Carbon Footprint in Flexible Ureteroscopy: A Comparative Study on the Environmental Impact of Reusable and Single-Use Ureteroscopes

The role of planetary health in urologic oncology

INTRODUCTION

Climate change and global warming are an omnipresent topic in our daily lives. Planetary health and oncology represent two critical domains within the broader spectrum of healthcare, each addressing distinct yet interconnected aspects of human well-being. We are encouraged to do our part in saving our planet. This should include the decisions we make in our professional life, especially in uro-oncology, as the healthcare sector significantly contributes to environmental pollution.

AREAS COVERED

There are many aspects that can be addressed in the healthcare sector in general, as there are structural problems in terms of energy consumption, water waste, therapeutic techniques, transportation and drug manufacturing, as well as in uro-oncology specific areas. For example, the use of different surgical techniques, forms of anesthesia and the use of disposable or reusable instruments, each has a different impact on our environment. The literature search was carried out using PubMed, a medical database.

EXPERT OPINION

We are used to making decisions based on the best outcome for patients without considering the impact that each decision can have on the environment. In the present article, we outline options and choices for a more climate-friendly approach in urologic oncology.

Environmental Impact of Flexible Cystoscopy: A Comparative Analysis Between Carbon Footprint of Isiris® Single-Use Cystoscope and Reusable Flexible Cystoscope and a Systematic Review of Literature

Introduction: There is an absence of data on the environmental impact of single-use flexible cystoscopes. We wanted to review the existing literature about carbon footprint of flexible cystoscopy and analyze the environmental impact of the Isiris® (Coloplast©) single-use flexible cystoscope compared to reusable flexible cystoscopes. Methods: First, a systematic review on single-use and reusable cystoscope carbon footprint was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Second, carbon footprints of Isiris single-use flexible cystoscope and reusable cystoscope were analyzed and compared. Life cycle of the single-use flexible cystoscope was divided in three steps: manufacturing, sterilization, and disposal. For the reusable cystoscope, several steps were considered to estimate the carbon footprint over the life cycle: manufacturing, washing/sterilization, repackaging, repair, and disposal. For each step, the carbon footprint values were collected and adapted from previous comparable published data on flexible ureteroscope. Results: The systematic literature review evidenced total carbon emissions within a range of 2.06 to 2.41 kg carbon dioxide (CO2) per each use of single-use flexible cystoscope compared to a wide range of 0.53 to 4.23 kg CO2 per each case of reusable flexible cystoscope. The carbon footprint comparative analysis between Isiris single-use flexible cystoscope and reusable cystoscope concluded in favor of the single-use cystoscope. Based on our calculation, the total carbon emissions for a reusable flexible cystoscope could be refined to an estimated range of 2.40 to 3.99 kg CO2 per case, depending on the endoscopic activity of the unit, and to 1.76 kg CO2 per case for Isiris single-use cystoscope. Conclusion: The results and our systematic literature review demonstrated disparate results depending on the calculation method used for carbon footprint analysis. However, the results tend rather toward a lower environmental impact of single-use devices. In comparison to a reusable flexible cystoscope, Isiris compared favorably in terms of carbon footprint.

The carbon footprint and wastage of intravitreal injections

PURPOSE

The healthcare system emits greenhouse gas emissions and produces waste that in turn threatens the health of populations. The objective of our study was to measure the ecological threat related to intravitreal injections.

METHODS

Emissions were separated into scope 2 corresponding to Heating, Ventilation and Air Conditioning (HVAC) of the building, and scope 3 corresponding to travels (patients and staff), and life cycle assessment (LCA) of medical devices (MD) and pharmaceutics. Greenhouse gas (GHG) emissions and waste for a single injection were first measured through a waste audit, and secondly anticipated theoretically with a calculator.

RESULTS

The average GHG emissions and waste measured were 277kgCO2eq/IVI and 0.5kg/IVI, respectively. Pharmaceuticals were responsible for 97% of total emissions. Emissions unrelated to pharmaceuticals counted for 8.4kgCO2eq/IVI. GHG emissions and waste estimated with the calculator were 276kgCO2eq/IVI and 0.5kg/IVI, respectively, showing that the calculator was accurate.

CONCLUSION

Our study provides a puzzle piece to carbon footprint and waste assessment in the field of ophthalmology. It may help provide concrete data for future green vs. vision discussions.

Comparing outcomes of single-use vs reusable ureteroscopes: a systematic review and meta analysis

Flexible ureterolithotripsy is a frequent urological procedure, usually used to remove stones from the kidney and upper ureter. Reusable uretero-scopes were the standard tool for that procedure, but recent concerns related to sterility and maintenance and repair costs created the opportunity to develop new technologies. In 2016, the first single-use digital flexible ureteroscope was introduced. Since then, other single-use ureteroscopes were developed, and studies compared them with the reusable ureteroscopes with conflicting results. The purpose of this study is to describe the literature that compares the performance of single-use and reusable flexible ureteroscopes in retrograde intrarenal surgery for urinary stones. A Systematic Review was performed in October 2022 in accordance with the Cochrane Handbook and the Preferred Reporting Items for Systematic Reviews and MetaAnalyses (PRISMA). A search in MEDLINE, EMBASE, Web of Science, Google Scholar and LILACS retrieved 10,039 articles. After screening, 12 articles were selected for the Meta-Analysis. No differences were found in stone-free rate (OR 1.31, CI 95% [0.88, 1.97]), operative time (MD 0.12, CI 95% [-5.52, 5.76]), incidence of post-operative fever (OR 0.64, CI 95% [0.22, 1.89]), or incidence of post-operative urinary tract infection (OR 0.63 CI 95% [0.30, 1.32]). No differences were observed in the studied variables. Hence, the device choice should rely on the availability, cost analysis and surgeons' preference.

Estimation of the carbon footprint of arthroscopic rotator cuff repairs in France

AIM

The main objective of this study was to estimate the carbon impact of arthroscopic rotator cuff repairs in France. The secondary objective was to assess the effectiveness of the following measures in reducing the carbon footprint associated with this technique: outpatient treatment, arthroscopic water filtration, surgery under locoregional anesthesia.

HYPOTHESIS

The hypothesis was that the carbon footprint could be significantly improved with the implementation of these three procedures.

METHODS

A continuous series of 26 patients who underwent surgery for a rotator cuff tear involving only one tendon between November 2020 and April 2021 were included. The evaluation protocol consisted of three parts: 1/ use of volatile anesthetic agents; 2/ electrical consumption linked to the procedure; 3/ emissions related to patient and staff travel, delivery of implants and waste management. Another series of 26 patients operated between November 2018 and April 2019 who had none of these three factors were matched.

RESULTS

The carbon impact of arthroscopic repair of the rotator cuff was estimated at 334.61±18.82kgCO2eq. The implementation of the three methods for improvement made it possible to significantly reduce emissions by 40.9±1.71kgCO2eq (12.2%) (p<0.001).

CONCLUSION

Performing surgery under locoregional anesthesia, on an outpatient basis with water purification, reduces the carbon impact of arthroscopic rotator cuff repair by more than 12%.

LEVEL OF EVIDENCE

III, retrospective case control.

Materials Science Toolkit for Carbon Footprint Assessment: A Case Study for Endoscopic Accessories of Common Use

Ironically, healthcare systems are key agents in respiratory-related diseases and estimated deaths because of the high impact of their greenhouse gas emissions, along with industry, transportation, and housing. Based on safety requirements, hospitals and related services use an extensive number of consumables, most of which end up incinerated at the end of their life cycle. A thorough assessment of the carbon footprint of such devices typically requires knowing precise information about the manufacturing process, which is rarely available in detail because of the many materials, pieces, and steps involved during the fabrication. Yet, the tools most often used for determining the environmental impact of consumer goods require a bunch of parameters, mainly based on the material composition of the device. Here, we report a basic set of analytical methods that provide the information required by the software OpenLCA to calculate the main outcome related to environmental impact, greenhouse gas emissions. Through thermogravimetry, calorimetry, infrared spectroscopy, and elemental analysis, we proved that obtaining relevant data for the calculator in the exemplifying case of endoscopy tooling or accessories is possible. This routine procedure opens the door to a broader, more accurate analysis of the environmental impact of everyday work at hospital services, offering potential alternatives to minimize it.

