedures result in occupational exposure among operating-room personnel. This narrative review examines fluoroscopic workflows in ureteroscopy, retrograde intrarenal surgery, percutaneous nephrolithotomy, and endoscopic combined intrarenal surgery, with particular emphasis on dose metrics, determinants of exposure, and practical optimization. Readily implementable measures consistent with the as-low-as-reasonably-achievable (ALARA) principle include low-dose and pulsed fluoroscopy, reduced pulse rates, collimation, last-image hold, optimized C-arm geometry, protective equipment, dosimetry, feedback, and team training. Evidence also supports fluoroscopy-free or fluoroscopy-minimized ureteroscopy and retrograde intrarenal surgery in selected patients, as well as ultrasound-guided percutaneous nephrolithotomy, including hybrid ultrasound-fluoroscopy workflows. Endoscopically assisted puncture, three-dimensional reconstruction, image fusion, navigation, augmented reality, and computer vision span different stages of clinical maturity; AI-assisted dose optimization remains experimental and lacks endourology-specific clinical validation. Standardized multidimensional reporting of patient and staff dosimetry, evidence-based technology classification, and procedure- and complexity-specific benchmarks are needed. Prospective multicenter studies should evaluate integrated image-guided workflows using clinically relevant outcomes, including radiation dose, stone-free outcomes, complications, operative time, usability, and cost.