A review of surgical techniques for radical prostatectomy

Since the early 20th century, radical prostatectomy has been used in the treatment of prostate cancer. However, before the widespread acceptance of prostate-specific antigen screening, the majority of cancers were clinically advanced and not amenable to cure, so relatively few men were candidates for this procedure. Modern advances have contributed dramatically to the reduction of complications and morbidity associated with radical prostatectomy. As a result, the procedure has become the most common treatment selected by men with localized prostate cancer. This article reviews several issues regarding radical prostatectomy, including surgical techniques, cancer control, intraoperative localization of the cavernous nerves, patient selection, and laparoscopic versus robotic approaches.     

Open versus laparoscopic radical prostatectomy

Expert laparoscopic surgeons have demonstrated that laparoscopic radical prostatectomy with or without robotic assistance can be performed with excellent results. There is no evidence that laparoscopic radical prostatectomy with or without robotic assistance offers any clinically relevant advantage over open radical prostatectomy. Laparoscopic radical prostatectomy with or without robotic assistance requires a significant learning curve, is a longer surgical procedure, carries greater costs, and requires an expanded operating room team. The literature suggests that laparoscopic radical prostatectomy is associated with more intraoperative complications and higher positive surgical margins. The lesser amount of postoperative bleeding associated with laparoscopic radical prostatectomy is not clinically relevant. Laparoscopic radical prostatectomy is not associated with less pain and does not facilitate earlier urinary catheter removal. The best way to improve overall outcomes after radical prostatectomy is to direct patients to expert open or laparoscopic surgeons.     

Global sharing of COVID-19 vaccines: A duty of justice,not charity

Global scarcity of COVID-19 vaccines raises ethical questions about their fair allocation between nations. Section I introduces the question and proposes that wealthy nations have a duty of justice to share globally scarce COVID-19 vaccines. Section II distinguishes justice from charity and argues that beneficiaries of unjust structures incur duties of justice when they are systematically advantaged at others expense. Section III gives a case-based argument describing three upstream structural injustices that systematically advantaged wealthy countries and disadvantaged poorer countries, contributing to global disparities of COVID-19 vaccines. Section IV examines more closely the duties of justice owed, including a duty to relinquish holdings, restitute victims, and restore relationships. Section V concludes that wealthy nations have a duty of justice to share COVID-19 vaccines with poor nations and to restore relationships damaged by injustice. All nations should take steps to transform unjust structures.     

The Park is Ruining our Livelihoods. We Support the Park! Unravelling the Paradox of Attitudes to Protected Areas

Despite considerable field-based innovation and academic scrutiny, the nexus between conservation approaches, local support for parks and park effectiveness remains quite puzzling. Common approaches to understanding notions of environmental justice are to understand distributional and procedural issues, representation in decision making, and recognition of authorities and claims. We took a different approach and analysed environmental justice claims through institutional, ideational and psychological lenses. We sought to understand how the national park could have such broad support from local communities despite their acknowledgement that it severely curtailed their livelihoods. We conducted 100 household interviews in three villages that border Nam Et-Phou Louey National Protected Area. Our study found that villagers 1) hold on to broken promises by the State for agricultural activities and alternative revenues without fully changing forest use behaviours; 2) were influenced heavily by the ‘educational’ programmes by the State; 3) accepted the authority of the State and lack of participation in decision-making based on historical experiences and values; 4) justified their burdens by over-emphasising the positive aspects of the park. Our findings present a complementary framework to explain environmental justice claims, allowing for a nuanced analysis of how people respond to justices and injustices, and specifically how injustices can be identified through proven social science concepts.     

Synthetic biology, patenting, health and global justice

The legal and moral issues that synthetic biology (SB) and its medical applications are likely to raise with regard to intellectual property (IP) and patenting are best approached through the lens of a theoretical framework highlighting the “co-construction” or “co-evolution” of patent law and technology. The current situation is characterized by a major contest between the so-called IP frame and the access-to-knowledge frame. In SB this contest is found in the contrasting approaches of Craig Venter’s chassis school and the BioBricks school. The stakes in this contest are high as issues of global health and global justice are implied. Patents are not simply to be seen as neutral incentives, but must also be judged on their effects for access to essential medicines, a more balanced pattern of innovation and the widest possible social participation in innovative activity. We need moral imagination to design new institutional systems and new ways of practising SB that meet the new demands of global justice.     