Time Efficiency and Performance of Single-Use vs Reusable Cystoscopes: A Randomized Benchtop and Simulated Clinical Assessment

Introduction: A flexible cystoscope is an indispensable tool for urologists, facilitating a variety of procedures in both the operating room and at bedside. Single-use cystoscopes offer benefits including accessibility and decreased burden for reprocessing. The aims of this study were to compare time efficiency and performance of single-use and reusable cystoscopes. Methods: Ten new Ambu® aScope™ 4 Cysto single-use and two Olympus CYF-5 reusable cystoscopes were compared in simulated bedside cystoscopy and benchtop testing. Ten urologists performed simulated cystoscopy using both cystoscopes in a randomized order. Times for supply-gathering, setup, cystoscopy, cleanup, and cumulative time were recorded, followed by a Likert feedback survey. For benchtop assessment, physical, optical, and functional specifications were assessed and compared between cystoscopes. Results: The single-use cystoscope demonstrated shorter supply-gathering, setup, cleanup, and cumulative times (824 vs 1231 seconds; p < 0.05) but a comparable cystoscopy time to the reusable cystoscope (202 vs 212 seconds; p = 0.32). The single-use cystoscope had a higher image resolution, but a narrower field of view. Upward deflection was greater for the single-use cystoscope (214.50° vs 199.45°; p < 0.01) but required greater force (2.5 × ). The working channel diameter and irrigation rate were greater in the reusable cystoscope. While the single-use cystoscope lacked tumor enhancing optical features, it had higher Likert scale scores for Time Efficiency and Overall Satisfaction. Conclusion: The single-use cystoscope demonstrates comparable benchtop performance and superior time efficiency compared to reusable cystoscopes. However, the reusable cystoscope has superior optical versatility and flow rate. Knowledge of these differences allows for optimal cystoscope selection based on procedure indication.

Reuse of Single-Use Devices in Endourology: A Review

Introduction: Single-use medical devices (SUDs) are labeled for single use only, but rising health care costs along with the absence of visible deterioration in the quality of SUDs after one use have led to their reprocessing and reuse. In the past, SUDs mainly consisted of equipment such as guidewires and catheters. However, SUDs have now expanded to flexible endoscopes and energy devices that are much more expensive. Reuse of such devices raises concerns of infection transmission, safety, and lack of effectiveness. We reviewed the disinfection process, cost benefits, potential harms, and legal status of the reuse of SUDs in endourology. Materials and Methods: PUBMED, Embase, and the Cochrane Library databases were searched for articles published between 1970 and March 2023 that reported the reuse of SUDs using the search terms "reuse"; "single-use device"; "disposable medical devices"; "reprocessing of single-use device"; "endourology"; and keywords related to cost, safety, sterilization, and legal status. Online resources were found using Google search engines. Articles on cost savings, device malfunction, disinfection, or legal status in different countries were reviewed. Results and Conclusions: Reusing SUDs has financial, environmental, and practical advantages. The potential savings on medical expenses is the most compelling argument for reprocessing disposable devices. Reusing medical equipment also contributes to the reduction of toxic biodegradable waste. However, there is a scarcity of data on the safety and efficacy of reused SUDs. For patient safety and to avoid complications, the practice must be regulated with established reprocessing standards.

Perspectives on technology: to use or to reuse, that is the endoscopic question-a systematic review of single-use endoscopes

OBJECTIVE

To compare clinical outcomes of single-use endoscopes with those of reusable endoscopes to better define their role within urology.

METHODS

A systematic search of electronic databases was performed. All studies comparing the clinical outcomes of participants undergoing urological procedures with single-use endoscopes to those of participants treated with reusable endoscopes were included. Results are reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement.

RESULTS

Twenty-one studies in 3943 participants were identified. Six different single-use flexible ureteroscopes and two different single-use flexible cystoscopes were assessed. There were no differences in mean postoperative infection rates (4.0% vs 4.4%; P = 0.87) or overall complication rates (11.5% vs 11.9%; P = 0.88) between single-use and reusable endoscopes. For patients undergoing flexible ureteroscopy there were no differences in operating time (mean difference -0.05 min; P = 0.96), length of hospital stay (LOS; mean difference 0.06 days; P = 0.18) or stone-free rate (SFR; 74% vs 74.3%; P = 0.54) between the single-use and reusable flexible ureteroscope groups.

CONCLUSION

This study is the largest to compare the clinical outcomes of single-use endoscopes to those of reusable endoscopes within urology, and demonstrated no difference in LOS, complication rate or SFR, with a shorter operating time associated with single-use flexible cystoscope use. It also highlights that the cost efficiency and environmental impact of single-use endoscopes is largely dependent on the caseload and reprocessing facilities available within a given institution. Urologists can therefore feel confident that whether they choose to 'use' or to 'reuse' based on the financial and environmental implications, they can do so without negatively impacting patient outcomes.

Single-Use Flexible Ureteroscopes: How Difficult Is It Today to Stay Up to Date? A Pictorial Review of Instruments Available in Europe in 2023

The invention of the flexible ureteroscope (fURS) and its subsequent spread have revolutionized the surgical management of urolithiasis and upper tract urothelial carcinoma (UTUC). During the last few years, single-use flexible ureteroscopes (su-fURSs) have been developed to improve the limitations of reusable fURSs, namely their cost, durability and risk of device contamination. Since the introduction of the first fully disposable digital fURS, several su-fURSs have been developed by various manufacturers. In this pictorial review, we combined the different physical and technical features of su-fURSs currently available on the market with Food and Drug Administration (FDA) and European Conformity (CE) approval, in order to help surgeons choose the appropriate device according to each case requirement and personal preferences. To the best of our knowledge, 17 su-fURSs with CE and FDA approval have been developed to date.

A Green Prescription: Integrating Environmental Sustainability in Urology Guidelines

Against the background of the climate crisis, there is an urgent need to include environmental sustainability recommendations in clinical practice guidelines. We highlight five domains for which suitable recommendations could help in mitigating the environmental impact of urology practice. PATIENT SUMMARY: Climate change is an urgent issue that requires global action. Guidelines published by urological societies should include recommendations for minimizing the impact of urology practice on the environment.

Reuse and Reprocessing of Endoscopic Instruments: Con

Reprocessing of endoscopic equipment generates greenhouse gas emissions, releases toxic substances into the environment, and consumes large quantities of water. The use of alternative materials, such as single-use devices with a low carbon footprint and recycled materials, and reprocessing without the use of water and toxic products represent sustainable solutions.

The impact of single-use digital flexible cystoscope for double J removal on hospital costs and work organization: A multicentric evaluation

BACKGROUND

Isiris-α® is a single-use digital flexible cystoscope with an integrated grasper designed for double J (DJ) stent removal. Aim of this study was to conduct a multicentric evaluation of the costs and criticalities of stent removals performed with Isiris®-α in different hospitals and health systems, as compared to other DJ removal procedures.

METHODS

After gathering 10 institutions worldwide with experience on Isiris-α®, we performed an analysis of the reported costs of DJ removal with Isiris-α®, as compared to the traditional reusable equipment used in each institution. The cost evaluation included instrument purchase, Endoscopic Room (EnR)/ Operatory Room (OR) occupancy, medical staff, instrument disposal, maintenance, repairs, decontamination or sterilization of reusable devices.

