Climate change will be the defining health crisis of the 21st century. The scope of climate change’s impact on human health is vast and threatens to undermine the past 50 years of gains in public health.^1-3 Furthermore, climate change-related health risks disproportionately impact marginalized and under-resourced populations.^4,5 In 2018, greenhouse gas and toxic air pollutant emissions resulted in the loss of 388,000 disability-adjusted life years (DALYs).⁶ The U.S. health care system produces 8%-10% of the country’s total greenhouse gas emissions⁷ and 25% of global health sector emissions—the highest proportion attributable to any individual country’s health sector.⁸ The U.S. health care system also produces an enormous amount of waste, estimated at 4-5 million tons per year.⁹ In order to provide equitable care to their communities, hospitals need to curb their carbon footprints, improve their waste management, and lead sustainability efforts by incorporating environmentally conscious solutions into their operations.

Table 1. Common Surgical Materials That Should Not Be Placed in Red-bag Waste Unless Visibly Soiled

Table 2. Single-use Urological Equipment and Devices That Can Be Reprocessed³²

Of interest to urologists, the operating room (OR) is an area where practical and significant changes can be made to lessen the impact of climate change. Between 20% and 33% of hospital waste is attributable to ORs¹⁰—have you ever noticed the mountain of waste produced by a surgical case and wondered if it all was necessary? A recent survey of surgeons showed that 90% agreed or strongly agreed that waste of sterile surgical items is an issue, and 95% agreed or strongly agreed to a willingness to change the OR workflow to reduce waste.¹¹ Although there will always be a minimum necessary level of waste to ensure sterility and patient safety, the amount of waste associated with supplies (such as sutures, ports, hemostatic devices/agents, catheters, and surgical clips) can serve as a target for decreasing waste and OR expenditure.¹² A study of 20 routine urological procedures found that €261.4 ($274.21) of supplies were wasted, accounting for up to 4% of total supply cost.¹³

The Stanford University Department of Urology demonstrated that adjusting urological surgeons’ preference cards after briefing them about unused disposable items resulted in a significant decrease in OR waste without affecting the quality of patient care. The intervention yielded a 92% reduction in waste, equating to potential cost savings of $19,760 annually for these urology ORs.¹⁴ Conrardy et al reported cost savings of up to 65% for surgical teams working with reusable gowns, linens, and basins instead of disposable products at 2 large academic medical centers. The average waste disposal savings in these hospitals was $13,300 per year. Additionally, the surgical teams preferred reusable products to disposable ones in terms of comfort and ease of use.¹⁵ The point illustrated is not only for urological surgery departments to become greener for the sake of reducing waste and promoting sustainability within their health systems, but also for the sake of decreasing health care costs without compromising outcomes.

The World Health Organization estimates that the costs of climate change’s direct damage to health will reach $2 billion to $4 billion per year by 2030.⁷ Since practicing sustainability in the OR and the movement to reduce health care costs are aligned, several specialties have already implemented synergistic initiatives in the OR. Anesthesiologists are avoiding desflurane because it has a higher carbon footprint than other commonly used agents like sevoflurane;¹⁶ Providence St Joseph Health system saved $500,000 annually after their network of hospitals in Oregon decreased desflurane usage by 80%.¹⁷ Anesthesiologists at the Mayo Clinic in Rochester reduced endotracheal tube and laryngoscope waste by 62.6% and 54.0%, respectively, after a presentation with pictures of the department’s waste; this intervention saved $4,255.01 in just 8 weeks.¹⁸ Ophthalmologists launched EyeSustain (https://eyesustain.org/), a global coalition seeking to deliver more environmentally friendly ophthalmic care, after research showed that cataract surgery—one of the most prevalent surgical procedures in the world¹⁹—has exorbitant financial costs from excessive wastefulness.²⁰ Additionally, otolaryngologists, orthopedic surgeons, and interventional radiologists are performing waste audits in their ORs.^21-23 Urologists must start doing the same.

Interventions to reduce the environmental and financial impact of health care in the OR are not only successful, but also feasible. Urologists can contribute to greener surgical practices through the “5 R’s”: reduce, reuse, recycle, rethink, and renew.²⁴ For example, as much as 90% of red-bag waste does not meet the criteria for red-bag waste;²⁵ many items do not need to be placed in red bags unless visibly soiled with blood or bodily fluids (Table 1). Using clear bags during surgical preparation and red bags right before the procedure may help segregate waste properly. Reducing hazardous waste is particularly important from a cost perspective, as hazardous waste accounts for 25% of total hospital waste yet >70% of waste management costs.^26,27 Urologists should also advocate for the reprocessing of single-use medical devices (Table 2). Urological surgeons saved thousands of dollars across 20 facilities through the reprocessing of these devices,^25,28 and the U.S. Government Accountability Office has found no evidence indicating that the use of reprocessed devices increases health risk.²⁹ Moreover, urologists should prioritize energy efficiency in the OR; an initiative at Carolinas Medical Center to turn off all OR lights and equipment not currently in use resulted in savings of $33,000.³⁰ Outside of the operating room, urologists can reduce waste by selecting individual sterile components for their in-clinic procedures; a recent study found that in-clinic procedures performed using prepackaged procedure kits produced an estimated 819.5 kg more waste annually than procedures for which clinicians selected individual sterile components.³¹ Medical trainees can make a difference by advocating for waste audits, participating in climate health research projects, and integrating sustainable health education into their school’s curriculum.

As climate change progresses, the urology community needs to integrate sustainability into the OR to reduce the environmental consequences of health care. Addressing OR waste can be daunting, but even small initiatives are viable, effective, and result in impressive cost savings. Systemwide commitment to greening the OR is not only an astute financial decision for urologists and hospital administrators—sustainable practices in the operating room are paramount for obtaining equitable health outcomes. Further research is needed to examine strategies for greening the urology OR.

Want to get involved or learn more? Check out the following organizations:

• Medical Students for a Sustainable Future (MS4SF): https://ms4sf.org/
• Healthcare Without Harm: https://noharm.org/
• Practice Greenhealth: https://practicegreenhealth.org/
• Global Consortium on Climate and Health Education: https://www.publichealth.columbia.edu/research/global-consortium-climate-and-health-education