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Single-Use Ureteroscopy and Environmental Footprint: Review of Current

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Article in Current Urology Reports · March 2023

DOI: 10.1007/s11934-023-01154-9

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Current Urology Reports
https://doi.org/10.1007/s11934-023-01154-9

Single‑Use Ureteroscopy and Environmental Footprint: Review

of Current Evidence
George Brown1 · Andrea Ong1 · Patrick Juliebø‑Jones2 · Niall F Davis3 · Andreas Skolarikos4 · Bhaskar Somani1

Accepted: 28 February 2023

© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2023

Abstract
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 ­(LithoVueTM by Boston Scientific) generated an equivalent amount of
carbon dioxide per case to a contemporary reusable flexible ureteroscope.
Summary 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.

Keywords Single-use · Ureteroscopy · Endourology · Carbon · Environment · Kidney calculi

Introduction to sterilisation, maintenance, and repair [2]. As a possible

solution to these issues, single-use flexible ureteroscopes
Ureteroscopy (URS) plays a central role in upper urinary (su-fURS) were developed and have subsequently received
tract diagnostics and urolithiasis treatment throughout the widespread interest and uptake. The first model was released
world [1]. Ureteroscopes may be semi-rigid or flexible in 2015, ­LithoVueTM, produced by Boston Scientific [3].
(fURS). The latter are more technologically advanced but Semi-rigid ureteroscopes, on the other hand, are more dura-
also more expensive and fragile. Until relatively recently, ble and incur less maintenance costs. The development of
workable fURS equipment was exclusively reusable (re- single-use URS equipment has therefore focussed on fURS
fURS) and, as such, required significant up-front institu- and it should be stated at the outset that any evaluation of
tional investment, as well as ongoing expenditures related single-use URS technology is essentially an evaluation of
fURS technology, rather than semi-rigid URS.
To date, the literature regarding su-fURS has focussed
* George Brown primarily on performance characteristics and cost analysis
[email protected]
in comparison to traditional re-fURS equipment. However,
1
Department of Urology, University Hospital Southampton, the environmental impact of this new disposable technol-
Southampton, UK ogy is yet to be ascertained. This review therefore aims to
2
Department of Urology, Haukeland University Hospital, identify and summarise the available evidence concerning
Bergen, Norway the environmental footprint of su-fURS. This has arguably
3
Department of Urology, Beaumont Hospital and Royal never been more important given that climate change repre-
College of Surgeons in Ireland, Dublin, Ireland sents one of the biggest public health threats of the twenty-
4
University of Athens, Athens, Greece first century and urgent reductions in carbon emissions are