Devices and systems targeted towards augmented robotic radical prostatectomy

Prostate cancer is the most frequent male cancer and the second cause of male cancer mortality in developed countries. Therefore, it represents a major public health issue. Health problem and the development of new therapeutic strategies to address this issue is essential. During a prostatectomy, the surgeon looks for a compromise between an exhaustive removal of pathologic tissue (to achieve the best carcinogenic prognosis) and the functional consequences linked to a wide excision (i.e.: avoid as much as possible urinary incontinence and sexual dysfunction). In this context, the ANR TecSan DEPORRA project regroups French research laboratories (TIMC-IMAG, FEMTO-ST), companies (Endocontrol-Medical, VERMON) and hospital departments (CIC-IT, Urology & pathology Department of the Grenoble University Hospital) to bring innovative tools for radical prostatectomy. These tools will provide to the surgeon new information from several imaging modalities (video, fluorescence and US imaging), and combine them in an augmented environment. We believe that this augmented environment will ultimately help the surgeon to perform his surgical gesture “optimally” and will improve the patient's carcinogenic and functional prognosis.     

Thoracoscopic lobectomy with the da vinci surgical system

Thoracoscopic upper lobectomy has been performed with the da Vinci surgical system in human cadavers. A minithoracotomy and two additional thoraco ports provided access to the thoracic cavity. An auxiliary port was used for both retraction of the lung and suction. The pulmonary vessels were ligated by robotic instruments, and the bronchi were divided after suturing robotically or with automatic staplers. A standard lymph node dissection was performed. The current da Vinci surgical system provided superior optics and enhanced dexterity. The application of the system for minimally invasive lobectomy may add benefits for both surgeon and patients.     

Socioeconomic and Racial Disparities in Environmental Health: Is Risk Assessment Part of the Problem or Part of the Solution?

The term “environmental justice” is a relatively recent addition to the lexicon of public health and risk-based decision making. Although it is currently a prominent public policy issue, there is no consensus-derived definition, nor is there general agreement about viable mechanisms for putting worthwhile social goals (e.g., fairness, equity, and justice) into operation. Nevertheless, the concept of environmental justice has focused attention on important questions of whether economically and politically disadvantaged communities bear a disproportionate burden of environmental pollution, and whether past environmental policies, programs and practices have been fair and equitable. Among individuals and organizations involved with issues of environmental justice there is a spectrum of strong and often contradictory convictions about the nature and role of risk assessment. Critics are convinced it is part of the problem and are inclined to see it as an ethically suspect, resource-intensive, elitist, never-ending process used to maintain the status quo. Advocates, on the other hand, contend that risk assessment is an essential policy and regulatory tool for identifying, evaluating, and resolving instances of environmental injustice, and that it provides a unifying conceptual framework and a common language for constructive dialogue on the issue. This article argues that, in practice, risk assessment has contributed to both the reality and the perception of environmental justice problems because of the overly narrow and restricted manner in which it has been applied. In principle, however, risk assessment is part of the solution to environment injustices because it provides a beneficial construct for framing key questions and fostering constructive debate about how to answer them. Well-designed research studies and high-quality risk assessments are necessary to define the dimensions of the problem, to understand the root causes, and to identify effective, efficient, and equitable solutions. Ultimately, attaining the goal of environmental justice depends on putting risk assessment principles into practice.     

Equity Under the Knife: Justice and Evidence in Surgery

Surgery is an increasingly common and expensive mode of medical intervention. The ethical dimensions of the surgeon‐patient relationship, including respect for personal autonomy and informed consent, are much discussed; but broader equity issues have not received the same attention. This paper extends the understanding of surgical ethics by considering the nature of evidence in surgery and its relationship to a just provision of healthcare for individuals and their populations.     

