Sustainability in urologic practice has gained increasing importance, as healthcare significantly contributes to global carbon emissions and environmental waste, with the sector responsible for 4.4% of global greenhouse gas emissions [16]. Urologists, like other medical professionals, face the challenge of reducing the environmental footprint of their procedures while maintaining high standards of patient care [2, 3]. Given the resource-intensive nature of procedures and technologies involved in urological practices, it is important to recognize the critical role of this aspect. A comparative analysis of single-use versus reusable medical devices in urology, ranging from cystoscopes and ureteroscopes to prostate biopsy tools and minimally invasive surgical devices, reveals the complex interplay between reducing carbon footprints, managing waste, and ensuring proper sterilization [2, 4]. These efforts align with several United Nations Sustainable Development Goals (SDGs), particularly SDG 3 (Good Health and Well-being), by promoting sustainable practices that uphold patient care, SDG 12 (Responsible Consumption and Production), by focusing on reducing CO2 emissions, waste disposal, and solid waste production associated with urologic equipment, and SDG 13 (Climate Action), by emphasizing the need to minimize environmental impacts through innovative and eco-friendly solutions [17]. A more balanced, environmentally conscious approach to selecting and using these devices is essential for sustainable urological practice.

One of the primary areas where urologists can have a significant impact on sustainability is within the operating room (OR). The OR is an energy-intensive environment that substantially contributes to a hospital’s overall carbon emissions, consuming three to six times more energy per square meter than other hospital areas [18]. The "Sustainability in the Operating Theatre" guide by the Royal College of Surgeons of England and the Intercollegiate Green Theatre Checklist provide structured, practical recommendations to address these challenges [19, 20]. It is essential to reduce energy consumption and waste within the OR through strategies such as implementing energy-efficient LED lighting, optimizing heating and ventilation systems, and ensuring equipment is powered down when not in use [19, 21].

Efficient sterilization practices, the adoption of reusable instruments, and the optimization of surgical workflows are emphasized as critical measures to minimize the environmental footprint. Waste audits, as highlighted in these resources, have proven effective in identifying areas for improvement, such as reducing unnecessary instruments in surgical trays and promoting the reuse of specific devices [19, 22]. Furthermore, the Green Theatre Checklist advocates for circular economy principles, including the reprocessing of single-use devices and the use of closed-loop recycling systems for surgical waste [20]. By integrating these sustainable practices into routine surgical workflows, urologists and surgical teams can significantly reduce the carbon footprint of the OR while maintaining clinical efficiency and patient care standards.

Endourological instruments including cystoscopes and ureteroscopes play a significant role in urological procedures, making it essential for urologists to understand their usage, sustainability, and environmental impact. Raising awareness about the environmental implications of these devices is vital for promoting sustainable practices in urology. Studies have revealed significant differences in environmental impact between single-use and reusable cystoscopes [5, 7,8,9,10]. Single-use cystoscopes like the aScope™ 4 Cysto produce lower CO2 emissions per procedure (between 2.06 and 2.41 kg CO2) compared to reusable ones like the CYF-VA2, which can generate up to 4.23 kg CO2 per use [7, 9]. This is due primarily to the energy-intensive reprocessing required for reusable devices, contributing significantly to emissions. However, it's important to note that single-use cystoscopes also generate a considerable amount of non-recyclable waste (up to 622 g per use) [7]. On the other hand, reusable cystoscopes, despite producing more waste through sterilization consumables, have a lower overall waste footprint per use due to their extended lifespan [7, 8]. In the current literature, there is only one study comparing ureteroscopes and suggests that the reprocessing of reusable devices has a significant impact on the environment. The Olympus URV-F ureteroscope emits 4.47 kg of CO2 per procedure, with 3.94 kg of that arising from the energy and water demands of sterilization. While the manufacturing carbon footprint of reusable ureteroscopes is spread out over multiple uses, the emissions from reprocessing can exceed those of single-use alternatives. For example, the single-use Lithovue™ ureteroscope emits slightly less CO2 at 4.43 kg per use, but this comes with the drawback of higher solid waste production, once again illustrating the trade-off between emissions reduction and waste management [11].

Sterilization processes are not only a contributor to CO2 emissions in cystoscopy and ureteroscopy but also in other urological procedures like TURBT and minimal invasive surgery [12, 14, 15]. In TURBT procedures, 13.3% of the carbon footprint arises from the sterilization of reusable instruments, primarily due to the use of autoclaves powered by steam from gas boilers [12]. These sterilization requirements significantly amplify the environmental impact of reusable instruments, despite their lower waste generation compared to single-use devices. Thus, sterilization practices must be reconsidered, with potential opportunities to optimize and reduce energy and water use through innovations like low-energy sterilization technologies. Beyond sterilization, transitioning from inpatient to day-case TURBT surgeries can result in significant carbon savings. The United Kingdom (UK) National Health Service (NHS) has already reduced its carbon footprint by approximately 2.9 million kg CO2 equivalents by increasing day-case surgery rates from 13% in 2013–2014 to 31% in 2021–2022. However, there is still considerable variation in day-case rates across NHS hospitals, and standardizing best practices could lead to further savings of 217,599 kg CO2e annually. Additionally, the study found no significant increase in 30-day readmission rates for hospitals with higher day-case surgery rates, confirming the safety of day-case TURBT for patients without complicating conditions. Standardizing best practices across NHS hospitals to increase day-case surgery rates could significantly enhance healthcare efficiency while simultaneously reducing emissions, aligning with broader environmental goals [23].

