A multicenter survey in France has resulted in proposed diagnostic reference levels (DRLs) for fluoroscopy performed during eight types of surgical procedures. The researchers shared their results in an article published online on 1 August in European Radiology.
Setting out to assess DRLs in surgery for the most frequent procedures, as required by the European Directive 2013/59/Euratom, researchers led by Joel Greffier of Nimes University Hospital in France retrospectively conducted a survey in six French facilities to analyze eight orthopedic, urology, and gastrointestinal surgical procedures. For each center, they recorded kerma area product (KAP) and fluoroscopy time for 30 patients who received elbow surgery and 50 patients who underwent the other seven surgical procedures during a period from September 2016 to September 2017. DRLs were calculated as the third quartiles of the distributions.
The researchers observed the delivered dose in surgery depends on the procedure, practice, and patient. They also proposed DRLs for the eight surgical procedures.
| Proposed DRLs by surgical procedure | ||||||||
| Hand/wrist (conventional C-arm/mini C-arm) | Elbow | Shoulder (intramedullary/ extramedullary) |
Hip (proximal femoral intramedullary nail) | Foot/ankle (conventional C-arm/mini C-arm) | Implantable venous access port insertion | Laparoscopic cholecystectomy | Double-J ureteral catheter insertion | |
| KAP (mGy cm2) | 125/30 | 185 | 1,500/420 | 2,130 | 250/55 | 345 | 1,185 | 2,195 |
| Fluoroscopy time (min) | 0.6/0.4 | 0.7 | 2.4/0.8 | 1.4 | 0.6/0.5 | 0.5 | 0.9 | 1.0 |
"The results of this study may serve as an input for the national radiation protection authorities to implement DRLs in surgery as required by the 2017 [International Commission on Radiological Protection] publication," the authors wrote. "These results will allow surgery departments to benchmark their practice with others and to optimize their protocols if necessary."
![Examples of ultrasound findings and techniques. (A) Images in a 39-year-old male patient with a mass in the left thigh. The mass is heterogeneous on the B-mode US image (compared with the patient in D) and showed increased microvascularity (superb microvascular imaging [SMI]) and shear-wave elastography (SWE) values. Undifferentiated pleomorphic sarcoma was diagnosed at biopsy (with pleomorphic rhabdomyosarcoma in surgical specimen). (B) Images in an 18-year-old male patient with a mass in the left leg. The mass is hypoechoic on the B-mode image, with no other findings suggestive of malignancy. The lesion is in contact with the cortex of the tibia, which is slightly irregular. CT revealed a doubtful anteromedial tibial erosion. The microvascular study demonstrated high vascularization, suggestive of malignancy. Periosteal Ewing sarcoma was diagnosed with both histologic and immunohistochemical confirmation. (C) Images in a 69-year-old female patient with a lump growing on the outside of the left leg. Multiple SWE examinations were performed (please note the high values obtained in the measurements, whereas the color map highlights the stiffness relative to adjacent tissues). SMI showed areas of increased vascularization to target for sampling. Undifferentiated spindle cell sarcoma was diagnosed at biopsy, with residual leiomyosarcoma in the surgical specimen after neoadjuvant therapy. (D) Images in a 56-year-old female patient with a mass in the right thigh. The mass is heterogeneous at both B-mode ultrasound (similar to patient A) and MRI (coronal T2-weighted spectral attenuated inversion recovery [SPAIR]; T1-weighted pre-contrast and postcontrast imaging), which even shows uptake after the administration of paramagnetic contrast material, which is traditionally suggestive of malignancy. Low values at SMI and elastography are suggestive of benignity. Spindle cell lipoma was diagnosed at biopsy, with atypical spindle cell lipomatous tumor in the surgical specimen.](https://img.auntminnieeurope.com/mindful/smg/workspaces/default/uploads/2026/08/images-radiol250278fig2.APCFLSvX6p.jpg?auto=format%2Ccompress&fit=crop&h=100&q=70&w=100)
![Examples of ultrasound findings and techniques. (A) Images in a 39-year-old male patient with a mass in the left thigh. The mass is heterogeneous on the B-mode US image (compared with the patient in D) and showed increased microvascularity (superb microvascular imaging [SMI]) and shear-wave elastography (SWE) values. Undifferentiated pleomorphic sarcoma was diagnosed at biopsy (with pleomorphic rhabdomyosarcoma in surgical specimen). (B) Images in an 18-year-old male patient with a mass in the left leg. The mass is hypoechoic on the B-mode image, with no other findings suggestive of malignancy. The lesion is in contact with the cortex of the tibia, which is slightly irregular. CT revealed a doubtful anteromedial tibial erosion. The microvascular study demonstrated high vascularization, suggestive of malignancy. Periosteal Ewing sarcoma was diagnosed with both histologic and immunohistochemical confirmation. (C) Images in a 69-year-old female patient with a lump growing on the outside of the left leg. Multiple SWE examinations were performed (please note the high values obtained in the measurements, whereas the color map highlights the stiffness relative to adjacent tissues). SMI showed areas of increased vascularization to target for sampling. Undifferentiated spindle cell sarcoma was diagnosed at biopsy, with residual leiomyosarcoma in the surgical specimen after neoadjuvant therapy. (D) Images in a 56-year-old female patient with a mass in the right thigh. The mass is heterogeneous at both B-mode ultrasound (similar to patient A) and MRI (coronal T2-weighted spectral attenuated inversion recovery [SPAIR]; T1-weighted pre-contrast and postcontrast imaging), which even shows uptake after the administration of paramagnetic contrast material, which is traditionally suggestive of malignancy. Low values at SMI and elastography are suggestive of benignity. Spindle cell lipoma was diagnosed at biopsy, with atypical spindle cell lipomatous tumor in the surgical specimen.](https://img.auntminnieeurope.com/mindful/smg/workspaces/default/uploads/2026/08/images-radiol250278fig2.APCFLSvX6p.jpg?auto=format%2Ccompress&dpr=2&fit=crop&h=167&q=70&w=250)
