Technologic Stewardship in Urology: A Call for Action.

For generations, urologists have been at the forefront of technological innovation. From surgical endoscopy and laser lithotripsy to robotic surgery and even implantable prosthetic devices, urologists have always led the charge. With each advance, patients have benefitted: whether that be greater stone-free rates, reduced blood loss, or renewed sexual function. But so too has the global landscape of urologic practice. Today, advances in the use of telehealth and telementorship have dramatically increased the scale and interconnectivity of the urologist’s professional networks.1Challacombe B. Kavoussi L. Patriciu A. Stoianovici D. Dasgupta P. Technology insight: telementoring and telesurgery in urology.Nat Clin Pract Urol. 2006; 3: 611-617https://doi.org/10.1038/ncpuro0626Crossref Scopus (49) Google Scholar Alongside this change have sprung international “uro-technology” physician working groups and countless industry start-ups focused entirely on developing cutting-edge devices to address urologic diseases with innovative approaches. Despite its strong promise, clinical integration of novel technology has also invited new challenges. For example, penile prostheses carry a notable risk of infection.2Gon L.M. de Campos C.C.C. Voris B.R.I. Passeri L.A. Fregonesi A. Riccetto C.L.Z. A systematic review of penile prosthesis infection and meta-analysis of diabetes mellitus role.BMC Urology. 2021; 21: 35https://doi.org/10.1186/s12894-020-00730-2Crossref Scopus (15) Google Scholar Robotic surgical technology democratized prostatectomy, but patients of low-volume surgeons have a significantly higher risk of biochemical recurrence after surgery, suggesting that the learning-curve associated with new technology is not to be ignored.3Vickers A.J. Bianco F.J. Serio A.M. et al.The surgical learning curve for prostate cancer control after radical prostatectomy.J Natl Cancer Inst. 2007; 99: 1171-1177https://doi.org/10.1093/jnci/djm060Crossref PubMed Scopus (346) Google Scholar Thus by nature of innovation, new technology will inevitably require re-training and re-learning, which may pose a transient risk to patients while surgeons “climb the curve”. Finally, there are systemic repercussions of new technologies, such as the carbon footprint of disposable urologic devices.4Davis N.F. McGrath S. Quinlan M. Jack G. Lawrentschuk N. Bolton D.M. Carbon Footprint in Flexible Ureteroscopy: A Comparative Study on the Environmental Impact of Reusable and Single-Use Ureteroscopes.J Endourol. 2018; 32: 214-217https://doi.org/10.1089/end.2018.0001Crossref PubMed Scopus (76) Google Scholar Patient outcomes, user interface, and systemic concerns aside, technology may pose a threat to the very heart of medical practice: the sacred relationship between physicians and patients. It’s well known that empathy and nonverbal communication with patients can significantly enhance patient experience. A qualitative, phenomenological study surveying cancer patients receiving intravenous chemotherapy found that gentle touch and asking permission before performing physical exams offered patients a greater sense of agency and a positive outlook on their care.5Leonard K.E. Kalman M. The Meaning of Touch to Patients Undergoing Chemotherapy.Oncol Nurs Forum. 2015; 42: 517-526https://doi.org/10.1188/15.ONF.517-526Crossref PubMed Scopus (12) Google Scholar In addition to clinical duties, use of technology can undermine patient empowerment. A single-institution survey-based study noted that intensive care unit patients viewed invasive technologies as a “necessary evil” requiring them to endure these interventions by “being invisible” to providers.6Stayt L.C. Seers K. Tutton E. Patients’ experiences of technology and care in adult intensive care.J Adv Nurs. 2015; 71: 2051-2061https://doi.org/10.1111/jan.12664Crossref PubMed Scopus (29) Google Scholar Furthermore, there is some evidence that employment of technology for specific urologic use-cases may not yield favorable results. Amongst post-prostatectomy men enrolling in either online or in-person guided group discussions for psychosocial aftercare, online participation was paradoxically associated with a harder time coping with cancer, adverse physical components of depression, and worse quality of life scores.7Lange L. Fink J. Bleich C. Graefen M. Schulz H. Effectiveness, acceptance and satisfaction of guided chat groups in psychosocial aftercare for outpatients with prostate cancer after prostatectomy.Internet Interv. 2017; 9: 57-64https://doi.org/10.1016/j.invent.2017.06.001Crossref PubMed Scopus (11) Google Scholar Technological innovations may pose potential harm to providers as well. Medical technology has greatly increased the number of tools available for clinicians to aid in evaluation, diagnosis, and management, all in hopes of enhancing patient care and clinical efficiency. However, despite the promise of new modalities to benefit patients and assist in clinical practice, recent data estimate burnout rates among urologists can reach up to 79%.10Shoureshi P. Guerre M. Seideman C.A. et al.Addressing Burnout in Urology: A Qualitative Assessment of Interventions.Urol Pract. 