April 12, 2025
In times of healthcare supply shortages, every drop counts. A 2025 study published in Urology Practice led by Kevin Koo, M.D., M.P.H., and Kevin M. Wymer, M.D., both urologists at Mayo Clinic in Rochester, Minnesota, offers an evidence-based roadmap to help urology practices navigate the use and conservation of surgical irrigation fluids. These fluids are critical during endoscopic procedures but often overlooked in broader resource planning.
The study was born out of necessity. In September 2024, Hurricane Helene caused significant disruptions in the U.S. saline manufacturing supply chain, leading to severe shortages of sterile saline used for irrigation during minimally invasive procedures. This led to a downstream impact on urologic endoscopic procedures, where such fluids are vital for clear visibility and safe operation.
"The sudden shortage of saline irrigation fluid had immediate consequences for our endoscopic surgical patients, so we needed to examine our data and lead the practice through evidence-based change," says Dr. Koo, an associate professor of urology at Mayo Clinic College of Medicine and Science.
To tackle this issue, the research team developed a practical, tiered framework to guide surgical teams in prioritizing procedures and using irrigation fluids more efficiently when supplies are low. The framework combines expert consensus, clinical urgency and fluid consumption data to classify procedures into five priority levels during shortages.
To establish this framework, the researchers analyzed saline irrigation consumption during 6,000 common endoscopic procedures performed by urologists at Mayo Clinic. The team found that four procedures — prostate enucleation, transurethral resection of the prostate, percutaneous nephrolithotomy and robotic water-jet prostate ablation — comprised 17% of all cases but consumed 42% of total fluid volume. The volume data was then used to stratify all endoscopic procedures into three tiers for expected irrigation fluid use.
In addition to volume use by case, the prioritization scheme also accounts for the clinical urgency of the procedures by categorizing them into three tiers. For instance, procedures performed to diagnose or treat cancers, such transurethral resection of bladder tumors, have higher urgency than procedures to manage nonobstructing kidney stones or minimally symptomatic prostate enlargement.
The researchers combined the fluid use and clinical urgency tiers to establish the five overarching priority levels to help urology practices navigate potential case deferrals using their evidence-based approach.
The framework also encourages surgical fluid stewardship, which is the mindful use of resources without compromising patient safety or outcomes. One key principle is that fluid use can be individualized based on the specific needs of a given procedure, and optimizing existing operating room processes can, in many cases, help reduce fluid use.
Stewardship-centered communication between surgeons and operating room staff can support using the minimum necessary irrigation fluid bags. The researchers encourage spiking one initial fluid bag at the start of the procedure and opening each additional bag only after confirming its necessity with the surgeons.
Even after the improvement in the sterile saline supply chain in March 2025, the researchers suggest that this framework has long-term relevance. As healthcare organizations face climate disruptions, rising costs and ongoing supply chain vulnerabilities, resource-conscious decision-making is more important than ever.
"Unfortunately, these types of supply constraints are likely to become more common moving forward, so it will be increasingly important to apply evidence-based, clinically mindful recommendations to minimize patient and healthcare staff impacts," says Dr. Wymer, an assistant professor of urology at Mayo Clinic College of Medicine and Science.
The study's authors hope that their framework will serve as both a guide and a conversation starter, encouraging hospitals and surgical centers to think proactively about resource use before the next crisis hits. With planning and coordination, even seemingly mundane aspects of surgery like irrigation fluid use can be made more resilient, sustainable and patient-centered.
For more information
Koo K, et al. Evidence-based framework for surgical irrigation fluid stewardship and endoscopic case prioritization during fluid shortages. Urology Practice. In press.
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