RESULTS

The main factor affecting the costs of the procedure was OR/EnR occupancy. Decontamination and sterilization accounted for a less important part of total costs. Isiris-α® was more profitable in institutions where DJ removal is usually performed in the EnR/OR, allowing to transfer the procedure to outpatient clinic, with a significant cost saving and EnR/OR time saving to be allocated to other activities. In the only institution where DJ removal was already performed in outpatient clinics, there is a slight cost difference in favor of reusable instruments in high-volume institutions, given a sufficient number to guarantee the turnover.

CONCLUSION

Isiris-α® leads to significant cost benefit in the institutions where DJ removal is routinely performed in EnR/OR, and brings significant improvement in organization, cost impact and turnover.

Single use flexible ureteroscopes: Current status and future directions

Introduction

Single use ureteroscopes are a technological innovation that have become available in the past decade and gained increased popularity. To this end, there are now an increasing number of both benchside and clinical studies reporting outcomes associated with their use. Our aim was to deliver a narrative review in order to provide an overview of this new technology.

Methods

A narrative review was performed to gain overview of the history of the technology's development, equipment specifications and to highlight potential advantages and disadvantages.

Results

Findings from preclinical studies highlight potenial advantages in terms of the design of single use ureteroscopes such as the lower weight and more recent modifications such as pressure control. However, concerns regarding plastic waste and environmental impact still remain unanswered. Clinical studies reveal them to have a non inferior status for outcomes such as stone free rate. However, the volume of evidence, especially in terms of randomised trials remains limited. From a cost perspective, study conclusions are still conflicting and centres are recommended to perform their own micro cost analyses.

Conclusions

Most clinical outcomes for single use ureteroscopes currently match those achieved by reusable ureteroscopes but the data pool is still limited. Areas of continued debate include their environmental impact and cost efficiency.

Reuse and Reprocessing of Endoscopic Instruments: For

Reusable endoscopes appear to be most environmentally sustainable when the carbon footprint of routine device maintenance is optimized. Single-use endoscopes may offer cost-savings in clinical settings that accelerate device damage, such as prolonged procedure time or complex patient anatomy. For many urology practices, a hybrid approach that integrates single-use and reusable devices may be most economically sensible and environmentally sound.

How Best to Implement Climate-smart Actions in Clinical Urologic Care

We highlight the need for multidisciplinary teamwork, education, practical sustainability actions, informed choices for devices, and research in urologic care to reduce its environmental impact while maintaining quality health care for patients.

Sustainability in Urology: Ideas for a Greener Future

Sustainability in urology can be achieved via conscientious practices that minimize the negative impact of our services while achieving ethical and responsible patient care. We highlight novel and actionable ideas that could pave the path towards healthier, greener urological practice.

Flexible Ureteroscopy: Global User Experience Using Disposable Devices

INTRODUCTION

Renal stone treatment through flexible ureteroscopy is widely established and successful. Ureteroscopes can broadly be classified into reusable and single-use disposable devices, each with their own advantages. Disposable scopes are cheaper to buy, maintain, and dispose of but may have a greater environmental impact and long-term cost. To establish the collective views of urologists, we conducted a multicentre, global study to demonstrate users' experience with single-use flexible ureteroscopes.  Methods: An online nine-question survey was distributed to urologists globally through email and social media platforms. Questions focused on user grade, experience, location, general opinion, advantages, disadvantages, and estimated cost of a single-use flexible ureteroscope. All responses were collated over a three-day period and analysed using descriptive statistics.

RESULTS

A total of 69 responses were received; the majority of responses were from the UK (75%), and most were consultants (64%). Two-thirds of those surveyed had used a single-use scope on a patient, and 95% of them stated they enjoyed using it, citing excellent vision and reduced need for maintenance. The majority (52%) stated that widespread adoption of disposable scopes was limited due to their prohibitive expense, with an average, sterling-converted responder-estimated cost of £991 (£100-£6000) per reusable scope.

CONCLUSION

Most urologists enjoyed using disposable scopes, finding them comparable or better than reusable devices. However, the initial cost can be prohibitive in certain centres. The potential environmental impact is a further concern as this remains largely unknown for now. In the meantime, it is likely that stone units will continue to use a combination of single-use and reusable scopes, considering their individual needs and budgets as well as local availability and price.

A Leak in the System: Addressing the Environmental Impact of Urologic Care

As urologists we have an opportunity to reduce the carbon footprint of the procedures we perform. We highlight some areas of interest in urology and potential initiatives to reduce the energy and waste footprint of urology care. Urologists can and should make an impact on the growing climate crisis.

Interventions for sustainable surgery: a systematic review

OBJECTIVE

To systematically evaluate interventions designed to improve the sustainability of surgical practice with respect to their environmental and financial impact.

BACKGROUND

Surgery contributes significantly to emissions attributed to healthcare due to its high resource and energy use. Several interventions across the operative pathway have, therefore, been trialed to minimize this impact. Few comparisons of the environmental and financial effects of these interventions exist.

MATERIALS AND METHODS

A search of studies published up to 2nd February 2022 describing interventions to increase surgical sustainability was undertaken. Articles regarding the environmental impact of only anesthetic agents were excluded. Data regarding environmental and financial outcomes were extracted with a quality assessment completed dependent upon the study design.

RESULTS

In all, 1162 articles were retrieved, of which 21 studies met inclusion criteria. Twenty-five interventions were described, which were categorized into five domains: 'reduce and rationalize', 'reusable equipment and textiles', 'recycling and waste segregation', 'anesthetic alternatives', and 'other'. Eleven of the 21 studies examined reusable devices; those demonstrating a benefit reported 40-66% lower emissions than with single-use alternatives. In studies not showing a lower carbon footprint, the reduction in manufacturing emissions was offset by the high environmental impact of local fossil fuel-based energy required for sterilization. The per use monetary cost of reusable equipment was 47-83% of the single-use equivalent.

CONCLUSIONS

A narrow repertoire of interventions to improve the environmental sustainability of surgery has been trialed. The majority focuses on reusable equipment. Emissions and cost data are limited, with longitudinal impacts rarely investigated. Real-world appraisals will facilitate implementation, as will an understanding of how sustainability impacts surgical decision-making.

Innovations in endourologic stone surgery: contemporary practice patterns from a global survey

OBJECTIVE

The purpose of this study is to evaluate the current availability of technology for urolithiasis treatment and ureteroscopy. Perioperative practice patterns, availability of ureteroscopic technologies, pre- and post-stenting practices, and methods to alleviate stent-related symptoms were assessed via a survey of members of the Endourological Society. Methods We distributed a 43-question survey online via the Qualtrics platform to members of the Endourological Society. The survey consisted of questions pertaining to the following topics: general (6), equipment (17), preoperative ureteroscopy (URS; 9), intraoperative URS (2), and postoperative URS (9). Results A total of 191 urologists responded to the survey. 51% of urologists were fellowship trained and dedicated an average of 58% of their practice to stone management. In terms of procedures, most urologists performed ureteroscopy most commonly (68%), followed by percutaneous nephrolithotomy (23%) and shockwave lithotripsy (11%). 90% of respondent urologists purchased a new ureteroscope within the last five years (16% single-use scopes, 53% reusable, and 31% purchased both). 57% of the respondents stated that they would be interested in a ureteroscope that can sense intrarenal pressure, with an additional 30% stating they would be interested depending on the cost. 80% of responders purchased a new laser within the last five years, and 59% changed their lasering technique due to the new laser. 70% are performing primary ureteroscopy for obstructing stones, and 30% prefer pre-stenting patients for subsequent URS (on average after 21 days). 59% of responders insert a ureteral stent after URS, which is removed, on average, after eight days in uncomplicated cases and 21 days after complicated URS. Most urologists give analgesics, alpha-blockers, and anticholinergics for stent-related symptoms and less than 10% prescribe opioids. Conclusion Our survey revealed urologists' eagerness for the early adoption of novel technologies and adherence to conservative practice patterns focused on patient safety.

