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The humble string: the impact of ureteral stent string extraction on patient cost savings and travel emissions
Grant L. Steele, MD¹, Alisa K. Sivapiromrat, BS², Xiu Liu, MS¹, Preeti Chachlani, MS¹, Avinash Maganty, MD, MS¹, Michelle Kim, MD, PhD¹.
¹Massachusetts General Hospital, Boston, MA, USA, ²Harvard Medical School, Boston, MA, USA.

BACKGROUND: Healthcare accounts for roughly 8.5% of United States' (US) carbon emissions, underscoring the need for system innovations that reduce environmental impact without compromising quality. The emission consequences of common urologic pathways, such as post-operative stent removal, remain poorly characterized. At-home stent removal via string extraction represents a feasible alternative; however, its impact on patient spending and travel emissions is unknown.
METHODS: We performed a retrospective cohort study of patients undergoing ureteroscopy, laser lithotripsy, and stent placement by four surgeons between June 2023 to May 2025. Our exposure of interest was manner of stent removal (home versus in-person string versus in-person cystoscopy). The outcomes of interest included distance traveled, cost, emergency department (ED) visits within 30 days, and carbon emissions. Distance traveled was estimated based on zip code data. Cost calculations accounted for patient travel and lost wages. Emissions per mile based on Environmental Protection Agency estimates. Chi-square test utilized to compare frequency of ED presentation.
RESULTS:456 patients were included. The 231 patients who removed stents at home saved $238.5 individually ($55,094 cumulatively) and reduced emissions by 0.016 metric tons individually (3.6 metric tons cumulatively [Table 1]). The average US household emits 48 metric tons annually. There was no significant difference in overall (p=0.35) or urologic-specific (p=1.0) ED visits between patients with string and stringless stents. Nine patients with stents on a string required ED presentation for removal.
CONCLUSIONS: Per patient emission and cost savings were modest. However, with over 50,000 similar cases performed annually in the US, there is potential for a meaningful impact. Further work should include larger sample sizes and assessment of telehealth-assisted removals to further minimize travel and ED presentations.

Table 1: Cost savings, emissions savings, and ED visits among cohort

Type of Removal	Total patients	Average Age (years)	Average Distance (miles)	Average Cost to Travel ($)	Average wages at risk ($)	Average total possible savings ($)	Average Emissions (metric tons CO2 equivalents)	ED visit	Urologic ED visit
Cystoscopy	160	60	18.2	29.8	216	245.8	0.014	24	15
String	296	55	18.8	31.0	203	234.0	0.015	34	28
String - Home	231	55	19.8	32.5	206	238.5	0.016	18	14
String - In Person	65	58	15.5	25.4	190	215.4	0.012	16	14

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