In robotic and laparoscopic surgeries, it has been showed that robotic prostatectomies have a lower carbon footprint compared to laparoscopic procedures. Robotic surgeries produce approximately 47.3 kg CO2 per procedure, whereas laparoscopic surgeries generate about 59.7 kg CO2. While robotic systems require less energy, their complex instrumentation and higher plastic content may have more significant long-term environmental impacts [15]. This difference is primarily due to the shorter operative times, reduced energy consumption during hospitalization, and the use of more reusable instruments in robotic surgeries. However, these results focus on operational emissions during the surgical procedure. While the manufacturing of instruments was approximated, the full impact of robot production, maintenance, and disposal was not explicitly detailed in the study. This omission is significant because the production, maintenance, and eventual disposal of robotic systems are resource-intensive and likely contribute significantly to their overall environmental impact. While robotic surgery demonstrates lower emissions during operation, its full life-cycle footprint, including manufacturing and disposal, must be considered to provide a more comprehensive evaluation of its sustainability. There is urgent need for improvements in the production and disposal of materials associated with these procedures, despite the short-term environmental benefits in terms of energy use offered by robotic surgery. The environmental impact of MISDs also points the importance of assessing the entire lifecycle of medical technologies. Plastics, in particular, contribute heavily to the carbon footprint of these devices [14]. A cradle-to-gate analysis shows that the manufacturing and packaging processes account for a large portion of the emissions, urging device manufacturers to explore sustainable materials and packaging solutions.

Leapman et al. conducted a LCA of prostate biopsy procedures and found that each emits 80.7 kg of CO2e. Energy consumption, primarily from MRI scans and facility operations, accounts for 57.8% of the emissions. Avoiding unnecessary biopsies or using MRI as a triage tool could lead to significant emissions reductions. Avoiding 100,000 unnecessary biopsies could prevent 8.1 million kg of CO2e emissions, equivalent to 4.1 million liters of gasoline. Similarly, using MRI to guide biopsies could save 1.4 million kg CO2e per 100,000 patients. The carbon footprint of these procedures varies based on regional energy sources, with countries like Sweden potentially seeing emissions reductions of up to 53% [13]. We should emphasize the importance of improving clinical practices to reduce the environmental impact of urological procedures.

The term ‘carbon footprint' in the medical field is not universally standardized, leading to variations in variables and assessment methodologies. Some studies primarily focus on greenhouse gas emissions related to production and energy consumption, while others incorporate broader environmental impacts, such as waste management and water usage. Our review revealed a significant difference in methodological approaches. Certain studies, such as those comparing single-use versus reusable cystoscopes, primarily assessed the carbon emissions from sterilization and reprocessing. Many studies did not account for indirect emissions related to waste transportation and disposal, which can significantly impact the overall carbon footprint, particularly for single-use devices. The exclusion of these factors led to underestimating the actual environmental burden. Future research should aim for a standardized life-cycle assessment, including direct and indirect carbon footprint contributors.

While carbon footprint is a key metric in environmental sustainability, the overall impact of medical waste generation must also be considered. The accumulation of solid waste, particularly from single-use devices, contributes to environmental degradation through increased landfill burden, incineration emissions, and waste transportation impacts. Furthermore, variations in production techniques, material compositions, and recycling processes over time may influence the reported carbon footprints of medical devices. Older studies may not fully reflect current advancements in sustainable manufacturing and waste management, necessitating cautious interpretation when comparing findings across different periods.

Moreover, it is imperative to address the environmental impact of anesthesiology in urology. General anesthesia, particularly inhaled agents like desflurane, significantly contributes to a hospital's carbon footprint [24, 25]. However, by embracing alternatives such as regional anesthesia and spinal anesthesia, we not only reduce carbon emissions but also improve patient outcomes by minimizing recovery times and hospital stays. The integration of these alternatives in urologic procedures is crucial for minimizing environmental impact and elevating the standard of patient care.

Reducing the carbon footprint in urology can be significantly achieved through day case surgeries, self-removal of catheters, and stent self-removal techniques, as these approaches minimize hospital stays, patient travel, and resource usage. Day-case procedures like HoLEP are safe and effective, even in remote hospital settings, reducing hospital emissions associated with extended patient stays [26]. Similarly, early removal of catheters after surgeries such as robot-assisted radical prostatectomy has demonstrated safety and effectiveness, allowing patients to manage catheter removal at home, thereby reducing unnecessary hospital visits and associated energy consumption [27]. Innovations such as stent on a string (SOS) for post-ureteroscopy patients have also proven safe and effective for self-removal stents at home, minimizing return hospital visits, reducing patient discomfort, and cutting healthcare costs [28, 29]. By adopting these strategies, urology departments can significantly reduce energy use, emissions, and resource wastage while maintaining high standards of patient care and outcomes.

Urology practice extends beyond the operating room. Policies regarding intermittent catheterization also have significant environmental implications. The extensive use of single-use catheters leads to substantial waste production. In the USA alone, this practice results in approximately 85 million pounds of waste annually [30]. While this policy aims to reduce infection risks, there is limited evidence that single-use catheters are more effective than reusable ones at preventing infections [6]. Supporting sustainable catheterization practices could reduce the environmental burden of urologic care.

Telemedicine and other innovations in patient management offer additional opportunities for sustainable urologic practice. Virtual consultations, which became more prevalent during the COVID-19 pandemic, have significantly reduced patient and provider travel, contributing to lower carbon emissions associated with healthcare [31]. Virtual care and decentralized diagnostic tools can help further minimize the carbon footprint of urologic practices.

Finally, efforts to integrate sustainability into clinical guidelines and institutional policies are needed for promoting a greener future in urology. The European Association of Urology has already begun incorporating environmental considerations into its guidelines, emphasizing the need for urologists to be mindful of the ecological impacts of their treatment choices [4]. By prioritizing low-impact interventions, reducing unnecessary tests, and considering the broader environmental effects of medical practices, the urology field can make meaningful contributions to global sustainability goals.