Expert discusses the potential for telesurgery in urology

In this interview, Vipul Patel, MD, discusses the use of telesurgery, specifically highlighting the technical and ethical considerations,¹ as well as the implications and future potential in urology. Patel is the executive director for the Society of Robotic Surgery, the medical director of the Global Robotics Institute at AdventHealth, and the Director of Urologic Oncology at AdventHealth Cancer Institute in Florida.

Vipul Patel, MD

What is telesurgery?

Telesurgery is a futuristic concept that is coming to the forefront now. It's where the surgeon and the patient are not in the same location; they're not connected by direct cable. With the current robotic system, the surgeon and the patient can be in different rooms, but they're still connected by the cable from the console to the robots, whereas in telesurgery, using either Wi-Fi or direct fiber or underground cable, the patient is truly distant. That's what telesurgery is; surgery at a remote location done telerobotically.

For our institution, we're not using robotic surgery yet. I don't think anybody in the United States or Europe or even Latin America is. This is being pushed forward by Asia–India, China, Japan–where they're not using it routinely, but they are using it in order to start the trials of performing robotic surgery and testing the capabilities and the distance. The issue with telesurgery is as the Wi-Fi connection is worse, the latency increases, or as a distance increases, the latency increases. Obviously, the surgeon’s movements have to be in sync with the robot’s movements. That's where the issue of latency comes in.

What are some of the technical challenges and considerations for implementing and utilizing telesurgery?

What makes telesurgery quite complicated is nobody really owns it. It has so many implications. It has the ethical implications of patient care: Who owns the patient? Who is responsible for complications? You're sometimes not seeing the patient at all personally. Then you have the medicolegal issues in terms of operating across borders, across countries. That hasn't been resolved. Right now, I could not operate from Florida to Texas. Whereas in telesurgery, that's kind of the point. You want to operate a distance. There’s also the issue of robotic compatibility. Not all robots are compatible with telesurgery, and most are not. I think that has to change.

The big issue that we've dealt with recently is latency, the issue of the signal delay. The surgeon has the ability to move the robot, and the optimal latency between what the surgeon does and the robot does is probably less than 100 milliseconds. But that's very difficult with even modern 5G. So, often the latency of the signal, which is when the surgeon moves to when the robot moves, is often over 200 milliseconds. That can be difficult, because obviously, things can change in the patient—the patient's breathing, the arteries of beating—and if there's too much latency, your movement happens in an area that you weren't intending it to. Improving the issue of signal latency is very important for telesurgery.

Could you expand on the ethical challenges and considerations for telesurgery?

It's very interesting, because all of a sudden, with telesurgery, you have 2 surgical teams: you have the surgeon who is distant and who is performing or mentoring the procedure, and then you have the surgeon or the surgical team next to the patient. Currently, you have a surgeon at both locations. In the future, you may only have 1 surgeon at the distant location. The ethical issues are about who is really responsible for the patient. Whose decision is final? Because obviously, there might be challenges and discussion about techniques and outcomes. The ethical dilemmas of telesurgery are very important. There's also the human aspect; you don't get to touch these patients or see them personally. That can obviously interfere with the patient-surgeon interaction. I think that part would be lost, where the patient would actually never meet the surgeon personally. But I think that's probably how it's going to go in the future.

The advantage of having telesurgery is the humanitarian benefits. It's a great way to get health care equity. Right now, high-end surgery is really in the big cities, and probably for the higher income people, whereas those who are more distant and less affluent are not getting the best care surgically. With telesurgery, someone from a large institution at a major metropolitan center can connect to the outskirts, to the smaller towns, to smaller countries, and actually help them. I think where that helps is, if a surgeon is in a distant country or a distant state, and they're having trouble and getting into a complication, wouldn't it be nice to be able to call an expert and say, "Hey, will you help me out and get me out of this problem?", which the expert most likely can. So, it has huge humanitarian benefits in that the patients are going to get better care, less complications, and more experienced surgeons. It concentrates care and improves care on a global level.

What do the early outcomes with telesurgery look like so far?

There are very few data out there. There are people who have done telesurgery, and everything that's in the literature is positive. We haven't obviously seen the failures; there will be. There are huge issues in terms of the signal. We have a cell phone, and when we're driving through certain areas, we drop a signal. Or we don't have 1 or 2 bars, sometimes. Imagine if that's happening during surgery. There’s also the issue of cybersecurity: what happens if the signal gets hacked? Cybersecurity is paramount in anything that is telesurgically related.

Most of the data are coming out of China at this point. They're using robotics, and the reason they're using it, when you ask them, is for their people. They don't have enough surgeons to take care of such a vast country. So, they're deciding to use the telecom network and robots in distant regions in order to try and provide good care to their distant population.

What are the implications of performing surgery via this method?

It's a long road. I think the rest of the world may do it before the US. We have a lot more regulations and rules, even across cities, never mind across states or across country borders. It's going to take us some time. What is interesting is we had our Congress for telesurgery about a month ago. We had 13 sitting presidents and 40 heads of department who attended from all different specialties, and they all got it. They all said this will be beneficial for us as surgeons and for our patients. The challenge is now getting medical societies and telecom regulators all on the same page, because nobody owns it. Actually, everybody has to own it. To get all these different people on 1 level and 1 agreement is very difficult. I think it's going to take us some time.

What does the future look like for telesurgery in urology?

I think telesurgery will happen. I think it has to happen. In urology, we're very deficient in the amount of doctors we have. More urologists are retiring and less are graduating. There's a big deficit, and every urologist sees that there's that deficit. I think the only way to get around that deficit is either going to be a full change of how we train our people and how we manage our practices, or we look at telesurgery, where there are certain centers of excellence that do a lot of surgery. It's going to be more efficient, and it's going to have less complications, because the high-end surgeons will be doing this. The implications for urology, and every specialty, are immense. It does improve care, and it helps the patient. I think this is what it will be, it just may take some time.

Reference

1. Patel V, Saikali S, Moschovas, et al. Technical and ethical considerations in telesurgery. J Robot Surg. 2024;18(1):40. doi:10.1007/s11701-023-01797-3