2022; 9: 101-107https://doi.org/10.1097/UPJ.0000000000000282Crossref Scopus (2) Google Scholar While it is well understood that the etiology of burnout is multifactorial, EHR and other supposed technological advancements are known contributors to burnout.11Kroth P.J. Morioka-Douglas N. Veres S. et al.Association of Electronic Health Record Design and Use Factors With Clinician Stress and Burnout.JAMA Netw Open. 2019; 2e199609https://doi.org/10.1001/jamanetworkopen.2019.9609Crossref PubMed Scopus (158) Google Scholar The call for technologic stewardship and safeguarding humanistic interactions and provider well-being comes at a critical time. The last few years have brought incredible strides in the clinical uses of artificial intelligence, from autonomous grading of pediatric hydronephrosis to histopathologic interpretation of prostate cancer.12Da Silva L.M. Pereira E.M. Salles P.G. et al.Independent real-world application of a clinical-grade automated prostate cancer detection system.J Pathol. 2021; 254: 147-158https://doi.org/10.1002/path.5662Crossref PubMed Scopus (33) Google Scholar More recently the rise of large language models, such as ChatGPT, has shown potential to revolutionize clinical workflows through automation of language based-tasks, including patient documentation. But as physicians, we have a duty to protect our patients and colleagues during this new age of devices, algorithms, and tools, all of which hold the potential to further erode the humanistic and interpersonal core of our relationships. To the best of our knowledge, there is currently no regulatory group, committee, or consortium affiliated with major urologic associations that focus on the humanistic impact of new technology. However, several general medical device regulatory groups, including the Medical Technologies Advisory Committee of the National Institute for Health and Care Excellence and the Committee on Emerging Science, Technology, and Innovation of the National Academy of Medicine, aim to develop a multidisciplinary team for monitoring the ethical, social, and societal implications of medical devices. Still, there is a pressing need to scale these groups to urology as to provide readily translatable and efficient feedback with individuals who routinely use emerging technology to care for their patients. The responsibility of technologic stewardship cannot solely be at the level of national, multidisciplinary governing bodies and councils. Providers, including trainees, should critically evaluate the technology used in their daily practice. The tools used to do so could be shared through dedicated continuing medical education sessions or grand round lecture series on potential unintended adverse effects of technology on patient relationships. Patients too are important stakeholders in technology stewardship and need to be rigorously surveyed on how technology has influenced their experience of care. Dedicated prospective research studies can help identify areas and opportunities to improve existing device interfaces and accessibility. From an evidence-based medicine perspective, critical appraisal frameworks for evaluating studies incorporating new technology, such as STREAM-URO, should be appended to include evaluation of interpersonal communication ramifications, feasibility of integration, and patient-level concerns.13Kwong J.C.C. McLoughlin L.C. Haider M. et al.Standardized Reporting of Machine Learning Applications in Urology: The STREAM-URO Framework.Eur Urol Focus. 2021; 7: 672-682https://doi.org/10.1016/j.euf.2021.07.004Abstract Full Text Full Text PDF Scopus (15) Google Scholar Finally, incentives need to be created for industry and inventors to prioritize patient care and provider well-being in addition to profitability. This may include aftermarket systems where companies are held liable and accountable for unanticipated problems created by their technologies and are actively involved with finding solutions to fix them. Preservation of the historic innovative nature of urology is vital to the growth of our specialty and care of our patients. But technological integration at the expense of humanism may create a care model where efficiency and financial capital replace sympathy and human capital. The path toward urologic technologic stewardship requires a multimodal approach with regulatory groups, industry leaders, trainees, physicians, patients, and stakeholders. Future research efforts are critical to illustrate the severity and setting of adverse technology effects in urology to systematically direct targeted interventions. None