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required from all sectors [4, 5]. The statistics from health however, difficult to be entirely exact with these estimations
services are particularly alarming. Combined emissions as, by authors’ own admission, some of this information was
from the health sectors in the USA, Canada, UK, and Aus- obtained from indirect sources.
tralia total 748 metric tons of carbon dioxide (­ CO2) equiva- Clearly, one surgical case incorporates the entire life cycle
lents annually and, if global healthcare services were a of a su-fURS but only a fraction of a re-fURS. Based on
country, it would be the fifth largest carbon emitter in the experience in their own institution, the authors made calcu-
world [6]. Within healthcare, surgical services are the most lations for re-fURS ­CO2 production on the expectation that
resource-intensive and polluting, producing vast quantities a scope would be used 16 times before a repair was required
of greenhouse gases [5]. Change is therefore required and and 180 times before it was decommissioned. Manufactur-
technology cannot continue to be assessed purely on its ing and repair C­ O2 generation was therefore divided by 180
technical and performance characteristics. Environmental and 16, respectively, to calculate the amount generated per
sustainability must be considered moving forwards. case. Ultimately, the study calculated that the L ­ ithoVueTM
generated 4.43kg of C ­ O2 per case and the URF-V generated
4.47kg of C ­ O2 per case. On this basis, the study concluded
Methods that su-fURS and re-fURS are roughly equivalent in terms
of carbon footprint and the paper has been used as a strong
Using the OvidSP platform, a literature search was con- endorsement of ­LithoVueTM and other single-use scopes (as
ducted via MEDLINE, Embase, and PsycINFO databases evidenced by the fact that it is cited on Boston Scientific’s
from the first records until 1 September 2022. Using the ­LithoVueTM webpage).
Boolean operators “AND” and “OR”, the search strategy There are some limitations to consider, however. Firstly,
was ureteroscop* OR pyeloscop* OR ureteropyeloscop* there may be physical differences in other types of su-fURS
OR endoscop* AND single-use OR one-use OR disposable and re-fURS, meaning that these results may not be rep-
AND environment* OR carbon. No limits were applied. resentative of all su/re-fURS equipment. A difference in
Titles, abstracts, and finally full-text articles were assessed weight would affect both manufacturing and solid waste
for relevance by all authors. Duplicates were removed. Pre- ­CO2 generation, for example. Indeed, other su-fURS brands
ferred Reporting Items for Systematic reviews and Meta- such as the Uscope ­UE3022TM and ­NeoflexTM are notably
Analyses (PRISMA) methodology was followed throughout lighter than the 0.3kg ­LithoVueTM at 0.147kg and 0.199kg,
[7]. Reference lists were also checked for relevant articles. respectively [9]. Secondly, the study did not include kg of
Studies were included if they provided any information on ­CO2 generated from intra-operative energy consumption in
the environmental impact of su-fURS. Citations that were the calculation of total C
­ O2 generated per case. Admittedly,
not available as full-text articles or were not available in this would be dependent on case length and even source of
English were excluded. Included articles were evaluated by electrical energy and is therefore difficult to quantify, but it
all authors and presented in a narrative format. should be considered, and it remains unanswered how much
electrical energy each device consumes per unit of time. If
one consumes significantly more than the other and is pow-
Results ered by a non-renewable source of electrical energy, then
this could have a significant impact on the overall calcula-
The search returned 158 results. Only one study by Davis tion of ­CO2 produced by case.
et al. [8•] provided any information about the carbon foot- Furthermore, there appears to be an error in the calcula-
print of su-fURS. tion of kg of ­CO2 produced by the URF-V. Each repair was
This study compared the calculated carbon footprint judged to generate 5kg of ­CO2 and was therefore divided by
in kilograms (kg) of ­CO2 per case, of a su-fURS (Boston 16 according to the author’s own judgement of case number
Scientific ­LithoVueTM) and a re-fURS (Olympus URF-V). until repair. This equates to 0.31kg of ­CO2 per case; how-
Kg of ­CO2 was calculated for the manufacturing process, ever, this parameter was included in the overall calculation as
sterilisation, and solid waste of each scope type, as well as 0.45kg. As there is no explanation for how 0.45kg was arrived
for repackaging and repair for the URF-V. Equivalent mass at, it must be considered an error and, if the same calculation
of ­CO2 for scope component parts (regardless of type) and is made using 0.31kg, the total C­ O2 produced by the re-fURS
the percentage of those parts per scope enabled a sensible is 4.33kg, 0.1kg less than the ­LithoVueTM. This in itself does
calculation that 11.49kg of C
­ O2 was produced for the manu- not drastically change the overall conclusion that su-fURS and
facturing of every 1kg of scope. Based on appropriate prior re-fURS are comparable, but it should be highlighted.
study data, 1kg of solid waste was treated as equivalent to Lastly, the calculation of ­CO2 production per case for
1kg of C­ O2. Judgements for kg of C­ O2 produced by repack- a re-fURS only holds true if that scope is indeed used 180
aging, repair, and sterilisation were also reasonable. It is, times and repaired every 16 cases. Any change in these