Prospective Analysis of Versatility and User Satisfaction with a Novel Single-Use Cystoscope with Working Channel

INTRODUCTION

In the present study, a prospective systematic assessment of the clinical utility of the Ambu® aScopeTM 4 Cysto Reverse Deflection with regard to image quality, maneuverability, and navigation in an outpatient and inpatient setting was performed.

MATERIALS AND METHODS

A prospective multicenter study was performed for evaluation of the instrument during routine cystoscopy. We evaluated the clinical performance of the instruments using a standardized user questionnaire in different categories including image quality, treatment success, imaging of all areas of the urinary bladder, quality of navigation, flexibility of the endoscope, and satisfaction with the device. Statistical analyses were performed by SPSS using the Kruskal-Wallis and Wilcoxon-Mann-Whitney tests. A p value of p ≤ 0.05 was defined as statistically significant.

RESULTS

A total of 200 cystoscopies were performed, and the questionnaire response rate was 100%. The image quality was rated as very good in 65.5% (n = 131), good in 30.5% (n = 61), and neutral in 4% (n = 8) of cases. The criteria for poor or very poor were not mentioned. The characteristic "treatment success based on image quality" was also evaluated as very good in 49% (n = 98) and good in 50.5% (n = 101). The analysis revealed a very good or good overall impression of the examiners in all cases. Replacement of the cystoscope was not necessary during any of the examinations. However, in 3 cases, technical difficulties were documented. Further analysis of the data showed that physicians with less professional experience rated the visualization of the urinary bladder (p = 0.007) and the treatment success with regard to image quality significantly worse (p = 0.007).

CONCLUSION

The Ambu® aScope™ 4 Cysto Reverse Deflection shows high satisfaction values among users in clinical routine. In analogy to other studies with flexible endoscopes, urologists with more professional experience show higher satisfaction values than examiners with less training in flexible endoscopy.

Anaesthesia and environment: impact of a green anaesthesia on economics

The excessive growth of the health sector has created an industry that, while promoting health, is now itself responsible for a significant part of global environmental pollution. The health crisis caused by climate change urges us to transform healthcare into a sustainable industry. This review aims to raise awareness about this issue and to provide practical and evidence-based recommendations for anaesthesiologists.

Climate-smart Actions in the Operating Theatre for Improving Sustainability Practices: A Systematic Review

CONTEXT

Surgical activity contributes to global warming though the production of greenhouse gases and consumption of resources. To date, no clinical practice guidelines have been made to promote and implement climate-smart actions.

OBJECTIVE

To perform a systematic review of the available actions that could limit CO₂ emission in the operating room (OR) and their potential benefits upon the environment, whilst preserving quality of care.

EVIDENCE ACQUISITION

MEDLINE and Cochrane databases were searched from January 1, 1990 to April 2021. We included studies assessing carbon footprint (CF) in the OR and articles detailing actions that limit or reduce CF.

EVIDENCE SYNTHESIS

Thirty-eight studies met the inclusion criteria. We identified six core climate-smart actions: (1) waste reduction by segregation; (2) waste reduction by recycling, reuse, and reprocessing; (3) sterilisation; (4) anaesthesia gas management; and (5) improvement of energy use. Quantitative analysis regarding the CF was not possible due to the lack of homogeneous data. For climate-smart actions, the analysis was limited by discrepancies in study scope and in the methodology of CO₂ emission calculation. Improvement of education and awareness was found to have an important impact on waste segregation and reduction. Waste management is the area where health care workers could have the strongest impact, whereas the main field to reduce CF in the OR was found to be energy consumption.

CONCLUSIONS

This review provides arguments for many climate-smart actions that could be implemented in our daily practice. Improving awareness and education are important to act collectively in a sustainable way. Further studies are mandatory to assess the impact of these climate-smart actions in the OR.

PATIENT SUMMARY

We performed a systematic review of the available scientific literature to reference all the climate-smart actions proposed to improve the sustainability of surgical activities. Waste segregation, waste reduction and recycling, reuse and reprocessing, sterilisation, anaesthesia gas changes, and improvement of energy use in the operating room were found to be the main areas of research. There is still a long way to go to homogenise and improve the quality of our climate-smart actions.

Single-Use Ureteroscopy and Environmental Footprint: Review of Current Evidence

PURPOSE OF REVIEW

Ureteroscopy is a well-established treatment modality for kidney and ureteric calculi in addition to playing a key role in upper tract cancer diagnostics. Traditional reusable flexible ureteroscopes are technologically advanced and expensive pieces of equipment that require repeat sterilisation and periodical repair. These issues have led to the development of single-use flexible ureteroscopes that are disposed of after each case. Whilst this may be advantageous in many respects, the environmental impact of such technology is yet to be fully determined. The aim of this review is to therefore identify and summarise the available literature concerning the environmental footprint of single-use ureteroscopy.

RECENT FINDINGS

To identify the latest research on this topic, a systematic search of world literature was conducted using the Medline, Embase, and PsycINFO databases. PRISMA guidelines were followed and articles were assessed by all authors and relevant study results were included in a narrative format. Only one relevant article was identified and included. This study found that a single-use flexible ureteroscope (LithoVue^TM by Boston Scientific) generated an equivalent amount of carbon dioxide per case to a contemporary reusable flexible ureteroscope. Literature concerning the environmental footprint of single-use ureteroscopy is worryingly lacking. No conclusions can be definitively drawn from a single study and further research is imperative given the global climate crisis and the significant contribution that healthcare services have to the environmental problem.

The impact of switching from single-use to reusable healthcare products: a transparency checklist and systematic review of life-cycle assessments

BACKGROUND

Replacing single-use products with reusable ones may reduce the environmental impact of healthcare. This study aimed to broadly assess the environmental effects of that substitution.

METHODS

A systematic review of comparative cradle-to-grave life-cycle assessments (LCAs) of single-use and reusable healthcare products was conducted. The main outcomes assessed were changes in the environmental impact that resulted after switching from single-use to reusable products. As no standardized transparency checklist was available, one was developed here using DIN ISO 14040/14044. The final checklist included 22 criteria used to appraise the included studies.

RESULTS

After screening, 27 studies were included in the analysis. The healthcare products were assigned to four categories: invasive medical devices, non-invasive medical devices, protection equipment and inhalers. The outcomes revealed a reduction in mean effect sizes for all environmental impacts except water use. Non-invasive medical devices have greater relative mitigation potential than invasive devices. On average, information on 64% of the transparency checklist items was reported. Gaps included the reporting of data quality requirements.

CONCLUSIONS

Switching to reusable healthcare products is likely to reduce most impacts on the environment except water use, but the effect size differs among product categories. Possible study limitations include location bias, no systematic search of the grey literature and small samples for some impacts. This study's strengths are its approach to product categories and developed transparency catalogue. This catalogue could be useful to inform and guide a future process towards creating a standardized transparency checklist for the systematic reviews of LCAs.

Targeted intervention to achieve waste reduction in gastrointestinal endoscopy

OBJECTIVE

Endoscopy is healthcare's third largest generator of medical waste in hospitals. This prospective study aimed to measure a single unit's waste carbon footprint and perform a pioneer intervention towards a more sustainable endoscopy practice. The relation of regulated medical waste (RMW; material fully contaminated with blood or body fluids or containing infectious agents) versus landfill waste (non-recyclable material not fully contaminated) may play a critical role.

