Ureteroscopy is the most common surgical procedure performed for kidney stone disease, thanks to improved scope performance, smaller scope size and broad resident training. However, reusable flexible ureteroscope durability has led to financial and consistency concerns given the initial capital outlay and repair costs, as well as functional deterioration over time, respectively. ¹

Single-use ureteroscopes with similar optics and maneuverability ² have increased in popularity on the premise of improved cost and consistency compared to reusable ureteroscopes. However, multiple expenses go into the per-case price of a ureteroscope, including initial acquisition, repair and reprocessing. The most detailed breakdown of these expenses was performed in a microcosting analysis of ureteroscopy during 2 months at a high volume academic institution. Taguchi and colleagues demonstrated that the overall per-case cost of a single-use digital ureteroscope ($2,852) was comparable to a reusable fiberoptic ureteroscope ($2,799). ³ Although detailed, the small case volume could not evaluate the impact of case-specific variables including indication for surgery, laterality, stone size and location.

Removing the operating variables, the study demonstrated that the major per-case expense for reusable ureteroscopes was in repair ($958, 34%), and for single-use ureteroscopes it was in initial acquisition ($1,500, 53%). While fiberoptic reusable ureteroscopes are inherently less durable compared to their digital counterparts, efforts to limit scope damage could certainly improve the reusable per case cost. Moreover, the price of a single-use ureteroscope is institution-specific. Contract negotiations and tiered pricing could improve the single-use per-case cost.

Cost comparability might also be dependent on an institution's ureteroscopy volume. It has been demonstrated that for higher volume centers reusable ureteroscopes are likely more cost-effective, while for lower volume centers the inverse is true. ² Certainly one of the greatest aspects of single-use ureteroscopes is bringing contemporary digital endoscopy to patients at centers that previously did not have the volume and/or could not afford reusable equipment. However, it does not have to be an all or none choice. If possible, a mixed strategy is likely the most cost-efficient. Diagnostic ureteroscopy or proximal ureter, renal pelvis or mid/upper pole stone burdens can likely be treated safely with a reusable ureteroscope. Ideally, moving lower pole stones to a different location can also be treated with a reusable ureteroscope to limit scope strain. But large lower pole stone burdens or those in patients with complex anatomy where the risk of scope damage is high are perfect cases for a single-use product. ²

As more manufacturers enter the single-use ureteroscope market, the ureteroscope price and the number of cases required to achieve cost-equivalence will likely decline, assuming reusable ureteroscope repair costs do not make a similar trend. We will likely see a greater proportion of single-use ureteroscope cases, yet the convenience of an off-the-shelf device adds an obscured cost to the environment.

The United States health care sector is a major contributor to our current climate crisis, with operating rooms often comprising the majority of a hospital's overall physical and energy waste. ⁴ Much of this is driven by single-use products. After ureteroscopy, we routinely dispose of our gowns, drapes, ureteral access sheath, irrigation device, tubing, laser, basket and wires. While the clinical role of a single-use ureteroscope is warranted, the increased physical waste production per case is concerning, especially as use increases.

Reusable ureteroscopes are certainly not free of environmental burden, as Davis et al concluded that the overall carbon footprint per case (4.47 kg of CO ₂) compared to single-use ureteroscopes (4.43 kg of CO ₂) was similar. ⁵ While the manufacturing cost (90% plastic) of a single-use ureteroscope comprised 86% (3.83 kg of CO ₂) of the overall per-case carbon footprint, the manufacturing of a reusable ureteroscope was only 1.3% (0.06 kg of CO ₂). The majority of the per-case carbon footprint for reusable ureteroscopes was in washing/sterilization (3.95 kg of CO ₂, 88%). Importantly, we have ways to retreat water and use clean, renewable energy sources. Our ability to deal with plastics is more challenging.

For nearly 50 years we have been emphasizing reduce, reuse and recycle in that order in an effort to curb the damage to our planet. As it relates to ureteroscopy this could imply reducing plastics from single-use products, but it could just as easily imply reducing ureteroscope damage, which has an environmental cost of repair. Pushing our reusable ureteroscope manufacturers to improve durability and training urologists to eliminate manual forcing, which can damage the fragile shaft, are also important reduction efforts. ¹ Furthermore, minimizing any unnecessary packaging of single-use items as well as blue wrap for our reusable products would help to reduce waste.

Reusability should be attempted for all products as long as patient safety can be maintained. For a single-use ureteroscope that has not reached its life expectancy, we should explore reprocessing options. There is a growing industry of reprocessing hospital equipment, from previously disposed surgical devices to patient transfer mats. The quality control for reprocessing these products is high, with functional devices being resterilized and sold back to hospitals at a cost-savings. A multi-use disposable ureteroscope would certainly make it more cost-effective by reducing the acquisition cost and improve the per-case carbon footprint.

The last option when a device has reached its life expectancy is recycling. We should be pushing our single-use device manufacturers to use recycling friendly components, not only in the product but also in the packaging. And they should be setting up convenient recycling programs for the plastics, electronics and metals to be repurposed or converted from waste to energy.

Urologists continue to be at the forefront of surgical technology and advancement. In 2021 our work should include being cognizant of the environmental impact of our profession. Undoubtedly, single-use ureteroscopes play an important role in our endoscopic management of kidney stones and can be a cost savings, depending on a hospital's volume and the per- case risk of reusable ureteroscope damage. Efforts to minimize the environmental burden by limiting single-use ureteroscopes to specific cases, developing multi-use options and recycling as the final step are imperative. There is a cost to throwing away a single-use ureteroscope, and our planet cannot afford it.