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numbers would, of course, change the calculation for better Although less comparable, disposable duodenoscopes
or worse. For example, if a scope was used 200 times and also seem to compare unfavourably to their reusable coun-
was only repaired every 20 cases, then its carbon footprint terparts. One study found that a single-use scope generated
would reduce. Conversely, if it were to break frequently and between 24 and 47 times the amount of greenhouse gases
be decommissioned early, then its ­CO2 generation would, in had a 4 times higher ecosystem impact and consumed 26
relative terms, increase. Re-fURS could therefore compare times more resources [15]. The vast majority of this was
either favourably or unfavourably to the carbon footprint of from the manufacturing process. Another study found that an
a single-use device, which is unaffected by these factors and average gastrointestinal endoscopy performed with a single-
generates a relatively fixed amount of C ­ O2, as shown in this use scope produced approximately 2kg of solid waste, and if
study. To illustrate this point, a recent meta-analysis showed all procedures in the USA were performed using disposable
that the pooled repair rate for re-fURS was equivalent to 15 equipment, the overall volume of waste would increase by
cases, validating the study’s use of 16 cases, whereas other 40% [16].
studies found the mean number of cases until the first repair The environmental impact of single-use bronchoscopes
was 11 or 12.5 and then 19 until another repair was required has also been examined. One study is available and it
[10•, 11, 12]. reported that a single-use scope generated 1.6kg of ­CO2 per
use compared to 2.9kg of C ­ O2 generated by a reusable scope
[17]. However, the study’s calculation was reliant on only
Discussion sterilising a single reusable scope at a time. If two or more
scopes are sterilised simultaneously (as they would be in
The purpose of our review was to identify all the relevant clinical practice), the impacts were comparable.
studies and synthesise their findings to answer a pre-defined
question. The lack of related literature relevant to this topic Other Considerations in Single‑Use Flexible
is worrying. Indeed, only one study met our inclusion cri- Ureteroscopy
teria [8•]. Some conference abstracts were identified on the
subject, which does indicate a certain degree of wider inter- A detailed analysis of su-fURS performance and cost con-
est; however, a lack of sufficient data precluded their final siderations is beyond the scope of this review, but a brief
inclusion. The only study included in this article indicates summary is provided here to better inform the discussion.
that there may be comparability in the carbon footprint of su- From a technical perspective, su-fURS appears to com-
fURS and re-fURS. However, it has a number of limitations, pare well with reusable equivalents and current literature
as have been described above. Firm conclusions regarding indicates that stone-free rates, complication rates, and opera-
the environmental impact of single-use technology in fURS tive times are equivalent [18]. Su-fURS does appear to be
cannot therefore be drawn at this moment in time. To this superior in terms of irrigation, with several studies showing
end, further research in this area is critical. disposable scopes have better flow rates, even when laser
fibres and baskets were occupying the working channel [9,
Environmental Footprint of Single‑Use Endoscopy 19].
in General Differences in image quality between su-fURS and re-
URS are less marked than when comparing scopes of the
With evidence lacking for su-fURS, lessons can be pos- digital and fibreoptic image generation. Evidence clearly
sibly learned from other single-use endoscopic equip- shows that digital scope images are superior to fibreoptic
ment. The closest equivalent to URS is cystoscopy where, and disposable and reusable digital scopes are comparable [20].
again, evidence is lacking. One study is available and had Better image quality undoubtedly conveys an advantage in
an equivalent comparative design to the included study upper tract diagnostics and therefore digital scopes (reusable
[13]. This study concluded that a single-use cystoscope or disposable) are generally preferred.
­(Ambu®ascopeTM 4 Cysto) had a significantly lower car- Single-use scopes also have better deflection abilities
bon footprint per case than a reusable equivalent (Olympus than their reusable counterparts, which is particularly advan-
CYF-VA2) (2.41 vs. 4.23kg of C ­ O2). Serious and justifiable tageous in treating lower pole stones with steep infundibu-
concerns regarding the study’s methodology have, however, lopelvic angles [9]. The implications of breaking single-use
been raised in another study [14]. The authors of this latter equipment are minimal compared to re-fURS, something
study highlighted issues with the calculation of C­ O2 gener- that in itself may convey an advantage in cases of challeng-
ated by reusable scope sterilisation and in the manufacturing ing anatomy by giving the surgeon more security and free-
of these scopes. With these errors corrected, the single-use dom to proceed where potential scope damage is anticipated.
scope would actually generate 3.09kg of ­CO2 per use, com- Single-use scopes also allow healthcare services in devel-
pared to 1.35kg of ­CO2 for the reusable scope. oping countries to offer URS as a treatment option when