DESIGN

In a four-stage prospective study, following a 4-week observational audit with daily weighing of both waste types (stage 1), stage 2 consisted of a 1-week intervention with team education of waste handling. Recycling bins were placed in endoscopy rooms, landfill and RMW bins were relocated. During stages 3 (1 month after intervention) and 4 (4 months after intervention), daily endoscopic waste was weighed. Equivalence of 1 kg of landfill waste to 1 kg carbon dioxide equivalent (CO_2e) and 1 kg of RMW to 3kgCO_2e was assumed. Paired samples t-tests for comparisons.

RESULTS

From stage 1 to stage 3, mean total waste and RMW were reduced by 12.9% (p=0.155) and 41.4% (p=0.010), respectively, whereas landfill (p=0.059) and recycling waste increased (paper: p=0.001; plastic: p=0.007). While mean endoscopy load was similar (46.2 vs 44.5, p=0.275), a total decrease of CO_2e by 31.6% (138.8kgCO_2e) was found (mean kgCO_2e109.7 vs 74.9, p=0.018). The annual reduction was calculated at 1665.6kgCO_2e. All these effects were sustained 4 months after the intervention (stage 4) without objections by responsible endoscopy personnel.

CONCLUSION

In this interventional study, applying sustainability measures to a real-world scenario, RMW reduction and daily recycling were achieved and sustained over time, without compromising endoscopy productivity.

International Alliance of Urolithiasis guideline on retrograde intrarenal surgery

OBJECTIVES

To set out the second in a series of guidelines on the treatment of urolithiasis by the International Alliance of Urolithiasis that concerns retrograde intrarenal surgery (RIRS), with the aim of providing a clinical framework for urologists performing RIRS.

MATERIALS AND METHODS

After a comprehensive search of RIRS-related literature published between 1 January 1964 and 1 October 2021 from the PubMed database, systematic review and assessment were performed to inform a series of recommendations, which were graded using modified GRADE methodology. Additionally, quality of evidence was classified using a modification of the Oxford Centre for Evidence-Based Medicine Levels of Evidence system. Finally, related comments were provided.

RESULTS

A total of 36 recommendations were developed and graded that covered the following topics: indications and contraindications; preoperative imaging; preoperative ureteric stenting; preoperative medications; peri-operative antibiotics; management of antithrombotic therapy; anaesthesia; patient positioning; equipment; lithotripsy; exit strategy; and complications.

CONCLUSION

The series of recommendations regarding RIRS, along with the related commentary and supporting documentation, offered here should help provide safe and effective performance of RIRS.

Comparison of single-use flexible ureteroscopes with a reusable ureteroscope for the management of paediatric urolithiasis

INTRODUCTION

To compare the efficacy, side effects, and cost-effectiveness between a single-use digital flexible ureteroscope and a reusable flexible ureteroscope in the treatment of paediatric renal stones.

METHODS

This analytic, case-control, monocentric study included all patients undergoing flexible ureterosopies for stone treatment. Between April 2016 and February 2019, a reusable (Flex-X^C®, Karl Storz) flexible ureteroscope was used (control group), whereas a single-use (Uscope®, PUSEN Medical©) flexible ureteroscope was used in all procedures from March 2019 to April 2021. Clinical and procedural outcomes, operative times, complication rates, hospital stay, and costs per procedure were evaluated.

RESULTS

Forty-three cases using a reusable flexible ureteroscope and thirty-nine using a single-use flexible ureteroscope were included in the study. Demographic patient characteristics, stone burden, location and composition, preoperative presence of a double-J stent, procedural outcomes, mean length of postoperative hospital stay, and complications (4.6% versus 5%, p = 0.81) were comparable between the two groups. Median operative duration for stone removal was 93 min (20-170) with reusable versus 81 min (55-107) with the single-use scope (p = 0.18). Scope failure occurred four times with the reusable scope and in no case with the single-use. The total cost per procedure associated with the use of single-use scopes (798 Euros) was lower than a reusable scope (1483.23 Euros).

DISCUSSION

Single-use flexible ureteroscopes were created to bypass the problems incurred when reusable scopes were damaged and therefore not available for use in surgical procedures. Single-use flexible ureteroscopes are always immediately available and ready to be used, even in urgent cases, as they typically do not require maintenance or sterilization. Compared with their reusable counterparts, single-use flexible ureteroscopes have similar digital performance (270°), image quality and we found no difference in the success and complication rates. Cost analysis of a reusable flexible ureteroscope must consider the purchase price, maintenance and repair costs, and decontamination costs (including handling, detergent, bacterial culture, transportation, and storage costs). In contrast, only purchase price is included in cost analysis for single-use flexible ureteroscopes. Our study suggests that single-use flexible ureteroscopes may be associated with lower costs per procedure than their reusable counterparts.

CONCLUSION

Single-use flexible ureteroscopes are an interesting alternative to their reusable counterparts, particularly in terms of material resource management. Cost analyses conducted using a low volume of cases representative of a paediatric urology division favour the use of single-use ureteroscopes.

Environmental Impact of Prostate Magnetic Resonance Imaging and Transrectal Ultrasound Guided Prostate Biopsy

BACKGROUND

Reducing low-value clinical care is an important strategy to mitigate environmental pollution caused by health care.

OBJECTIVE

To estimate the environmental impacts associated with prostate magnetic resonance imaging (MRI) and prostate biopsy.

DESIGN, SETTING, AND PARTICIPANTS

We performed a cradle-to-grave life cycle assessment of prostate biopsy. Data included materials and energy inventory, patient and staff travel contributed by prostate MRI, transrectal ultrasound guided prostate biopsy, and pathology analysis. We compared environmental emissions across five clinical scenarios: multiparametric MRI (mpMRI) of the prostate with targeted and systematic biopsies (baseline), mpMRI with targeted biopsy cores only, systematic biopsy without MRI, mpMRI with systematic biopsy, and biparametric MRI (bpMRI) with targeted and systematic biopsies. We estimated the environmental impacts associated with reducing the overall number and varying the approach of a prostate biopsy by using MRI as a triage strategy or by omitting MRI. The study involved academic medical centers in the USA, outpatient urology clinics, health care facilities, medical staff, and patients.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Greenhouse gas emissions (CO₂ equivalents, CO₂e), and equivalents of coal and gasoline burned were measured.

RESULTS AND LIMITATIONS

In the USA, a single transrectal prostate biopsy procedure including prostate MRI, and targeted and systematic biopsies emits an estimated 80.7 kg CO₂e. An approach of MRI targeted cores alone without a systematic biopsy generated 76.2 kg CO₂e, a systematic 12-core biopsy without mpMRI generated 36.2 kg CO₂e, and bpMRI with targeted and systematic biopsies generated 70.5 kg CO₂e; mpMRI alone contributed 42.7 kg CO₂e (54.3% of baseline scenario). Energy was the largest contributor, with an estimated 38.1 kg CO₂e, followed by staff travel (20.7 kg CO₂e) and supply production (11.4 kg CO₂e). Performing 100 000 fewer unnecessary biopsies would avoid 8.1 million kg CO₂e, the equivalent of 4.1 million liters of gasoline consumed. Per 100 000 patients, the use of prostate MRI to triage prostate biopsy and guide targeted biopsy cores would save the equivalent of 1.4 million kg of CO₂ emissions, the equivalent of 700 000 l of gasoline consumed. This analysis was limited to prostate MRI and biopsy, and does not account for downstream clinical management.

CONCLUSIONS

A prostate biopsy contributes a calculable environmental footprint. Modifying or reducing the number of biopsies performed through existing evidence-based approaches would decrease health care pollution from the procedure.

