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MEDICAL ETHICS: "It's Not Easy Being Green": Environmental Considerations for the Practicing Urological Surgeon

By: Robin Djang, MD; Michael S. Cookson, MD | Posted on: 01 Nov 2022


The past 20 years have shown an explosion in innovative surgical tools and technology for use by urologists. New surgical instruments, enhanced lasers, the evolution of robotic surgery, image guidance, biopsy equipment, access sheaths, and stents have allowed urological surgeons unprecedented ability to treat disease and cure illness.

However, a little discussed caveat to this evolving surgical practice is the generation of large amounts of surgical waste and disposable by-products.

After a long surgical case, once the patient has been taken to the post-anesthesia care unit, stop and take a moment to look around the room. No doubt, surgical staff are working to clean and turn over the operating room (OR) for the next case. Looking at the waste that is hauled out is probably the last thing on a surgeon’s mind.

Take a second to appreciate the volume of surgical waste each case generates. It’s clear from the numerous large bags that an enormous amount of waste is generated in each room every day. Now, multiply times the number of ORs in your hospital and again by the number of days each year they run. Now do this exercise in each hospital in the United States and you start to see the tip of the iceberg!

As a society, we are increasingly becoming attuned to how much energy we use, where our energy comes from, and the environmental impact of our economic activity from food packaging to Amazon boxes to electric vs gas powered vehicles. But while the day-to-day environmental impact of our daily lives is at the forefront of discussion, it is less so for our workplace at the clinic or hospital. Why is that?

Environmental Considerations

Health care facilities are a leading contributor to waste in the United States. A 2011 review suggested that hospitals, clinics, and health facilities are the second leading contributor of waste in the U.S., with operating and labor/delivery waste accounting for 70% of that waste stream alone.1,2 U.S. hospitals create up to 5.9 million tons of waste annually according to Practice GreenHealth, a sustainability analytics nonprofit organization.

While innovations in surgical instruments have no doubt improved surgical care and patient outcomes, where do we as urological surgeons fit into the role of waste management? Do we hold any responsibility for the garbage that is generated for the sake of a patient? Does it matter how much waste is generated as long as the patient outcomes are good? Can environmental considerations coexist at the intersection of value-based care and patient outcomes?

Defining the Scope of the Problem

Unfortunately, there is a critical lack of information on how much surgical waste is generated both at the OR and institutional level. A literature review of surgical waste, environmental sustainability, and OR recycling yields several review articles and observational studies documenting waste generated in 1 OR day. One article from an orthopedic group documented the total waste generated after 1 knee arthroplasty case to be 29.3 lbs on average.3 Of this, 19.2% was biohazard waste, 12.1% was blue sterile wrap, and 2.2% was recyclable waste. Based on the above average numbers, the authors estimated approximately 899,241 lbs of landfill waste were generated for all total knee arthroplasties performed in Canada for 2008-2009 alone.

Unpublished data from 2 institutions draw a similar conclusion for urological waste. A robot-assisted laparoscopic prostatectomy generated 2 lbs of recycled trash, 9.5 lbs of regular trash, and 2 lbs of biohazard waste for an average total of 13.5 lbs per case. A cystoscopy and simple bladder biopsy generated 0.6 lbs of recycled waste, 4.6 lbs of regular trash (excluding any fluids), and 0.4 lbs of biohazard waste for an average of 5.6 lbs per case (see Figure).

Figure. Waste generated after 1 robot-assisted laparoscopic prostatectomy case. Recyclable plastics and paper waste are not separated into different waste streams at our institution. Left to right: 1 bag of surgical tray sterile wrap, 1 bag of surgical drapes, 1 bag of surgical gowns and gloves, 2 bags of instrument paper/plastic packaging, and 1 dark-blue bag of biomedical waste.

Incredibly, published literature on urological-specific surgical waste does not currently exist.

What Can We Do?

As always, common sense prevails. Change surgical preference cards to ensure accuracy and minimize waste. Sutures, instruments, and single-use disposables can often be held in the room and opened as needed instead of opened automatically for each case. Chasseigne et al concluded that up to 20% of total cost allocated to surgical supplies is often wasted with instruments or supplies opened, unused and then discarded due to “anticipation of surgeon needs.”4

While single-use cystoscopes continue to see increased use and growth given ease of use and cost considerations, there is ongoing debate about the economics and environmental impacts of this new technology. Boucheron et al suggest decreased wastewater, dry waste, and overall environmental energy consumption in favor of disposable cystoscopes.5 Another option may be a hybrid solution where reusable cystoscopes are used with disposable sheaths.

Medical waste, once generated, ideally should be segregated into general waste (unsoiled and paper products), infectious/biological waste for incineration, and recycling. A significant amount of waste is miscategorized with up to 90% of red-bag waste not meeting biological hazardous criteria. This has significant financial implications. While red-bag waste accounts for only 24% of medical waste, it accounts for 86% of waste management costs.2

We can also educate ourselves on our institution’s specific waste stream. In general, while reusable surgical instruments are sterilized by autoclave and chemical disinfection, most biomedical trash (eg, contaminated with bodily fluid or tissue) continues to be incinerated. Dry waste not exposed to blood or biological contamination is diverted to landfills. Recycling of dry packaged waste and plastics is likely on an institutional basis alone.

For this reason, a hospital-wide recycling program is an ideal way to address the significant plastic waste stream generated from surgical procedures. Essentially all surgical instruments and disposables come prepackaged in paper or plastic products. These plastics can be easily diverted to recycling steams if they remain uncontaminated or could be decontaminated. Tieszen et al determined that gross surgical waste reductions of up to 73% could be obtained by establishing plastic and paper recycling programs within an institution.6


There will not be a one-size-fits-all answer or approach to deal with the problem of surgical waste. In the end, sterility and patient safety remain paramount concerns for both the operating surgeon and patient. However, significant gains can be realized by addressing the waste knowledge gap, educating surgeons and staff on waste streams and garbage generated per case, and making common sense improvements to reduce this growing concern.

Larger improvements can be realized from a systems-wide, administrative, and manufacturing basis with physicians advocating for change at the department and hospital-wide levels.

We owe it to our patients and our society to provide the best quality care in a safe and nurturing environment. We also owe it to society to do our part to reduce medical waste, and to look to ways to improve our environment by refocusing attention on reducing medical waste and looking for ways to reduce our carbon footprint and shrink our growing landfill.

  1. Rizan C, Steinbach I, Nicholson R, Lillywhite R, Reed M, Bhutta MF. The carbon footprint of surgical operations: a systematic review. Ann Surg. 2020;272(6):986-995.
  2. Kwakye G, Brat GA, Makary MA. Green surgical practices for health care. Arch Surg Chic Ill. 1960. 2011;146(2):131-136.
  3. Stall NM, Kagoma YK, Bondy JN, Naudie D. Surgical waste audit of 5 total knee arthroplasties. Can J Surg J Can Chir. 2013;56(2):97-102.
  4. Chasseigne V, Leguelinel-Blache G, Nguyen TL, et al. Assessing the costs of disposable and reusable supplies wasted during surgeries. Int J Surg Lond Engl. 2018;53:18-23.
  5. Boucheron T, Lechevallier E, Gondran-Tellier B, et al. Cost and environmental impact of disposable flexible cystoscopes compared to reusable devices. J Endourol. 2022; doi:10.1089/end.2022.0201.
  6. Tieszen ME. A quantitative, qualitative, and critical assessment of surgical waste: surgeons venture through the trash can. JAMA. 1992;267(20):2765.