The inflamed gallbladder burst open. A dozen or so small stones and a dark yellow fluid oozed out, pooling in the patient’s abdominal cavity. Dr. C, the general surgeon I was working with, spent the next hour clearing the debris. Collect, irrigate, suction, repeat.

As a medical student observing, I wondered how often the cleanup routine occurred. “I must’ve pulled it a little too hard,” Dr. C explained as he peered back into what looked like an arcade machine. He was remotely controlling the tetrapodal mechanical spider hovering above the patient, also known as the da Vinci. I’d come to be more familiar with it as I started my urology rotation.

Urology is a leading field in the development of robotic-assisted surgery (RAS).¹ In 2001, the same year the da Vinci first became commercially available, the first cases of robot-assisted prostatectomy were performed in Europe.^2,3 In 2003, the Vattikuti Institute of Detroit documented the Vattikuti Institute prostatectomy, which is now known as the robotic-assisted prostatectomy.⁴ The first series of robot-assisted radical cystectomies were also detailed that same year.⁵ Today, an estimated 85% of prostatectomies are performed robotically, many using the da Vinci.¹ The robot arm’s reach has even extended to assist in nephrectomies, pyeloplasties, renal transplantations, and more, thus solidifying the use of robotics in mainstream urological practice.⁶

The main advantage of robotic surgical platforms (RSPs) is their propensity to be more cost-effective than open and laparoscopic surgical procedures.⁷ Several studies have measured cost-effectiveness using length of hospital stays and length of operating times, finding RSPs to be the superior method. Other advantages include improved surgical precision, reduced blood loss, and minimal scarring.^2,8,9Many of these economic analyses of RAS actually emerge from the field of urology, emphasizing the role of RSPs in the field.⁷

RSPs, however, are not without disadvantages. These platforms are typically bulky and require large operating room (OR) suites to provide adequate space for the consoles, computer towers, and robotic arms.¹⁰ By opting to perform a RAS, the surgeon also relinquishes their sense of touch. In combination with the strength of the robotic arms, this can lead to technical errors and increased learning curves.¹¹ Not to mention, RSPs are expensive, costing between $1 million and $2.5 million.¹²

Given these disadvantages, there is still room for improvement and significant innovation aimed at addressing the challenges associated with robotic surgery. This year, on March 14, Intuitive announced that the US Food and Drug Administration provided clearance for the fifth generation of their flagship RSP, the da Vinci 5.¹³Intuitive’s newest creation addresses many of the disadvantages and barriers to cost-efficiency of robotic surgery. The da Vinci 5’s integration of essential OR technologies, including insufflation and an electrosurgical unit, reduce operating suite crowding. The new software developments allow surgeons to track their utilization of the platform on an app to an incredibly specific level of detail. For example, the app records the movement of instruments within space on a 3D graph, as well as the degree of force applied to each instrument throughout a procedure. Surgeons performing robot-assisted procedures will now be able to feel the subtle forces exerted on tissue while operating from across the room, as opposed to nothing at all. This means less accidental visceral and vascular injuries, which is especially helpful in urology, since most anatomy is composed of soft tissue that can be easily damaged and deformed.¹⁴ Furthermore, the greater comfort offered by the customizable console position could prolong a surgeon’s years in practice. This is significant in urology, where surgeries like radical cystectomies or pyeloplasties can be lengthy, requiring sustained precision and focus for several hours.

However, ethical dilemmas arise with the progress of this technology, particularly with respect to the mass collection of data. Surgical techniques and de-identified patient outcomes have immense potential for analysis and utilization. According to the privacy policy published on Intuitive’s website,¹⁵ the data that they collect includes but is not limited to: identification information (name, DOB, geolocation), contact information, personal characteristics (travel and meal preferences), professional information (title, employer, specialty, resume, memberships, education, training), “data related to the use of and interactions with products” (date, time, training pathway and records, procedure information, kinematics), and recordings (photos, audio, video). This data is then used for managing commercial relationships with existing and prospective customers, as well as conducting market research, among other purposes.

Data collection, of course, has the potential to improve surgical practices and drive further technologic innovation. Nonetheless, with absolute and unregulated control over huge quantities of data contributing to the creation of proprietary technology, corporations may create barriers to entry for up-and-coming competitors. The private ownership of massive international datasets may limit the dissemination of advancements in robotic surgery to only those health systems that can afford it. Thus, the risk of eventual monopolization of the surgical robotics market may exacerbate existing disparities in health care access and widen the gap between resource-rich institutions and underserved communities. Ultimately, the unrestricted harvesting of such data by corporations like Intuitive has serious implications for future monopolization and corporate influence in health care.

In light of these dangers, it is essential to establish robust ethical frameworks and regulatory safeguards to govern corporations’ collection, storage, and utilization of surgical data. While the ostensible goal of data collection is to improve surgical practices, enhance patient care, and drive innovation, regulatory bodies should mandate transparency requirements for corporate data practices and impose penalties for breaches of privacy and data misuse. In this way, we can start navigating the ethical complexities of data access in robotic surgery earlier and move technological innovation in a direction that will serve the best interests of patients and society at large. Taking steps such as these will uphold ethical principles, drive innovation, prioritize patient welfare, and foster accountability.

For a more thorough review of robotic surgery in urology, check out this article by Brassetti et al⁴: https://doi.org/10.3390/s23167104