PATIENT SUMMARY

We estimated that prostate magnetic resonance imaging (MRI) with a prostate biopsy procedure emits the equivalent of 80.7 kg of carbon dioxide. Performing fewer unnecessary prostate biopsies or using prostate MRI as a tool to decide which patients should have a prostate biopsy would reduce procedural greenhouse gas emissions and health care pollution.

Green endoscopy: British Society of Gastroenterology (BSG), Joint Accreditation Group (JAG) and Centre for Sustainable Health (CSH) joint consensus on practical measures for environmental sustainability in endoscopy

GI endoscopy is highly resource-intensive with a significant contribution to greenhouse gas (GHG) emissions and waste generation. Sustainable endoscopy in the context of climate change is now the focus of mainstream discussions between endoscopy providers, units and professional societies. In addition to broader global challenges, there are some specific measures relevant to endoscopy units and their practices, which could significantly reduce environmental impact. Awareness of these issues and guidance on practical interventions to mitigate the carbon footprint of GI endoscopy are lacking. In this consensus, we discuss practical measures to reduce the impact of endoscopy on the environment applicable to endoscopy units and practitioners. Adoption of these measures will facilitate and promote new practices and the evolution of a more sustainable specialty.

Best Practice in Interventional Management of Urolithiasis: An Update from the European Association of Urology Guidelines Panel for Urolithiasis 2022

PURPOSE

The European Association of Urology (EAU) has updated its guidelines on clinical best practice in urolithiasis for 2021. We therefore aimed to present a summary of best clinical practice in surgical intervention for patients with upper tract urolithiasis.

MATERIALS AND METHODS

The panel performed a comprehensive literature review of novel data up to May 2021. The guidelines were updated and a strength rating was given for each recommendation, graded using the modified Grading of Recommendations, Assessment, Development, and Evaluations methodology.

RESULTS

The choice of surgical intervention depends on stone characteristics, patient anatomy, comorbidities, and choice. For shockwave lithotripsy (SWL), the optimal shock frequency is 1.0-1.5 Hz. For ureteroscopy (URS), a postoperative stent is not needed in uncomplicated cases. Flexible URS is an alternative if percutaneous nephrolithotomy (PCNL) or SWL is contraindicated, even for stones >2 cm. For PCNL, prone and supine approaches are equally safe. For uncomplicated PCNL cases, a nephrostomy tube after PCNL is not necessary. Radiation exposure for endourological procedures should follow the as low as reasonably achievable principles.

CONCLUSIONS

This is a summary of the EAU urolithiasis guidelines on best clinical practice in interventional management of urolithiasis. The full guideline is available at https://uroweb.org/guidelines/urolithiasis.

PATIENT SUMMARY

The European Association of Urology has produced guidelines on the best management of kidney stones, which are summarised in this paper. Kidney stone disease is a common condition; computed tomography (CT) is increasingly used to diagnose it. The guidelines aim to decrease radiation exposure to patients by minimising the use of x-rays and CT scans. We detail specific advice around the common operations for kidney stones.

Environmental impact of single-use and reusable flexible cystoscopes

OBJECTIVES

To compare the carbon footprint and environmental impact of single-use and reusable flexible cystoscopes.

MATERIALS AND METHODS

We analysed the expected clinical lifecycle of single-use (Ambu aScope™ 4 Cysto) and reusable (Olympus CYF-V2) flexible cystoscopes, from manufacture to disposal. Performance data on cumulative procedures between repairs and before decommissioning were derived from a high-volume multispecialty practice. We estimated carbon expenditures per-case using published data on endoscope manufacturing, energy consumption during transportation and reprocessing, and solid waste disposal.

RESULTS

A fleet of 16 reusable cystoscopes in service for up to 135 months averaged 207 cases between repairs and 3920 cases per lifecycle. Based on a manufacturing carbon footprint of 11.49 kg CO₂ /kg device for reusable flexible endoscopes and 8.54 kg CO₂ /kg device for single-use endoscopes, the per-case manufacturing cost was 1.37 kg CO₂ for single-use devices and 0.0017 kg CO₂ for reusable devices. The solid mass of single-use and reusable devices was 0.16 and 0.57 kg, respectively. For reusable devices, the energy consumption of reusable device reprocessing using an automated endoscope reprocessor was 0.20 kg CO₂ , and per-case costs of device repackaging and repair were 0.005 and 0.02 kg CO₂ , respectively. The total estimated per-case carbon footprint of single-use and reusable devices was 2.40 and 0.53 kg CO₂ , respectively, favouring reusable devices.

CONCLUSION

In this lifecycle analysis, the environmental impact of reusable flexible cystoscopes is markedly less than single-use cystoscopes. The primary contributor to the per-case carbon cost of reusable devices is energy consumption of reprocessing.

Environmental and health outcomes of single-use versus reusable duodenoscopes

BACKGROUND AND AIMS

The large-scale effects of duodenoscopes on the environment and public health have not been quantified. Our aim was to perform an exploratory life cycle assessment comparing environmental and human health effects of single-use duodenoscopes (SDs) and reusable duodenoscopes (RDs).

METHODS

We evaluated 3 duodenoscopes: conventional RDs, RDs with disposable endcaps, and SDs. The primary outcomes were impacts on climate change and human health, complemented by multiple environmental impacts.

RESULTS

Performing ERCP with SDs releases between 36.3 and 71.5 kg of CO₂ equivalent, which is 24 to 47 times greater than using an RD (1.53 kg CO₂) or an RD with disposable endcaps (1.54 kg CO₂). Most of the impact of SDs comes from its manufacturing, which accounts for 91% to 96% of its greenhouse gas emission. The human health impact of RDs becomes comparable with the SD lower bound if disposable endcaps or other design modifications can reduce serious infection rates below a target rate of 23 cases per year (.0046%).

CONCLUSIONS

Although SDs may provide incremental public health benefit compared with RDs, it comes at a substantially higher cost to the environment. As infection rates continue to decrease from more regimented cleaning protocols and enhanced designs such as disposable endcaps to facilitate cleaning, the negative impact to human health from contaminated RDs could be comparable with SDs.

An in vitro Comparative Assessment of Single-Use Flexible Ureteroscopes Using a Standardized Ureteroscopy Training Model

INTRODUCTION

Perceived benefits like decreased contamination rates and reduced postoperative incidence of complications after urolithiasis surgery have led to increased adoption of single-use flexible ureteroscopes (su-fURS). Using a validated, standardized simulator model with enhanced "fluoroscopic" capabilities, we performed an in vitro comparative assessment of four commercially available models of su-fURS. Both objective and subjective parameters were assessed in this study.

METHODS

Two standardized tasks, (1) exploration of the model's kidney collecting system and (2) repositioning of a stone fragment from the upper renal to lower renal pole were assigned to participants, who performed these tasks on all four scopes. Four models of su-fURS (Boston LithoVue, PUSEN PU3033A, REDPINE, INNOVEX EU-ScopeTM) were assessed, with task timings as end-points for objective analysis. Cumulative "fluoroscopic" time was also recorded as a novel feature of our enhanced model. Post-task questionnaires evaluating specific components of the scopes were distributed to document subjective ratings.

RESULTS

Both subjective and objective performances (except stone repositioning time) across all four su-fURS demonstrated significant differences. However, objective performance (task timings) did not reflect subjective scope ratings by the participants (Rs < 0.6). Upon Kruskal-Wallis H test with post hoc analyses, REDPINE and INNOVEX EU-ScopeTM were the preferred su-fURS as rated by the participants, with overall scope scores of 9.00/10 and 9.57/10.

CONCLUSIONS

Using a standardized in vitro simulation model with enhanced fluoroscopic capabilities, we demonstrated both objective and subjective differences between models of su-fURS. However, variations in perception of scope features (visibility, image quality, deflection, maneuverability, ease of stone retrieval) did not translate into actual technical performance. Eventually, the optimal choice of su-fURS fundamentally lies in individual surgeon preference, as well as cost-related factors.

