REVIEW   Free access

Minerva Urology and Nephrology 2021 December;73(6):700-10

DOI: 10.23736/S2724-6051.21.04240-3

Copyright © 2021 EDIZIONI MINERVA MEDICA

language: English

Bioethical implications of robotic surgery in urology: a systematic 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, 11}, Karl H. PANG ¹², Giuseppe SIMONE ¹³, Vittoroadolfo TAMBONE ¹⁴, Piergiorgio TUZZOLO ¹, Roberto M. SCARPA ¹, Rocco PAPALIA ¹

¹ Department of Urology, Campus Bio-Medico University, Rome, Italy; ² Department of Urology, University of Verona, Verona, Italy; ³ Unit of Surgery, Campus Bio-Medico University, Rome, Italy; ⁴ Institute of Philosophy of Scientific and Technological Practice, Campus Bio-Medico University, Rome, Italy; ⁵ Section of Anesthesia and Intensive Care, Department of Anesthesia, Intensive Care and Pain Therapy, Campus Bio-Medico University, Rome, Italy; ⁶ School of Medicine, Division of Urology, Department of Oncology, San Luigi Hospital, University of Turin, Orbassano, Turin, Italy; ⁷ Laboratory of Biomedical Robotics and Biomicrosystems, Campus Bio-Medico University, Rome, Italy; ⁸ Department of Urology, Careggi Hospital, University of Florence, Florence, Italy; ⁹ Department of Urology, Humanitas Gradenigo, Turin, Italy; ¹⁰ Department of Urology, Nuovo Ospedale Civile S. Agostino Estense, University of Modena and Reggio Emilia, Modena, Italy; ¹¹ Polyclinic Hospital of Modena, Modena, Italy; ¹² Unit of Academic Urology, Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK; ¹³ Department of Urology, Regina Elena National Cancer Institute, Rome, Italy; ¹⁴ Unit of Anthropology and Applied Ethics, Campus Bio-Medico University, Rome, Italy

INTRODUCTION: Robotic technologies are being increasingly implemented in healthcare, including urology, and 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 was 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.
EVIDENCE ACQUISITION: We performed a review of the pertaining literature through a systematic search of two databases (PubMed and Web of Science) in August 2020.
EVIDENCE SYNTHESIS: 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 (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) safety (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) gender gap (no data about gap differences in accessibility to robotic platforms were retrieved from our search); 4) costs (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); and 5) learning curve (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 sexes. 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 surgical procedures; Urology