Snakebites in “Invisible Populations”: A cross-sectional survey in riverine populations in the remote western Brazilian Amazon

In the Brazilian Amazon, long distances, low healthcare coverage, common use of ineffective or deleterious self-care practices, and resistance to seeking medical assistance have an impact on access to antivenom treatment. This study aimed to estimate snakebite underreporting, and analyze barriers that prevent victims from obtaining healthcare in communities located in 15 municipalities on the banks of the Solimões, Juruá and Purus Rivers, in the remote Western Brazilian Amazon. Information on the participants’ demographics, previous snakebites, access to healthcare, time taken to reach medical assistance, use of self-care practices, and the reason for not accessing healthcare were collected through semi-structured interviews. In the case of deaths, information was collected by interviewing parents, relatives or acquaintances. A total of 172 participants who reported having suffered snakebites during their lifetime were interviewed. A total of 73 different treatment procedures was reported by 65.1% of the participants. Participants living in different river basins share few self-care procedures that use traditional medicine, and 91 (52.9%) participants reported that they had access to healthcare. Living in communities along the Juruá River [OR = 12.6 (95% CI = 3.2–49.7; p<0.001)] and the use of traditional medicine [OR = 11.6 (95% CI = 3.4–39.8; p<0.001)] were variables that were independently associated to the lack of access to healthcare. The main reasons for not accessing healthcare were the pprioritization of traditional treatments (70.4%), and the failure to recognize the situation as being potentially severe (50.6%). Four deaths from complications arising from the snakebite were reported, and three of these were from communities on the banks of the Juruá River. Only one of these received medical assistance. We found an unexpectedly high underreporting of snakebite cases and associated deaths. Snakebite victims utilized three main different healing systems: 1) self-care using miscellaneous techniques; 2) official medical healthcare generally combined with traditional practices; and 3) self-care using traditional practices combined with Western medicines. To mitigate snakebite burden in the Brazilian Amazon, an innovative intervention that would optimize timely delivery of care, including antivenom distribution among existing community healthcare centers, is needed.     

Environmental migrants,structural injustice,and moral responsibility

Climate change and environmental problems will force or induce millions of people to migrate. In this article, I describe environmental migration and articulate some of the ethical issues. To begin, I give an account of these migrants that overcomes misleading dichotomies. Then, I focus attention on two important ethical issues: justice and responsibility. Although we are all at risk of becoming environmental migrants, we are not equally at risk. Our risk depends on our temporal position, geographical location, social position, and the kind of society in which we live. We all contribute to environmental problems, but we do not contribute equally. About 11% of the world population is responsible for 50% of carbon emissions. These inequalities raise issues of justice because many of the people who are at high risk have contributed little to the problems. Since the issues of justice are relatively clear and compelling, I focus more attention on issues of responsibility. I use Iris Marion Young’s account of responsibility for structural injustice to address four key questions about moral responsibility and environmental migration.     

Anesthetic Challenges in Robotic-assisted Urologic Surgery

Robotic-assisted surgery has evolved over the past two decades with constantly improving technology, assisting surgeons in multiple subspecialty disciplines. The surgical requirements of lithotomy and steep Trendelenburg positions, along with the creation of a pneumoperitoneum and limited access to the patient, all present anesthetic management challenges in urologic surgery. Patient positioning requirements can cause significant physiologic effects and may result in many complications. Good communication among team members and knowledge of the nuances of robotic surgery have the potential to improve patient outcomes, increase efficiency, and reduce surgical and anesthetic complications.Key words: Robotic surgery, Urologic surgery, Anesthesia complications, Pneumoperitoneum, Peripheral nerve injury, Patient positioningWith recent advancements in surgical procedures, there is a greater emphasis on minimally invasive techniques with the goal of improving patient outcomes and satisfaction while decreasing surgical morbidity and mortality. Robotic-assisted surgery, the latest innovation in the field of minimally invasive surgeries, first came into medical practice in 1999.¹ The basic principle behind this technology is that the robot “teleports” the surgeon to the operating site and enables operation on the patient from an ergonomic console using three-dimensional vision and autonomous control of wristed laparoscopic surgical instruments.^2,3There are numerous advantages to robotic-assisted surgery, such as improved precision and enhanced accuracy of the movements that can potentially improve patient outcomes.^4,5 In particular, the advent of laparoscopic surgery in the late 1980s also highlighted certain limitations, such as loss of typical three-dimensional vision, reduced surgeon coordination, and greatly limited touch.¹ The use of robotic technology overcame many of these new obstacles as technology improved over the years.⁶ The da Vinci® system (Intuitive Surgical, Sunnyvale, CA) mimics a human wrist and includes three distinct pieces: (1) a console; (2) a surgical cart with four arms that represent a surgeon’s left and right arms, an arm to hold and position the endoscope, and a fourth arm to perform other tasks; and (3) an optical three-dimensional tower that provides stereoscopic vision and runs software.¹Since the late 1990s, surgeons have performed a variety of robot-assisted surgical procedures, including cardiac, thoracic, general surgical, gynecologic, and urologic procedures.¹ Since then, robotic-assisted techniques are being increasingly used for various urologic procedures, including prostatectomy, partial and total nephrectomy, and microsurgical procedures.^7–9 Both the number and variety of urologic procedures performed with robotic assistance have increased significantly, with tens of thousands of cases performed per year in the United States alone.This review specifically focuses on anesthetic considerations related to urologic surgery with robotic technology. The surgical requirements of the steep Trendelenburg position, along with creation of a pneumoperitoneum and limited physical access to the patient, present anesthetic management challenges in urologic surgery.     

