Bioethical approach to robot-assisted surgery

The ethical landscape of robot-assisted surgery: a systematic review

Robot-assisted surgery has been widely adopted in recent years. However, compared to other health technologies operating in close proximity to patients in a vulnerable state, ethical issues of robot-assisted surgery have received less attention. Against the background of increasing automation that is expected to raise new ethical issues, this systematic review aims to map the state of the ethical debate in this field. A protocol was registered in the international prospective register of systematic reviews (PROSPERO CRD42023397951). Medline via PubMed, EMBASE, CINHAL, Philosophers' Index, IEEE Xplorer, Web of Science (Core Collection), Scopus and Google Scholar were searched in January 2023. Screening, extraction, and analysis were conducted independently by two authors. A qualitative narrative synthesis was performed. Out of 1723 records, 66 records were included in the final dataset. Seven major strands of the ethical debate emerged during the analysis. These include questions of harms and benefits, responsibility and control, professional-patient relationship, ethical issues in surgical training and learning, justice, translational questions, and economic considerations. The identified themes testify to a broad range of different ethical issues requiring careful deliberation and integration into the surgical ethos. Looking forward, we argue that a different perspective in addressing robotic surgical devices might be helpful to consider upcoming challenges of automation.

Role of 3D printing in healthcare: A comprehensive review on treatment and training

Additive manufacturing (AM) is revolutionizing healthcare by enabling the creation of customized 3D printed (3DP) medical equipment, implants, orthoses, prosthetics, drugs, and organs. With the availability of different types of materials suitable for 3DP and healthcare applications, this technology allows for the precise fabrication of patient-oriented prosthetics, dental implants, and orthopedic devices, significantly improving fit and functionality. Additionally, 3DP drugs, such as Oral Dispersible Formulations (ODFs) and polypills, are surpassing the traditional "one pill fits all" concept, offering more tailored medication solutions. This innovation also supports the development of personalized medications and bioprinted tissues, opening the way for advancements in regenerative medications and tailored therapies. 3D-bioprinted organs are addressing the growing demand for organ transplants. In surgical planning, 3D-printed anatomical models provide students and professionals with hands-on practice, which is crucial for skill development and understanding complex anatomies. Surgeons can also practice and refine techniques before actual procedures, enhancing precision and improving outcomes during real operations. This paper focus on highlighting the progression and motivations behind the cross-disciplinary applications of AM within the healthcare sector providing customized medical devices, drug delivery systems and diagnostic tools for personalized treatment and skill refinement. This paper is designed for a broad audience, including manufacturing professionals and researchers, who are interested in exploring the medical implications of this transformative technology.

Using qualitative research methods to understand how surgical procedures and devices are introduced into NHS hospitals: the Lotus study protocol

INTRODUCTION

The development of innovative invasive procedures and devices are essential to improving outcomes in healthcare. However, how these are introduced into practice has not been studied in detail. The Lotus study will follow a wide range of 'case studies' of new procedures and/or devices being introduced into NHS trusts to explore what information is communicated to patients, how procedures are modified over time and how outcomes are selected and reported.

METHODS AND ANALYSIS

This qualitative study will use ethnographic approaches to investigate how new invasive procedures and/or devices are introduced. Consultations in which the innovation is discussed will be audio-recorded to understand information provision practice. To understand if and how procedures evolve, they will be video recorded and non-participant observations will be conducted. Post-operative interviews will be conducted with the innovating team and patients who are eligible for the intervention. Audio-recordings will be audio-recorded, transcribed verbatim and analysed thematically using constant comparison techniques. Video-recordings will be reviewed to deconstruct procedures into key components and document how the procedure evolves. Comparisons will be made between the different data sources.

ETHICS AND DISSEMINATION

The study protocol has Health Research Authority (HRA) and Health and Care Research Wales approval (Ref 18/SW/0277). Results will be disseminated at appropriate conferences and will be published in peer-reviewed journals. The findings of this study will provide a better understanding of how innovative invasive procedures and/or devices are introduced into practice.

Bioethical implications of robotic surgery in urology: a narrative review

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.

Discussing surgical innovation with patients: a qualitative study of surgeons' and governance representatives' views

OBJECTIVES

Little is known about how innovative surgical procedures are introduced and discussed with patients. This qualitative study aimed to explore perspectives on information provision and consent prior to innovative surgical procedures.

DESIGN

Qualitative study involving semi-structured interviews. Interviews were audio recorded, transcribed and analysed thematically.

PARTICIPANTS

42 interviews were conducted (26 surgeons and 16 governance representatives).

SETTING

Surgeons and governance representatives recruited from various surgical specialties and National Health Service (NHS) Trusts across England, UK.

RESULTS

Participants stated that if a procedure was innovative, patients should be provided with additional information extending beyond that given during routine surgical consultations. However, difficulty defining innovation had implications for whether patients were informed about novel components of surgery and how the procedure was introduced (ie, as part of a research study, trust approval or in routine clinical practice). Furthermore, data suggest surgeons found it difficult to establish what information is essential and how much detail is sufficient, and governance surrounding written and verbal information provision differed between NHS Trusts. Generally, surgeons believed patients held a view that 'new' was best and reported that managing these expectations could be difficult, particularly if patient views aligned with their own.

CONCLUSIONS

This study highlights the challenges of information provision and obtaining informed consent in the context of innovative surgery, including establishing if and how a procedure is truly innovative, determining the key information to discuss with patients, ensuring information provision is objective and balanced, and managing patient expectations and preferences. This suggests that surgeons may require support and training to discuss novel procedures with patients. Further work should capture consultations where new procedures are discussed with patients and patients' views of these information exchanges.