After a long day in surgery, your neck, back and wrist ache. Once home, you spend a few hours on your laptop completing notes, and by bedtime your neck and lower back are even more sore and stiff. You don’t talk about it at work. After all, your colleagues might think you’re weak. You are confident you provide outstanding care for your patients and your discomfort is just “part of the job.” Your practice is thriving, family demands are increasing, and time for exercise and “self-care” is limited. Your colleague in the vascular department surprised you recently when he retired early due to back problems. Sometimes you wonder if you can do this job for another 20 years. You are not alone. In fact, close to half of urologists experience work-related pain, and 9% worry they might need to retire early.¹ Understanding your risks and the strategies that can help prevent work-related musculoskeletal injury will help you protect your most valuable asset—you.

The majority of surgeons across specialties report work-related musculoskeletal pain.² Pain prevalence and body locations vary based on surgical modality, with pure laparoscopy most commonly causing discomfort.^2,3 Survey rates of work-associated musculoskeletal pain in urologists vary between 47% and 62%.^2,4,5 The 2017 AUA Census, which is less likely to suffer from response bias than pure ergonomics surveys, found 46% of urologists experience work-related pain, with rates rising to 65% in women urologists under age 45.¹ A small survey of endourologists in 2011 noted 64% had orthopedic complaints (38% back pain, 28% neck pain, 17% hand pain).⁶ A recent survey of endourologists focused on benign prostatic hyperplasia surgery (transurethral prostatectomy and holmium laser enucleation of the prostate) found that 69% complained of work-related pain or injury, with the most affected areas being the neck (64%), back (57%), shoulder (48%) and hand (40%).⁷

Endourology and laparoscopy were noted to be risk factors for chronic musculoskeletal complaints in a survey of European urologists.⁴ Rates of pain and injury increase with high-risk intraoperative body mechanics such as static positioning, repetitive twisting, application of high force, awkward postures and high loading.⁸ These risks are amplified by long working periods without breaks, which prevent recovery. Based on a validated ergonomic risk scale, researchers used wearable technology to monitor surgeon intraoperative body position and found that 65% of operative time was spend in high-risk neck positions, 30% in high-risk torso positions and 11% in high-risk shoulder positions (fig. 1).⁹ These high-risk positions were associated with increased subjective surgeon pain ratings.⁹

Endourology increases strain on the wrist and thumb more than other surgical modalities.¹⁰ Innovations in flexible ureteroscopy that appear to improve ergonomics and decrease pain rates include robotic assistance, use of a supportive chair designed for endourology, and (lighter) disposable ureteroscopes with easier deflection that cause less wrist and thumb pain.^11,12 MEL (modified ergonomic lithotripsy) is a creative strategy that adjusts the patient’s position to optimize surgeon ergonomics. After placement of an access sheath, the patient is placed in a 35% inclined lithotomy position and the surgeon remains seated for the procedure.¹¹

Appropriate body positioning is central to optimal surgical ergonomics, and resources for many of the surgical modalities used in urology are available.^2,3,10 There is less guidance available for endourology, including whether it is ideal to sit or stand. Standing while using a foot pedal loads the body weight on the opposite leg while the working forefoot hovers in excessive flexion over the pedal.¹⁰ Sitting can be helpful to avoid such postures but the presence of the chair can then disrupt the assistant’s position and cause difficulty in proper monitor positioning. Place foot pedals directly in front of the working foot so it remains in neutral alignment.² Place monitors in the line of sight and in line with the endoscope at approximately 3-4 feet away with the center of the screen 10-20 degrees below eye level to avoid excessive back and neck rotation.^2,10 Placing the top of the screen at eye level is usually a reasonable approximation (fig. 2).

Changing habits can be difficult, especially for surgeons accustomed to risky intraoperative postures. Intermittent “postural resets” facilitate the opportunity for readjustment out of high-risk postures. Extra weight increases ergonomic risk by increasing muscle load, so decrease weight by utilizing light scopes, lead, loupes and headlamps. Two-piece lead also distributes the weight of the lead, reducing direct pressure on the shoulders.¹² Antifatigue floor mats are commercially available and may reduce discomfort among endourologists.¹³

Intraoperative microbreaks involve pausing the procedure at a noncritical juncture (every 20-40 minutes) and engaging in a 60-second series of targeted stretches without breaking scrub. Microbreak stretches improve mental focus and decrease surgeon discomfort without increasing operative time.¹⁴ One barrier is that surgeons engrossed in surgery often forget to take breaks, so researchers have used an app with automatic reminders to help implement this practice into surgery workflow.¹⁵ Information on accessing this free resource can be found at ORstretch.mayoclinic.org. Consistent use of a program of pre- and postoperative surgeon exercises and stretches targeting the neck, shoulder and back was found to have some benefit in a randomized trial after 6 months.¹⁶ In a large international survey of urologists, exercise outside the operative room was correlated with reductions in work-related pain in a dose-dependent fashion.⁵ Physical therapy and/or regular massage can also help improve pain (therapeutic) and maintain flexibility (preventive).

Prior to the electronic medical record and wide adoption of computers, nonoperative patient care activities allowed time for musculoskeletal recovery. However, today most surgeons spend much of their nonoperative workday at poorly configured computer workstations, which stress the same muscles and joints affected by performing surgery. Although workstation optimization is beyond the scope of this article, it is an important consideration in preventing musculoskeletal pain and dysfunction.

Figure 2. Endourology monitor adjustment.

Multiple publications have reported lack of ergonomic knowledge among urologists.^4,10 There is a growing consensus that surgical ergonomics instruction should be provided during residency, lest we fail to prepare the next generation of urologists to do their job safely.¹⁷ Few urology residency programs offer formal ergonomics training, but interest is growing. One example is the recently launched Society of Surgical Ergonomics, which is a collaboration between human factors/ergonomics professionals and surgeons from a variety of specialties (including urology) with the mission of improving education, decreasing work-related injury, and facilitating interdisciplinary innovation and research (https://www.societyofsurgicalergonomics.org/).

It is important to consider work-related discomfort in context rather than as only a personal issue. Pain and irritability reduce cognitive bandwidth for patient care decisions, relating to team members, high quality communication and productive teaching interactions. Taking a moment to adjust your surgical environment, using intraoperative stretch breaks and optimizing your computer workstations should not be considered self-serving, but rather indicate savvy choices to improve safety for both you and your patients today, while simultaneously protecting your future health and urological career.