Editorial comment: The reusability conundrum: Considerations for reusing surgical disposables in research setting

The exact prevalence of reusing disposables in any surgical discipline remains largely unknown, mainly due to the ethical and legal issues and a lack of reporting, but a study in 1987 estimated it to be around 40% in Canada. Surprisingly, only 38% of these hospitals reusing disposables had a written procedure for reprocessing, and only 32% emphasized the number of times a device had been reused at that time.[1] Recently, researchers in the field of urology have shown interest in this issue and I congratulate the authors of this study for their work.[2] However, this study has a number of shortcomings, which probably show why it is so difficult to conduct a study on the reusability of surgical disposable equipments. We will discuss them one by one, with suggestions on how future studies could be improved in their scientific validity and generalizability. Firstly, there is a lack of randomization/blinding and the numbers are small for a multicentric study. The multicentric nature implies that the centers may have differences in stone and scope handling and management protocols, and in lasers usage in the terms of type and energy settings, and all of these may have impacted the durability of the scope. Also, a selection bias is evident, as the authors have used new scopes for large stones, the objectives of the study are poorly defined objectives, no cost-saving analysis has been performed, no carbon footprint analysis has been done, and certain execution issues are present which could have been improved, such as a lack of detailed baseline data, lack of comparison of surgerical duration, poor Stone Free Rates (SFR) in reused group, and consideration of clinically insignificant stone size (4 mm) for surgery. This is not the first, and most definitely won’t be the last study to address this issue.[3] While reusability per law appears to be a reasonable explanation for using a scope 3 times, several other things need to be considered in this regard, like the physical or chemical reaction between the scope material and reprocessing and sterilization method/agent,[4] the durability of the scope and material used in its deflection mechanism, coatings, and vision mechanism, to withstand repeated reprocessing and sterilization/disinfection cycles. All these factors need to be set right at the start of the study, and it is probably best to have a scientifically backed departmental policy before actually conducting such a study.[5] Another issue for the standardisation of the procedures using reused disposables in a research setting is ergonomics. The authors describe, “A questionnaire was administered to the surgeon prior to the procedure to assess the vision and maneuverability of the ureteroscope.” However, it would have been better to include an objective measure of vision and maneuverability for this assessment, along with the subjective criteria laid out above.[6] Before reuse, we also need to have a proper look at the scope to assess any features of minor or major damage.[7] There are objective methods to check the deflection of the scope by using a graph paper. A structured assessment should be used while conducting such studies.[8] In addition to all of the above, these instruments can only be used after sterilization or high-level disinfection as an alternative. Reprocessing and resterilization come with their quality related implications. All the methods of sterilization come with control methods for various sterilization techniques. These controls may be in the form of color indicators or microbiological control. This microbiological control may take anywhere from 4 h to 48–72 h to reflect a positive control culture.[9,10] In case the culture is positive, there are serious potential ethical, medical, and medicolegal implications. Further, it is recommended to aerate the ethylene oxide sterilized instruments for some time before reusing them, which needs to be followed. Therefore, all these factors need to be taken into account while framing a study and rigorous data on adherence of the researching team with the quality control of sterilization needs to be provided.[10,11] The underlying ethical issues in such studies stem from the fact that a single-use critical item is about to be reused,[12] and it is important that the participants are informed of the fact that a single-use device is about to be reused in them. However, it is likely that after this information is shared, many of the participants will decline to participate in such a study. The answer to this lies in the adherence to a reprocessing protocol which is efficacious in microbial killing and, at the same time, is gentle on the scope material. The carbon footprint debate is difficult to settle, with literature showing reusable ureteroscopes to be equivalent in carbon footprint to the disposable single-use devices.[13] This debate is probably only going to become more intense in the due course, but definitely, reusing the disposable scopes, if done with proper infection control measures, is likely to be more cost-effective for the hospitals and will reuce the overall financial burden. There is a need of better studies to provide greater insights into this topic in the interest of improving healthcare affordability and reducing the nonbiodegradable waste generation while preserving the quality of care for the patient and removing the ethical and medicolegal dilemmas for the Urologist. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.

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