Evidence-Based Framework for Surgical Irrigation Fluid Stewardship and Endoscopic Case Prioritization During Fluid Shortages.

Introduction: The US supply disruption of surgical irrigation fluids in September 2024 prompted the need for fluid conservation and potential deferral of urology procedures. We characterized fluid use in common endoscopic procedures to articulate recommendations for irrigation fluid stewardship and case prioritization during fluid shortages.

Methods: We reviewed case volumes and irrigation fluid use for endoscopic urological procedures at our institution during January-September 2024. We convened a panel of high-volume urologists and used a 3-step modified Delphi method to determine consensus recommendations for fluid stewardship and case prioritization.

Results: Among 6155 cases, the procedures consuming the highest mean per-case fluid volumes were prostate enucleation (26.6 L), transurethral resection of the prostate (16.7 L), percutaneous nephrolithotomy (12.4 L), and robotic water-jet prostate ablation (10.9 L). These 4 procedures comprised 17% of all cases but consumed 42% of total fluid volume. To prioritize procedures for potential deferral, procedures were stratified into 3 fluid tiers based on fluid consumption and 3 urgency tiers based on clinical indication. Combining both fluid and urgency tiers, we identified 5 procedural priority levels in which lower priority cases that consume more fluid and treat less urgent indications are deferred first. Finally, we defined 4 fluid stewardship principles addressing patient and trainee needs.

Conclusions: Among endoscopic urology cases, the 4 most fluid-intensive procedures consume 42% of surgical irrigation fluid. A case prioritization framework that accounts for fluid consumption and clinical urgency can help urology practices navigate potential case deferrals. Fluid stewardship principles may optimize fluid conservation to minimize adverse impact on patients and trainees.