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 Current Urology Reports

the initial cost and/or availability of specialist repair ser- Author Contribution GB, AO—data collection, writing, PJ, ND, AS—
vices preclude access to reusable equipment. However, the editing, BS—conceptualisation, editing, All authors have reviewed and
approved the submitted manuscript.
proposed advantage of avoiding cross-contamination by
using disposable equipment, often quoted by manufacturers, Compliance with Ethical Standards
appears to be unfounded, with evidence showing that using
su-fURS does not reduce the occurrence of post-operative Conflict of Interest The authors wish to highlight that Professor
infection when compared to re-fURS [21]. Bhaskar Somani is an endourology section editor for Current Urology
Reports. All other authors declare no competing interests.
Regarding cost, the comparison between su- and re-
fURS is made difficult by the varying purchase price of Human and Animal Rights and Informed Consent All reported studies/
different scopes and particularly by the frequency of re- experiments with human or animal subjects performed by the authors
fURS repair, which is the key difference between the two have been previously published and complied with all applicable ethi-
cal standards (including the Helsinki declaration and its amendments,
technologies. The price of su-fURS can also reasonably institutional/national research committee standards, and international/
be expected to reduce as time goes on, meaning state- national/institutional guidelines).
ments about the cost-effectiveness of su-fURS are likely
to go out of date relatively quickly. Given the number of
variables to be accounted for when performing cost analy-
sis, individual studies have, unsurprisingly, reported the
References
costs of re-fURS to be quite variable. The only systematic
Papers of particular interest, published recently, have
review in this area concluded that re-fURS was likely to be
been highlighted as:
more cost-effective in high-volume centres, but acknowl-
• Of importance
edged that there was significant heterogeneity in study
design and calculation of re-fURS costs [22]. There is cur- 1. Pietropaolo A, Bres-Niewada E, Skolarikos A, Liatsikos E,
rently no definitive consensus on which type of scope is Kallidonis P, Aboumarzouk O, Tailly T, Proietti S, Traxer O,
more economical and this is likely to vary centre by centre Giusti G, Rukin N, Özsoy M, Talso M, Emre S, Emiliani E, Atis
depending on the acquisition price for each type and the G, Somani B. Worldwide survey of flexible ureteroscopy prac-
tice: a survey from European Association of Urology sections
cost of reprocessing and repair for re-fURS. Ureteroscopy of young academic urologists and uro-technology groups. Cent
has advanced over the last two decades, but this advancing European J Urol. 2019;72(4):393–7.
technology needs to be balanced with cost-effectiveness 2. Bahaee J, Plott J, Ghani K. Single-use flexible ureteroscopes:
and the environmental impact it has going forwards [23, how to choose and what is around the corner? Curr Opin Urol.
2021;31(2):87–94.
24]. 3. Butticè S, Sener TE, Netsch C, Emiliani E, Pappalardo R, Magno
C. LithoVue™: a new single-use digital flexible ureteroscope.
Cent European J Urol. 2016;69(3):302–5.
Conclusions 4. Costello A, Abbas M, Allen A, Ball S, Bell S, Bellamy R,
Friel S, Groce N, Johnson A, Kett M, Lee M, Levy C, Maslin
M, McCoy D, McGuire B, Montgomery H, Napier D, Pagel
Current evidence for the environmental impact of su-fURS C, Patel J, de Oliveira J, Redclift N, Rees H, Rogger D, Scott
is derived from a single paper that indicates that a su-fURS J, Stephenson J, Twigg J, Wolff J, Patterson C. Managing the
­(LithoVueTM) is equivalent in terms of kg of C ­ O2 generated health effects of climate change: Lancet and University Col-
lege London Institute for Global Health Commission. Lancet.
per case to a re-fURS (Olympus URF-V). This study was 2009;373(9676):1693–733.
well-designed and informative overall but does have notable 5. MacNeill A, Lillywhite R, Brown C. The impact of surgery on
limitations, many of which are inherent to a study of this global climate: a carbon footprinting study of operating theatres
type with a large number of variables that require reasonable in three health systems. Lancet Planet Health. 2017;1(9):e381–8.
6. Sherman J, MacNeill A, Thiel C. Reducing pollution from the
assumption and estimation (for example case number before health care industry. JAMA. 2019;322(11):1043–4.
scope repair and before decommissioning). The majority of 7. Page M, McKenzie J, Bossuyt P, Boutron I, Hoffmann T, Mulrow
available literature regarding su-fURS remains focussed on C, Shamseer L, Tetzlaff J, Akl E, Brennan S, Chou R, Glanville
performance and technical characteristics with environmen- J, Grimshaw J, Hróbjartsson A, Lalu M, Li T, Loder E, Mayo-
Wilson E, McDonald S, McGuinness L, Stewart L, Thomas J,
tal considerations remaining a secondary concern. No firm Tricco A, Welch V, Whiting P, Moher D. The PRISMA 2020
conclusions on the environmental impact of su-fURS can be statement: an updated guideline for reporting systematic reviews.
drawn from the results of a single article. If the endourology BMJ. 2021;372: n71.
community is to keep pace with the changing and increas- 8.• Davis N, McGrath S, Quinlan M, Jack G, Lawrentschuk N, Bolton
D. Carbon Footprint in flexible ureteroscopy: a comparative study
ingly environmentally conscious face of surgery and society on the environmental impact of reusable and single-use uretero-
in general, then more research focussed on the sustainability scopes. J Endourol. 2018;32(3):214-217. The only study that has
of URS is urgently required. looked into the environmental impact of single-use ureteroscopy