Minimally Invasive Therapy for Prostate Cancer: Use of Nomograms to Counsel Patients about the Choice and Probable Outcome of Therapy

Despite dramatic and recently accelerated advances in the reduction of morbidity linked to radical prostatectomies, significant short- and long-term morbidity is still associated with this surgical procedure. Currently both surgical and nonsurgical minimally invasive options are available for men with clinically localized prostate cancer, including laparoscopic and robotic radical prostatectomy, brachytherapy, and cryosurgical ablation of the prostate, with others, such as high intensity focused ultrasound, under investigation. In continued efforts to improve patient outcomes and to tailor treatment options to individual patient circumstances, nomograms have been developed and are increasingly being used by physicians and patients, alike, to guide therapeutic choices at each stage of disease. This tool predicts the possibility of successful treatment for the patient based on factors such as prostate-specific antigen levels, clinical stage of disease, and biopsy results. The current and future development, design, availability, and use of nomograms is described along with the historic and newer minimally invasive treatment options for prostate cancer.     

Vision-Based Framework of Single Master Dual Slave Semi-Autonomous Surgical Robot System

BackgroundIn the traditional Robot assisted minimally invasive surgery (RMIS) scenario, the instruments are fully controlled by the surgeon through tele-operation. Recent works have widely explored the surgical intelligence by integrating advanced approaches to enhance the surgical operating room (OR) outcomes.MethodsWe propose a novel single-master dual-slave framework for semi-autonomous suturing task, laparoscope information is introduced to feed back into the robotic control loop to guide the movement of surgical instrument.ResultsExperimental results demonstrate that the proposed method can handle the single-master dual-slave semi-autonomous suturing subtask. Furthermore, the framework exhibits compelling performance leading to the efficiency of surgical OR.ConclusionsAdding vision information into the robotic control loop can achieve the semi-autonomous operation, improve the surgical OR efficiency, this capability yields new level of intelligence for the RMIS.     

FURTHERING INJUSTICES AGAINST WOMEN: GENETIC INFORMATION, MORAL OBLIGATIONS, AND GENDER

The purpose of this paper is to show that a decontextualized approach to ethical issues is not just unhelpful for the decision making process of real, situated human beings, but dangerous. This is so, because by neglecting the context in which people make moral decisions we run the risk of reinforcing or furthering injustices against already disadvantaged groups. To show this, I evaluate three moral obligations that our ability to obtain genetic information has made salient: the duty to obtain genetic information about ourselves, the obligation to inform family members about genetic risks and the duty not to reproduce when we know that there is a high risk of transmitting a serious disease or defect. I will argue here that in ignoring the context in which these moral obligations are put into practice, and in particular the situation of women in our society, those who defend these moral duties might be furthering injustices against women.     

The PSIP project for Adverse Drug Events prevention

The objective of Clinical Decision Support (CDSS) systems coupled with Computerised Physician Order Entry (CPOE) systems is to improve patient safety. However, there are still issues to be considered to improve the quality of CDSS, especially the difficulty to share the knowledge developed by institutions or healthcare organisations and to exploit it for other medical application. The aim of the Patient Safety through Intelligent Procedures (PSIP) project is to propose innovative tools to generate and provide relevant knowledge to healthcare professionals and patients for Adverse Drug Events (ADE) prevention. The particularity of the PSIP project is to consider the share of knowledge and the interoperability of medical applications via the elaboration of a Global Knowledge Platform (GKP). In this paper, we present the different components of the PSIP GKP and we show its implementation through three medical applications: a web application, an Electronic Health Record (EHR) and a CPOE.     

