Healthcare in England is responsible for 4-5% of the country’s carbon footprint which is defined as the amount of greenhouse gasses, primarily carbon dioxide, released into the atmosphere by a particular activity.
The six greenhouse gasses which vary in their relative contributions to global warming include carbon dioxide, methane, nitrous oxide, hydrofluorocarbons, perfluorocarbons, and sulphur hexafluoride. The ‘carbon footprint’ is usually expressed in equivalent tons of carbon dioxide (CO2-eq) a year; air pollution in the UK is of course relevant to both respiratory and cardiovascular disease and linked to 36,000 deaths per annum.
In NHS staff engagement surveys, over 90% of staff from what is the UK’s largest employer believe it is important to support the environment and in the clinically busy decade since 2007, there has been an encouraging 18% reduction in carbon emissions.
The ‘NHS Long Term Plan’ was announced in 2019 and has committed to the following changes:
- By 2025, the NHS will reduce its carbon footprint by 51% against 2007 levels with 2% of this coming from changing anaesthetic practice.
- By 2023/24 business mileage and NHS fleet emissions will be reduced by 20% and outpatient visits will be reduced by a third.
- A reduction in the use of single use plastics.
By 2050, the UK Government has agreed to reach net zero carbon and an expert panel was convened early in 2020 to review the available evidence but in healthcare the business cases for change are less well developed compared to the commercial sector.
‘Sustainability’ is a term we will hear more frequently and refers to meeting clinical need without compromising society or nature while ‘sustainable development’ refers to the process necessary to achieve this outcome. This involves reducing variation in practice and shifting the focus to preventative care rather than cutting services.
What is the effect on the environment within the field of surgery and urology?
To produce a healthier environment, change does not have to be dramatic; small alterations in generic working patterns in secondary care such as switching off computers and printers overnight, encouraging shared car journeys and the use of public transport or bicycles can all play a role in sustainability. Working from home even one day a week could save over 230kg of CO2 per year for a commute of only 16 miles.
Is this really relevant to urologists I hear our readers muttering; absolutely, as part of an organisation with 1.3 million employees and the changes that are required in the UK are firmly supported by all the professional governing organisations. An international study published in 2011  evaluated greenhouse gas emissions from three quaternary-care hospitals. The preferred use of desflurane as an anaesthetic was associated with a ten-fold difference in anaesthetic gas emissions between hospitals and the carbon footprint of surgery was estimated to be 9.7 million tonnes of CO2 per annum. Of all the inhaled anaesthetic agents, deslfurane is one of the most harmful to our environment, one bottle having the same effect on the environment as burning 440kg of coal. It is now time to systematically question the necessity for a general anaesthetic for many procedures in urology. Template prostate biopsies are now routinely performed under local anaesthesia but how often do we allow adult patients to choose general rather than local anaesthesia when discussing circumcision and minor penile surgery?
Shockwave lithotripsy has proven efficacy in the treatment of ureteric calculi and, of course, under the recent National Institute for Health & Care Excellence (NICE) guidelines, should now be offered to all appropriate patients who present with an acute ureteric stone. A straightforward ureteroscopy is a rewarding procedure for surgeon, trainee and of course the suppliers of wires, baskets and laser fibres but every urologist is aware of the vast amount of clinical waste generated by even the most straightforward procedure. If we are passionate about our environment, and indeed our budget, should we put more energy into avoiding opening incorrect or unnecessary disposables during endoscopic surgery?
Davis et al.  evaluated the environmental impact of reusable and single-use flexible ureteroscopes, rather surprisingly finding comparable carbon footprints of approximately 4. kg of CO2 per case. The calculations were based on 16 cases before requiring repair and further research in this field should include modelling a variable number of cases per instrument.
The transition from metal to disposable laparoscopic instruments and the adoption of robotic surgery has also come at a price to the environment both in terms of CO2 use and the utilisation of single-use plastic items . The decision-making at local and national level behind the procurement of laparoscopic and robotic equipment should now assess and even consider mandating the use of reusable equipment .
Virtual urology clinics
The COVID-19 response has accelerated the introduction of changes in the delivery of healthcare including the rapid adoption of virtual outpatient clinics. A small number of UK studies have already addressed the environmental impact of conversion to virtual follow-up; Eddison et al.  systematically evaluated this method of consultation revealing a potential annual reduction in carbon footprint of 0.7 to 4.35 metric tonnes of carbon dioxide.
In summary, sustainability is now not an optional extra when formulating plans for current and future urological healthcare and this new dimension adds to the significant challenges facing the NHS and our speciality. Sustainable development is the logical way forward both for business and patient care in urology; let us lead the way in our dynamic speciality.
1. Macneil AJ, Lillywhite R, Brown CJ. The impact of surgery on global climate: a carbon foot printing study of operating theatres in three health systems. Lancet Planet Health 2017;1(9):381-8.
2. Davis NF, McGrath S, Quinlan M, et al. Carbon footprint in flexible ureteroscopy. A comparative study on the environmental impact of reusable and single use ureteroscopes. J Endourol 2018;32(3):214-17.
3. Woods DL, McAndrew T, Nevadunsky N, et al. Carbon footprint of robotically-assisted laparoscopy, laparoscopy and laparotomy: a comparison. Int J Med Robot Comput 2015;11(4):406-12.
4. Misrai VA, de la Taille A, Zorn KC, et al. A plea for the evaluation of the carbon footprint of new mini invasive surgical technologies in urology. Eur Urol 2020 [in press].
5. Edison MA, Connor MJ, Miah S, et al. Understanding virtual urology clinics: a systematic review. BJU Int 2020 [Epub ahead of print].