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OBJECTIVES: To evaluate the carbon footprint of the perioperative transurethral resection of bladder tumour (TURBT) pathway from decision to treat to postoperative discharge, and model potential greenhouse gas (GHG) emissions reduction strategies. MATERIALS AND METHODS: This process-based attributional cradle-to-grave life-cycle assessment (LCA) of GHG emissions modelled the perioperative TURBT pathway at a hospital in Southwest England. We included travel, energy and water use, all reusable and consumable items, and laundry and equipment sterilisation. Resource use for 30 patients undergoing surgery was recorded to understand average GHG emissions and the inter-case variability. Sensitivity analysis was performed for manufacturing location, pharmaceutical manufacturing carbon-intensity, and theatre list utilisation. RESULTS: The median (interquartile range) perioperative TURBT carbon footprint was 131.8 (119.8-153.6) kg of carbon dioxide equivalent. Major pathway categories contributing to GHG emissions were surgical equipment (22.2%), travel (18.6%), gas and electricity (13.3%), and anaesthesia/drugs and associated adjuncts (27.0%), primarily due to consumable items and processes. Readily modifiable GHG emissions hotspots included patient travel for preoperative assessment, glove use, catheter use, irrigation delivery and extraction, and mitomycin C disposal. GHG emissions were higher for those admitted as inpatients after surgery. CONCLUSIONS: This cradle-to-grave LCA found multiple modifiable GHG emissions hotspots. Key mitigation themes include minimising avoidable patient travel, rationalising equipment use, optimally filling operating theatre lists, and safely avoiding postoperative catheterisation and hospital admission where possible. A crucial next step is to design and deliver an implementation strategy for the environmentally sustainable changes demonstrated herein.

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INTRODUCTION: Surgery represents a major source of carbon emissions, with numerous initiatives promoting more sustainable practices. Healthcare innovation and the development of a digitally capable workforce are fundamental in leveraging technologies to tackle challenges, including sustainability in surgery. METHODS: A surgical hackathon was organised with three major themes: (1) how to make surgery greener, (2) the future of plastic surgery in 10 years, and (3) improving healthcare outcomes using machine learning. Lectures were given on sustainability and innovation using the problem, innovation, market size, strategy and team (PIMST) framework to support their presentations, as well as technological support to translate ideas into simulations or minimum viable products. Pre- and post-event questionnaires were circulated to participants. RESULTS: Most attendees were medical students (65%), although doctors and engineers were also present. There was a significant increase in delegates' confidence in approaching innovation in surgery (+20%, p < 0.001). Reducing waste packaging (70%), promoting recyclable material usage (56%) and the social media dimension of public perceptions towards plastic surgery (40%) were reported as the most important issues arising from the hackathon. The top three prizes went to initiatives promoting an artificial intelligence-enhanced operative pathway, instrument sterilisation and an educational platform to teach students research and innovation skills. CONCLUSIONS: Surgical hackathons can result in significant improvements in confidence in approaching innovation, as well as raising awareness of important healthcare challenges. Future innovation events may build on this to continue to empower the future workforce to leverage technologies to tackle healthcare challenges such as sustainability.

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Self-removal of urinary catheter as an option after robot-assisted radical prostatectomy (RARP) has never been explored in literature. We report the feasibility and outcome of the first study of this novel concept in our hospital. We conducted a prospective audit of self-TWOC (trial without catheter) in men who underwent consecutive RARP in our centre between April 2022 and September 2022. Men who had self-TWOC filled a questionnaire about the outcomes of self-TWOC. Carbon footprint and carbon offset for each hospital TWOC avoided were calculated. Of the 129 who underwent self-TWOC, 112 filled the questionnaire and were hence included in the final analysis. Self-TWOC was successful in all the 112 (100%) men in the study. 99.1% of men were satisfied with self-TWOC at home. We managed to avoid 79.6 ± 36.72 km of travel and 77 min of travel time for every self-TWOC. This also saved 85£/patient on clinic expenses and fuel cost savings of 9.87-15.99£ per patient depending on car engine size/type. The carbon footprint calculated was 20 kg CO2 assuming average engine sized diesel/petrol cars and 10 kg CO2 for an average UK petrol hybrid car. The calculated carbon offset per patient for diesel/petrol cars: 0.32£, petrol hybrid: 0.16£. Self-TWOC for 80-160 patients will save the carbon emissions equivalent to that of a passenger on a London-New York Trans-Atlantic flight. Self-TWOC is safe, affordable and is sustainable to the environment. Widespread acceptance of this practice change will be a small, but steady step towards greener health systems across the world.

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BACKGROUND: Hybrid surgical instruments contain both single-use and reusable components, potentially bringing together advantages from both approaches. The environmental and financial costs of such instruments have not previously been evaluated. METHODS: We used Life Cycle Assessment to evaluate the environmental impact of hybrid laparoscopic clip appliers, scissors, and ports used for a laparoscopic cholecystectomy, comparing these with single-use equivalents. We modelled this using SimaPro and ReCiPe midpoint and endpoint methods to determine 18 midpoint environmental impacts including the carbon footprint, and three aggregated endpoint impacts. We also conducted life cycle cost analysis of products, taking into account unit cost, decontamination, and disposal costs. RESULTS: The environmental impact of using hybrid instruments for a laparoscopic cholecystectomy was lower than single-use equivalents across 17 midpoint environmental impacts, with mean average reductions of 60%. The carbon footprint of using hybrid versions of all three instruments was around one-quarter of single-use equivalents (1756 g vs 7194 g CO2e per operation) and saved an estimated 1.13 e-5 DALYs (disability adjusted life years, 74% reduction), 2.37 e-8 species.year (loss of local species per year, 76% reduction), and US $ 0.6 in impact on resource depletion (78% reduction). Scenario modelling indicated that environmental performance of hybrid instruments was better even if there was low number of reuses of instruments, decontamination with separate packaging of certain instruments, decontamination using fossil-fuel-rich energy sources, or changing carbon intensity of instrument transportation. Total financial cost of using a combination of hybrid laparoscopic instruments was less than half that of single-use equivalents (GBP £131 vs £282). CONCLUSION: Adoption of hybrid laparoscopic instruments could play an important role in meeting carbon reduction targets for surgery and also save money.

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