Three research priorities for just and sustainable urban systems: Now is the time to refocus

Now is the time to refocus efforts in urban research and design. A changing climate and extreme weather events are presenting unique challenges to urban systems around the world. These challenges illuminate the social barriers that accompany disruptive events such as resource inequities and injustices. In this perspective, we provide three research priorities for just and sustainable urban systems that help to address these matters. The three research priorities are: (1) social equity and justice, (2) circularity, and (3) digital twins. Conceptual context and future research directions are provided for each. For social equity and justice, the future directions are mandatory equity analysis and inclusionary practices, understanding and reconciling historical injustices, and intentional integration with diverse community stakeholders. For circularity applications, they are better metrics for integration, more robust evaluation frameworks, and dynamic modeling at multiple spatial and temporal scales. Future directions for digital twins include developing principles to reduce complexity, integrating model and system components, and reducing barriers to data access. These research priorities are core to meeting several of the United Nations Sustainable Development Goals (i.e., 1—No Poverty, 8—Decent Work and Economic Growth, 10—Reduced Inequalities, and 11—Sustainable Cities and Communities). Useful social and technical matters are discussed throughout, where we highlight the importance of prioritizing localized research efforts, provide guidance for community-engaged research and co-development practices, and explain how these priorities interact to align with the evolving field of industrial ecology.     

Tailored Medicine: Whom Will it Fit? The Ethics of Patient and Disease Stratification

A key selling point of pharmacogenetics is the genetic stratification of either patients or diseases in order to target the prescribing of medicine. The hope is that genetically 'tailored' medicines will replace the current 'one-size-fits-all' paradigm of drug development and usage. This paper is concerned with the relationship between difference and justice in the use of pharmacogenetics. This new technology, which facilitates the identification and use of difference, has, we shall argue, the potential to lead to injustice either by the inappropriate use of difference or through the inappropriate failure to use difference. We build on empirical data from a detailed study of the range of options for the development of pharmacogenetics to present a consideration of the ethical issues that surround patient and disease stratification. In it we explore the ways in which the use of pharmacogenetics may lead to the creation of new, genetically stratified, forms of difference and new forms of injustice based on these divisions. We also examine the ways in which existing forms of difference and social stratification may interact with the use of pharmacogenetics. In conclusion, we suggest how an understanding of these ethical issues could usefully inform future policy discussions.     

Healthcare professionals as gatekeepers in research involving refugee survivors of sexual torture: An examination of the ethical issues

This paper examines the ethical issues that arise when healthcare providers act as gatekeepers to research involving vulnerable populations. Traumatised refugees serve as an example of this subset of research participants. Highlighting the particular vulnerabilities of this group, we argue that specific ethical considerations are required that go beyond the conventional research approaches. While gatekeeping responds to some of those vulnerabilities, it risks wronging through unwarranted paternalism. Instead, we will propose that a relational ethics of justice and care serves as a more appropriate framework for responding to the challenges of research involving traumatised refugees. Specifically, such a framework allows us to reflect more deeply on the role of the gatekeeper. In conclusion, we recommend that clinicians and researchers collaborate with survivors’ advisory groups in the development of specific research ethical guidelines.     

Response: Freedom from Pain as a Rawlsian Primary Good

In a recent article in this journal, Carl Knight and Andreas Albertsen argue that Rawlsian theories of distributive justice as applied to health and healthcare fail to accommodate both palliative care and the desirability of less painful treatments. The asserted Rawlsian focus on opportunities or capacities, as exemplified in Normal Daniels’ developments of John Rawls’ theory, results in a normative account of healthcare which is at best only indirectly sensitive to pain and so unable to account for the value of efforts of which the sole purpose is pain reduction. I argue that, far from undermining the Rawlsian project and its application to problems of health, what the authors’ argument at most amounts to is a compelling case for the inclusion of freedom from physical pain within its index of primary goods.