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Minerva Urology and Nephrology 2021 Jul 26

DOI: 10.23736/S2724-6051.21.04240-3


language: English

Bioethical implications of robotic surgery in urology: a narrative review

Francesco ESPERTO 1 , Francesco PRATA 1, Alessandro ANTONELLI 2, Rossana ALLONI 3, Laura CAMPANOZZI 4, Rita CATALDO 5, Angelo CIVITELLA 1, Cristian FIORI 6, Giampaolo GHILARDI 4, Eugenio GUGLIELMELLI 7, Andrea MINERVINI 8, Giovanni MUTO 9, Bernardo ROCCO 10, Chiara SIGHINOLFI 10, Karl H. PANG 11, Giuseppe SIMONE 12, Vittoradolfo TAMBONE 13, Piergiorgio TUZZOLO 1, Roberto M. SCARPA 1, Rocco PAPALIA 1

1 Department of Urology, Campus Bio-Medico University of Rome, Rome, Italy; 2 Department of Urology, University of Verona, Verona, Italy; 3 Surgery Unit, Campus Bio-Medico University of Rome, Rome, Italy; 4 Institute of Philosophy of Scientific and Technological Practice, Campus Bio-Medico University of Rome, Rome, Italy; 5 Anesthesia and Intensive Care Section, Department of Anesthesia, Intensive Care and Pain Therapy, Campus Bio-Medico University of Rome, Rome, Italy; 6 Division of Urology, Department of Oncology, School of Medicine, San Luigi Hospital, University of Turin, Orbassano, Turin, Italy; 7 Laboratory of Biomedical Robotics and Biomicrosystems, Campus Bio-Medico University of Rome, Rome, Italy; 8 Department of Urology, Careggi Hospital, University of Florence, Florence, Italy; 9 Department of Urology, Humanitas Gradenigo University, Turin, Italy; 10 Department of Urology, Ospedale Policlinico e Nuovo Ospedale Civile S. Agostino Estense, University of Modena and Reggio Emilia, Modena, Italy; 11 Academic Urology Unit, Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK.; 12 Department of Urology, Regina Elena National Cancer Institute, Rome, Italy; 13 Anthropology, and Applied Ethics, Campus Bio-Medico University, Rome, Italy

BACKGROUND: Robotic technologies are being increasingly implemented in healthcare, including urology, holding promises for improving medicine worldwide. However, these new approaches raise ethical concerns for professionals, patients, researchers and institutions that need to be addressed. The aim of this review is to investigate the existing literature related to bioethical issues associated with robotic surgery in urology, in order to identify current challenges and make preliminary suggestions to ensure an ethical implementation of these technologies.
METHODS: We performed a narrative review of the pertaining literature through a systematic search of two databases (PubMed and Web of Science) in August 2020.
RESULTS: Our search yielded 76 articles for full-text evaluation and 48 articles were included in the narrative review. Several bioethical issues were identified and can be categorized into five main subjects: 1) robotic surgery accessibility; 2) safety; 3) gender gap; 4) costs and 5) learning curve. 1) Robotic surgery is expensive, and in some health systems may lead to inequality in healthcare access. In more affluent countries the national distribution of several robotic platforms may influence the centralization of robotic surgery, therefore potentially affecting oncological and functional outcomes in low-volume centers. 2) There is a considerable gap between surgical skills and patients’ perception of competence, leading to ethical consequences on modern healthcare. Published incidence of adverse events during robotic surgery in large series is between 2% and 15%, which does not significantly differ amongst open or laparoscopic approaches. 3) No data about gap differences in accessibility to robotic platforms were retrieved from our search. 4) Robotic platforms are expensive but a key reason why hospitals are willing to absorb the high upfront costs is patient demand. It is possible to achieve cost-equivalence between open and robotic prostatectomy if the volume of centers is higher than 10 cases per week. 5) A validated, structured curriculum and accreditation has been created for robotic surgery. This allows acquisition and development of basic and complex robotic skills focusing on patient safety and short learning curve.
CONCLUSIONS: Tech-medicine is rapidly moving forward. Robotic approach to urology seems to be accessible in more affluent countries, safe, economically sustainable, and easy to learn with an appropriate learning curve for both sex. It is mandatory to keep maintaining a critical rational approach with constant control of the available evidence regarding efficacy, efficiency and safety.

KEY WORDS: Robotics; Ethics; Minimally invasive surgery; Urology; Training

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