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AUA ADVOCACY Advocacy for Environmental Sustainability in Urologic Operating Rooms: Implications for Environmental and Human Well-Being

By: Isabella S. Florissi, MD, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland; Oscar Li, BS, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland; Sunil H. Patel, MD, MA, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland | Posted on: 03 Jun 2024

In the US, health systems generate 6 million tons of medical waste,1 1 million tons of noninfectious plastic,2 and a startling 8.5% of the nation’s total greenhouse gas emissions each year.3 Operating rooms and labor and delivery suites are 3 to 6 times more energy intensive than clinical areas4 and generate 60% of total hospital regulated medical waste.5 Because regulated biohazardous waste requires specific costly and environmentally harmful processes for safe elimination, proper separation of medical waste into regulated medical waste (RMW) and nonregulated municipal waste is integral to minimizing the cost and carbon footprint associated with waste disposal.

In an analysis of waste generated from 31 urologic cases performed at a single institution during a 3-month period, an average of 11.11 kg in waste was generated per case: RMW represented 31% of the total waste, while non-RMW represented 53% of total waste weight. Improper disposal of non-RMW items was identified in all cases, highlighting the importance of cautious separation of medical waste to reduce the financial and environmental burden of its disposal.6 Noting that 80% of packaging waste is generated before a patient enters the operating room, precautions focused on separating this large proportion of nonbiohazardous waste before exposure to bodily fluids could be beneficial in reducing the cost of waste disposal (Figure).7


Figure. The intersection of health systems, environmental waste, and human illness in the operating room. Used with permission of Oscar Li.

It is essential that urologists take action to streamline waste disposal in operative rooms, revise operative trays and preference cards to minimize the inclusion of extraneous instruments,8 reduce the amount of printed resources utilized in exchange for virtual information, and raise awareness at their institution about environmental sustainability in operative settings. Urologists, especially those practicing in academic settings, can utilize their role as educators in promoting change towards a culture of sustainability in current and future generations of trainees. Moreover, as the global urology device market is worth over $35 billion and expected to grow significantly in the next decade,9 urologists can collaborate with device manufacturers to create more efficient and sustainable packaging and reduce their carbon footprint. These efforts can be further supported in collaboration with sustainability committees within health care groups, across other surgical subspecialties, through advocacy groups within the AUA, and even with larger organizations such as the American Medical Association.

Environmental emissions associated with waste disposal pose a significant threat to medical well-being. In fact, by-product components of plastics including bisphenol A (BPA) have been shown to accumulate in a dose-ependent fashion in human tissue and act as carcinogens and endocrine disruptors.10 In the US, 90% of the population is exposed to BPAs, which have been linked to breast cancer and hepatocellular carcinoma.10 Moreover, it has been demonstrated in animal models that BPA activates the androgen receptor, suggestive of a link between BPA and the development of prostate cancer.11 Follow-up analyses of patients with prostate cancers identified higher levels of urinary BPA concentration in patients with prostate cancer.12 Additional studies indicate that BPA can also adversely affect the efficacy of androgen deprivation therapy, which is the mainstay of treatment for prostate cancer,11 cause kidney toxicity via direct glomerular injury,13 and alter mitochondrial metabolism, promoting the progression of bladder cancer.14 Plastic by-products may also be associated with tumor progression and with attenuating the efficacy of cancer treatment.15

Considering the significant impact of waste generation and its by-products on environmental and human well-being, environmental sustainability in operating rooms is integral to protecting our planet and its inhabitants. To this end, advocacy efforts are underway to effect change in operative environmental sustainability. On Earth Day 2022, the White House/US Health and Human Services put forward the Health Sector Climate Pledge, asking health care institutions to commit to reducing health care–related environmental emissions by half by 2030, and to achieving carbon neutrality by 2050.16 As of November 16, 2023, the petition has been signed by 133 organizations representing 900 hospitals.16 Within hospitals, waste audits have effectively identified and addressed potential sources of preventable waste in operation rooms.17–19

US health care represents 18% of the nation’s economy, and 10% of the global economy.20 As such, changes towards environmental sustainability in operating rooms, which are the most prominent source of revenue for health systems, would have a significant impact on environmental and human well-being. Hospitals contributing to the 2019 Environmental Excellence Awards saved $68 million on sustainability initiatives in 2018, reduced 309 million kBtus of energy, and avoided the production of 146,750 tons of waste and 182,370 metric tons of carbon emissions. This equated to a median savings of $100,000 across 327 hospitals.21 Importantly, surgeons are ready to make a change. Of surgeons interviewed at 2 major academic centers in the United States, 95% of survey respondents demonstrated willingness to reduce operative room waste and promote environmental sustainability,22 suggesting that urologists today have a responsibility and willingness to change to protect their environment, their communities, and their future patients.

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