13
Current Urology Reports

compared to reusable equipment. This study is fully examined 18. Mazzucchi E, Marchini G, Berto F, Denstedt J, Danilovic
in the Results section. A, Vicentini F, Torricelli F, Battagello C, Srougi M, Nahas
9. Dragos L, Somani B, Keller E, De Coninck V, Herrero M, Kamphuis G, W. Single-use flexible ureteroscopes: update and perspec-
Bres-Niewada E, Sener E, Doizi S, Wiseman O, Traxer O. Charac- tive in developing countries. A narrative review. Int Braz J
teristics of current digital single-use flexible ureteroscopes versus Urol. 2022;48(3):456-467.
their reusable counterparts: an in-vitro comparative analysis. Transl 19. Marchini G, Batagello C, Monga M, Torricelli F, Vicentini
Androl Urol. 2019;8(Suppl 4):S359–70. F, Danilovic A, Srougi M, Nahas W, Mazzucchi E. In vitro
10.• Rindorf D, Tailly T, Kamphuis G, Larsen S, Somani B, Traxer evaluation of single-use digital flexible ureteroscopes: a prac-
O, Koo K. Repair rate and associated costs of reusable flexible tical comparison for a patient-centered approach. J Endourol.
ureteroscopes: a systematic review and meta-analysis. Eur Urol 2018;32(3):184–91.
Open Sci. 2022;37:64-72. An important paper looking at asso- 20. Talso M, Proietti S, Emiliani E, Gallioli A, Dragos L, Orosa A,
ciation of repair rates and cost of reusable scopes. Servian P, Barreiro A, Giusti G, Montanari E, Somani B, Traxer
11. Hennessey D, Fojecki G, Papa N, Lawrentschuk N, Bolton O. Comparison of flexible ureterorenoscope quality of vision:
D. Single-use disposable digital flexible ureteroscopes: an an in vitro study. J Endourol. 2018;32(6):523–8.
ex vivo assessment and cost analysis. BJU Int. 2018;121(Suppl 21. Baboudjian M, Gondran-Tellier B, Abdallah R, Tadrist A, Sichez
3):55–61. P, Akiki A, Gaillet S, Delaporte V, Karsenty G, Lechevallier E,
12. Martin C, McAdams S, Abdul-Muhsin H, Lim V, Nunez-Nateras Boissier R. Single use and reusable flexible ureteroscopies for
R, Tyson M, Humphreys M. The economic implications of a the treatment of urinary stones: a comparative study of periop-
reusable flexible digital ureteroscope: a cost-benefit analysis. J erative complications. Prog Urol. 2021;31(6):368–73.
Urol. 2017;197(3 Pt 1):730–5. 22. Talso M, Goumas I, Kamphuis G, Dragos L, Tefik T, Traxer O,
13. Hogan D, Rauf H, Kinnear N, Hennessey D. The carbon foot- Somani B. Reusable flexible ureterorenoscopes are more cost-
print of single-use flexible cystoscopes compared with reusable effective than single-use scopes: results of a systematic review from
cystoscopes. J Endourol. 2022. https://d​ oi.o​ rg/1​ 0.1​ 089/e​ nd.2​ 021.​ PETRA Uro-group. Transl Androl Urol. 2019;8(Suppl 4):S418–25.
0891. Epub ahead of print. 23. Wright A, Rukin N, Somani B. Ureteroscopy and stones:
14. Rizan C, Bhutta MF. Re: The carbon footprint of single-use current status and future expectations. World J Nephrol.
flexible cystoscopes compared to reusable cystoscopes: meth- 2014;3(4):243–8.
odological flaws led to the erroneous conclusion that single-use 24. Somani B, Robertson A, Kata S. Decreasing the cost of flexible
is “better”. J Endourol. 2022. https://​doi.​org/​10.​1089/​end.​2022.​ ureterorenoscopic procedures. Urology. 2011;78(3):528–30.
0482. Epub ahead of print.
15. Le N, Hernandez L, Vakil N, Guda N, Patnode C, Jolliet O. We confirm that this work has not been published or submitted for
Environmental and health outcomes of single-use versus publication elsewhere.
reusable duodenoscopes. Gastrointest Endosc. 2022;S0016-
5107(22)01765-5. https://​doi.​org/​10.​1016/j.​gie.​2022.​06.​014. Publisher's Note Springer Nature remains neutral with regard to
Epub ahead of print. jurisdictional claims in published maps and institutional affiliations.
16. Namburar S, von Renteln D, Damianos J, Bradish L, Barrett J,
Aguilera-Fish A, Cushman-Roisin B, Pohl H. Estimating the Springer Nature or its licensor (e.g. a society or other partner) holds
environmental impact of disposable endoscopic equipment and exclusive rights to this article under a publishing agreement with the
endoscopes. Gut. 2022;71(7):1326–31. author(s) or other rightsholder(s); author self-archiving of the accepted
17. Sørensen B, Grüttner H. Comparative study on environmental manuscript version of this article is solely governed by the terms of
impacts of reusable and single-use bronchoscopes. Am J Envi- such publishing agreement and applicable law.
ron Prot. 2018;7(4):55–62.

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