HealthcareLCA: an open-access living database of health-care environmental impact assessments

Anthropogenic environmental change negatively effects human health and is increasing health-care system demand. Paradoxically, the provision of health care, which itself is a substantial contributor to environmental degradation, is compounding this problem. There is increasing willingness to transition towards sustainable health-care systems globally and ensuring that strategy and action are informed by best available evidence is imperative. In this Personal View, we present an interactive, open-access database designed to support this effort. Functioning as a living repository of environmental impact assessments within health care, the HealthcareLCA database collates 152 studies, predominantly peer-reviewed journal articles, into one centralised and publicly accessible location, providing impact estimates (currently totalling 3671 numerical values) across 1288 health-care products and processes. The database brings together research generated over the past two decades and indicates exponential field growth.

Willingness to Pay and Preferences Among Patients Undergoing Cystoscopies: Results from a Large Survey-Based Study in Spain

Purpose

Cystoscopy procedures can cause distress among patients. Patient perspectives on health services are essential inputs in decision-making. This study investigated the patient preferences in Spain regarding single-use cystoscopes (SUC) compared to reusable cystoscopes and their willingness to pay (WTP) for cystoscopy procedures.

Patients and Methods

Between May and June 2021, an anonymous survey was distributed to Spanish patients who had previously undergone a cystoscopy. The survey included patient preference measures on reusable cystoscopes compared to SUCs and a discrete choice experiment. The survey was distributed through a human data science company (IQVIA), collected using an online survey tool (QuestionPro^®), and analyzed using Stata/MP, StataCorp.

Results

Of 300 respondents, 148 (49.33%) were female and 150 (50%) were male, and mainly between 18–49 years (247, 82.33%). Most (265, 88%) preferred to have their procedure performed with a SUC rather than a reusable cystoscope. Among these patients, 215 (80%) could imagine asking their doctor to use a SUC. A total of 231 (77%) respondents indicated an increased level of concern about the risk of exposure to contamination related to their cystoscopy following the COVID-19 pandemic. Patients would pay 62 EUR to have their initial consultation and cystoscopy procedure on the same day (p < 0.001), 59 EUR to reduce the environmental impact, and 57 EUR to reduce the risk of contamination (p < 0.001).

Conclusion

Patients prefer to undergo cystoscopy using an SUC on the same day as their initial consultation. The increased contamination concerns due to the COVID-19 pandemic and WTP to reduce the risk of cystoscope contamination may explain patients’ preferences for SUCs. The most important attributes related to their cystoscopy procedure are the ability to have their procedure performed on the same day as their initial consultation, the reduction of the environmental impact, and the reduction of the contamination risk.

Comparison of Surgical Outcomes between Single-Use and Reusable Flexible Ureteroscopes for Renal Stone Management: A Systematic Review and Meta-Analysis

Background and Objectives: Disposable flexible ureteroscopes have been widely used because of their cost-effectiveness and higher sterility potential compared with reusable flexible ureteroscopes. This study aimed to compare the surgical outcomes and complication rates in patients who undergo reusable or disposable flexible ureteroscopic stone surgeries (fURS) for urinary stone disease. Materials and Methods: A systematic review and meta-analysis were conducted under the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. This systematic review was registered with PROSPERO (CRD42022331291). Clinical trials comparing reusable and disposable fURS for stone disease were found from PubMed, EMBASE, Cochrane Library, and the Web of Science up to March 2022. Participants were patients with upper urinary tract stones; the interventions were reusable or disposable fURS. Outcomes, including stone-free rate, operation time, length of hospital stay, and complication rate, were compared for analysis. Results: Overall, 111 studies were identified, but after removing duplicate studies, 75 studies remained. Thirty-two of these studies were excluded. Of the 43 screened studies, 11 met the eligibility criteria. There was no difference in the stone-free rate (SFR) between disposable and reusable fURS (p = 0.14; OR = 1.36; 95% CI, 0.9 to 2.04). For operation time, no difference was identified between reusable and disposable fURS groups (p = 0.12; MD = -5.31; 95% CI, -12.08 to 1.46). For hospital stay, there was also no difference between the two groups (p = 0.61; MD = -0.03; 95% CI, -0.17 to 0.10). There was no significant difference in complication rate between the two groups (p = 0.85; OR = 0.95; 95% CI, 0.56 to 1.61). Conclusions: There were no differences in the SFR, operation time, length of hospital stay, and complication rate between reusable and disposable fURS. Disposable fURS may be a comparable alternative to reusable fURS.

Re: The Carbon Footprint of Single-Use Flexible Cystoscopes compared to Reusable Cystoscopes. Methodological flaws led to the erroneous conclusion that single-use is "better"

N/A.

The environmental impact of surgery: A systematic review

BACKGROUND

Climate change is a significant public health threat. Health care comprises 10% of greenhouse gas emissions in the United States, where surgery is especially resource intensive. We did a systematic review to assess and summarize the published evidence of the environmental impact of surgery.

METHODS

We searched Medline, Embase, Web of Science, and GreenFILE databases for publications that report any environmental impact measure by all surgical subspecialties, including anesthesia. Inclusion criteria were published in English, original research, and passed peer review. Because data were heterogeneous and the aim was broad, we conducted a qualitative summary of data. Where possible, we compare impact measures.

RESULTS

In the study, 167 articles were identified by our search strategy and reviewed, of which 55 studies met criteria. Eight were about anesthesia, 27 about operating room waste, and 6 were life cycle assessments. Other topics include carbon footprint and greenhouse gas emissions. Nine papers fell into 2 or more categories. Overall, the operating room is a significant source of emissions and waste. Using anesthetic gases with low global warming potential reduces operating room emissions without compromising patient safety. Operating room waste is often disposed of improperly, often due to convenience or knowledge gaps. There are environmental benefits to replacing disposable materials with reusable equivalents, and to proper recycling. Surgeons can help implement these changes at their institution.

CONCLUSION

Although there is a clear need to lower the carbon footprint of surgery, the quality of research with which to inform protocol changes is deficient overall. Our attempt to quantify surgery's carbon footprint yielded heterogeneous data and few standardized, actionable recommendations. However, this data serves as a starting point for important future initiatives to decrease the environmental impact of surgery.

Cost and Environmental Impact of Disposable Flexible Cystoscopes Compared to Reusable Devices

Objectives: To quantify the environmental impact and costs associated with flexible cystoscopy procedures from an institutional perspective, with particular attention for the comparison between disposable and reusable cystoscopes. Materials and Methods: This is a single-center retrospective study, including all flexible cystoscopies performed between 2020 and 2021 using reusable or single-use devices. The Ambu aS4C single-use cystoscope (Ballerup, Denmark) gradually replaced the reusable device in our center, with exclusive use from October 2021. Reprocessing costs for reusable cystoscopes were evaluated using a micro-costing approach. The environmental impact of reusable and disposable cystoscopes was assessed by the amount of waste and water consumed for each procedure. Results: A total of 1578 flexible cystoscopies using reusable cystoscopes were performed in 2020, and 550 cystoscopies were performed using the Ambu aS4C cystoscope from October 2021 to February 2022. The cost of flexible cystoscopy with a reusable and a disposable endoscope was €196 and €192, respectively. The amount of waste generated by reprocessing reusable and disposable cystoscopes was 800 and 200 g per procedure, respectively. Water consumption for sterilization of the reusable cystoscope was 60 L per procedure, whereas no water consumption was required with the Ambu aS4C cystoscope. A 100% Ambu aS4C cystoscope use would reduce waste generation and water consumption by 946.8 kg and 94.68 m³ per year. Conclusion: In this study, implementing a strategy of using 100% disposable cystoscopes was associated with similar costs and reduced waste generation and water consumption compared to reusable devices. Future studies are needed to compare the carbon footprint of these devices, through a comprehensive and rigorous life cycle assessment from manufacturing to recycling.

Cost-Effectiveness of 90-Day Single-Use Flexible Cystoscope Trial: Single Center Micro-Costing Analysis and User Satisfaction

OBJECTIVE

To evaluate cost-effectiveness and user satisfaction of a single-use flexible cystoscope at a tertiary care center we conducted a 90-day trial. Single-use flexible cystoscope advancements have introduced alternative options to reusable scopes. However, there is a paucity of cost-effectiveness and provider satisfaction studies examining the implementation of a hospital-based transition to single-use cystoscopes.

METHODS

Following institutional device-approval we initiated a 90-Day trial period (November 1, 2020 - January 29, 2021) where all flexible, transurethral, and percutaneous, urologic care was provided with a disposable AMBU® aScope^TM. We performed a micro-costing analysis examining payor per case cost of the reusable flexible cystoscope (including servicing & processing) to the disposable units. Provider surveys assessed visual quality, deflection, ease of working channel and overall satisfaction on a 10-point Likert scale.

RESULTS

Over the 90-day period, we encountered 84 cases (78 operative, 5 inpatient, 1 emergency department (ED)) where flexible cystoscopy was required. One disposable flexible cystoscope was successfully used in 78/84 (93%) cases. Of the 6 failures, 2 were due to an inability to access a disposable scope/monitor. Per use cost of the reusable flexible cystoscope at our center was $272.41 versus $185.00 for the single use. Extrapolating our average case volume and conservative failure rate (3 single use failures/month, requiring reusable), transitioning to predominately single use scopes results in $39,142.84 annual cost savings.

CONCLUSIONS

This single center 90-Day trial of disposable flexible cystoscopy identified per-use costs to be less when a single-use flexible cystoscope was utilized at a high-volume tertiary care center.

The Carbon Footprint of Single-Use Flexible Cystoscopes compared to Reusable Cystoscopes

INTRODUCTION

Single-use devices for endourological procedures are becoming more popular. The environmental impact of single-use instruments is relatively unknown. This study aimed to compare the carbon footprint of single-use versus reusable flexible cystoscopes based on waste production and estimated carbon emissions.

METHODS

An analysis of the solid waste produced when using the aScope™ 4Cysto (Ambu®) single-use flexible cystoscope compared to the reusable Cysto-Nephro Videoscope CYF-VA2 (Olympus®) was performed. The solid waste generated was measured (grams) and recorded as either recyclable, landfill or contaminated, and CO2 produced by disposal, manufacture and cleaning was calculated.

RESULTS

40 flexible cystoscopies (20 single-use and 20 reusable) were analysed. Median total weight of waste produced was 622g (IQR621-651) for the single-use cystoscope compared to 671.5g (IQR659-677.5) for the reusable cystoscope (p<0.0001). More waste was disposed of by incineration after single-use than reusable cystoscopy (496g [IQR495-525] vs 415g [IQR403-421.5], p<0.0001). However, more waste went to landfill after reusable cystoscopy (256g±0 vs 126g±0, p<0.0001). There was no difference in weight of waste produced based on the indication for cystoscopy (p=0.1570). A total of 2.41kg of CO2 (IQR 2.40-2.44) was produced per case for the single-use flexible cystoscope compared with 4.23kg of CO2 (IQR 4.22-4.24) for the reusable cystoscope (p<0.0001).

CONCLUSION

Environmental accountability is essential in modern healthcare. This study highlights that disposable flexible cystoscopes have a significantly lower impact on the environment in terms of carbon footprint and landfill. We propose that environmental impact studies should be a routine part of device development for a sustainable future.

Building sustainable and resilient surgical systems: A narrative review of opportunities to integrate climate change into national surgical planning in the Western Pacific region

Five billion people lack access to surgical care worldwide; climate change is the biggest threat to human health in the 21st century. This review studies how climate change could be integrated into national surgical planning in the Western Pacific region. We searched databases (PubMed, Web of Science, and Global Health) for articles on climate change and surgical care. Findings were categorised using the modified World Health Organisation Health System Building Blocks Framework. 220 out of 2577 records were included. Infrastructure: Operating theatres are highly resource-intensive. Their carbon footprint could be reduced by maximising equipment longevity, improving energy efficiency, and renewable energy use. Service delivery Tele-medicine, outreaches, and avoiding desflurane could reduce emissions. Robust surgical systems are required to adapt to the increasing burden of surgically treated diseases, such as injuries from natural disasters. Finance: Climate change adaptation funds could be mobilised for surgical system strengthening. Information systems: Sustainability should be a key performance indicator for surgical systems. Workforce: Surgical providers could change clinical, institutional, and societal practices. Governance: Planning in surgical care and climate change should be aligned. Climate change mitigation is essential in the regional surgical care scale-up; surgical system strengthening is also necessary for adaptation to climate change.

Bilateral same session flexible ureterorenoscopy for endoscopic management of bilateral renal calculi is noninferior to unilateral flexible ureterorenoscopy for management of multiple unilateral renal calculi: outcomes of a prospective comparative study

PURPOSE

The aim of the study was to prospectively evaluate safety and efficacy of bilateral same session ureterorenoscopy (BSS-FURS) for management of bilateral renal calculi.

METHODS

A prospective comparative study was designed to compare the results of BSS-FURS with unilateral flexible ureterorenoscopy (U-FURS) for management of renal calculi between June 2003 and May 2016. A sample size of 55 patients in each arm was calculated considering a 20% increase in the incidence of complications with BSS-FURS over 15% complication rate in U-FURS (alpha = 0.05; Beta = 0.90). Patient demographics, stone burden, total operative time, postoperative creatinine level, duration of hospital stay, perioperative complications and stone free rate (SFR) were compared in both the groups. The literature pertaining to BSS-FURS was reviewed.

RESULTS

Although the study group patients had higher overall stone burden (18.60 ± 7.70 mm vs. 13.32 ± 6.43 mm) and significantly longer operative time (48.30 ± 16.71 min vs. 32.95 ± 13.05 min; p < 0.05) as compared to the control group, the length of hospital stay, SFR (67.85% vs. 78.5%; p = 0.436) and perioperative complications were comparable in both the groups. Most patients who developed postoperative fever from both groups had struvite stones.

CONCLUSION

BSS-FURS is a safe and efficient procedure for the management of bilateral renal calculi in the hands of an experienced endourologist. It has comparable SFR and morbidity compared to U-FURS. Caution should be exercised in patients with struvite stones, as they are more likely to develop postoperative fever.

Carbon footprint modelling of national health systems: Opportunities, challenges and recommendations

Health care presents significant contributions towards climate change. An awareness of a health systems carbon footprint provides a quantification of its environmental impact, an understanding of carbon intensive areas to target with reduction measures and a means of mapping trends in emissions over time. Attempts at calculating the carbon footprint of national health systems are few, predominantly of developed nations, and are limited by data availability and methodological inadequacies. There is a need to mobilise countries to understand the role of health care in contributing towards climate change and for them to start engaging in ongoing calculations of their national health system carbon footprints. There is also a need to improve data availability and information systems to allow for such calculations, especially in developing countries where there may be differences in carbon hotspots. Finally, there is a need for continued improvements in the carbon footprint modelling methodology of health systems as data collection and available emission factors, especially of health care specific products and supply chain emissions, improves. Health systems need to join the global fight against climate change.

Climate change is a significant threat to global health.

Health systems contribute to climate change.

Carbon footprint modelling allows focused decarbonisation of health systems.

Improvements in health care data collection for carbon modelling is needed.