EUROPEAN UROLOGY xxx (xxxx) xxx
available at www.sciencedirect.com
journal homepage: www.europeanurology.com
Platinum Opinion
The Humanitarian Impact of Telesurgery and Remote Surgery in
Global Medicine
Vipul Patel a,b, Jacques Marescaux c, Marcio Covas Moschovas a,b,*
a
AdventHealth Global Robotics Institute, Celebration, FL, USA; b University of Central Florida, Orlando, FL, USA; c IRCAD Research Institute Against Digestive
Cancer, Strasbourg, France
The evolution of advanced telecommunications and surgical
robots has led to a transformative era for global health care
equity. Since the landmark transatlantic surgery in 2001
between New York (USA) and Strasbourg (France), several
improvements have been described in the telesurgery field
[1]. The incorporation of 5G connectivity in recent new
models for robotic surgical platforms has opened opportu-
nities for remote surgery to level the current surgical
demand worldwide [2]. It is estimated that 300 million pro-
cedures are currently performed annually around the world,
but another 143 million are required to adequately address
population needs [3]. Lack of or a delay in appropriate sur-
gical treatment has impacts on patient mortality, disability,
and quality of life, especially for neurovascular, cardiac, and
oncological diseases. Against this background, telesurgery
has significant humanitarian implications, such as better
access to surgical education and the ability to deliver
advanced surgical care to remote and underserved areas
of the world. Our recent experiences in Asia highlight the
potential of telesurgery and brought to the forefront the
complexity of organizing such a revolutionary and evolu-
tionary program.
Telesurgery allows skilled surgeons to perform proce-
dures remotely, effectively bridging geographical gaps that
often limit access to specialized medical care [4]. This is par-
ticularly crucial for populations in rural or underserved
areas, where the scarcity of medical resources poses signif-
icant challenges, especially in developing countries. Tele-
surgery also has the potential to revolutionize health care
economics, sparing patients, their families, and health care
workers from unnecessary travel and associated costs. It is
estimated that in the USA, total yearly costs associated with
failure of care delivery, including quality of care, such as
* Correspondent author. AdventHealth Global Robotics Institute, Celebration, FL, USA.
E-mail address: marcio.doc@hotmail.com (M. Covas Moschovas).
https://doi.org/10.1016/j.eururo.2024.04.029
0302-2838/Ó 2024 European Association of Urology. Published by Elsevier B.V. All rights reserved.
Please cite this article as: V. Patel, J. Marescaux and M. Covas Moschovas, The Humanitarian Impact of Telesurgery and Remote Surgery in Global
Medicine, Eur Urol (2024), https://doi.org/10.1016/j.eururo.2024.04.029
medical errors, varied between $102.4 billion and USD
$165.7 billion [5]. In this context, telesurgery could mini-
mize potential mistakes while improving surgical teaching
methods via telementoring, whereby an expert supervises
a novice surgeon or a complex case remotely.
Telesurgery can facilitate swift and timely interventions
in emergencies for which time is of the essence. Expert sur-
geons can remotely guide local medical teams or even per-
form surgeries, significantly reducing the risk of
complications. The impact on cardiovascular emergencies,
such as myocardial infarctions and cerebrovascular events,
is particularly significant. It is estimated that approximately
one-fifth of individuals who experience a stroke suffer from
after-effects such as musculoskeletal and sensory disabili-
ties and medical problems [6]. The ability of telesurgery to
provide correct treatment at the right time has the potential
to save thousands of lives and minimize the mortality and
disability associated with these critical events. Telesurgery
is a natural progression of robotic surgery; it brings the clin-
ical benefits of minimally invasive procedures to more
patients via a long-distance connection. We believe that
the benefits of telesurgery are real in terms of expanding
the availability of robotic surgery to more patients and
addressing emergencies and complex cases at the appropri-
ate time.
During natural disasters or humanitarian crises, when
access to medical expertise is severely limited, telesurgery
could represent a vital lifeline, offering immediate support,
ensuring patients receive essential health care during
recovery, and significantly aiding relief efforts. However,
substantial technological, economic, social, cybersecurity,
licensing, legal, and policy barriers still restrict the
implementation of remote surgery, whether locally or
2 EUROPEAN UROLOGY XXX (XXXX) XXX
across borders [4]. We believe that a wide range of stake-
holders, including patients, surgeons, telecom companies,
hospitals, insurers, licensing agencies, and government bod-
ies, must collaborate to overcome these challenges. While
the road ahead may be long and require unprecedented
cooperation, especially given the increasing disparities in
health care access, the humanitarian benefits of telesurgery
offer a promising pathway towards greater equality, and
can drive collaboration and perseverance out of necessity.
There are still some open questions to address regarding
when and how we should perform remote surgery and
which areas would benefit from this practice. While certain
Asian groups have had success in oncological procedures
with promising short-term outcomes, Telesurgery is still
in its initial phase and requires more studies and invest-
ment. Therefore, we have been developing an international
telesurgery program and a consensus among robotic sur-
geons, engineers, telecommunications technicians, and
experts from referral centers with the potential to address
the current limitations and factors inhibiting expansion of
telesurgery worldwide. The first question concerns the
latency and distance limitations of current surgical and tele-
com technologies, and the fundamental physics of the speed
of light transmission through fibers and satellite networks.
These limitations still need to be fully overcome as technol-
ogy and understanding evolve, but recent improvements in
5G and fiber-optic networks allow faster connections with
high stability over long distances [2]. However, some coun-
tries and regions still need an appropriate 5G and fiber
infrastructure.
We have had solid experience in Asia and witnessed the
benefits of telesurgery in uro-oncology. In China, we
observed a wide range of robotic surgical platforms with
the potential for telesurgery communication. We tested
three robotic surgery platforms (Edge Medical, Kang Duo,
and Microport Toumai) in human clinical trials over signif-
icant distances. We also tested these systems on porcine
models at distances of >2000 km, with minimal latency, jit-
ter, and drops on a stable 5G wireless network. Moreover,
we demonstrated a robotic radical prostatectomy at a dis-
tance of 1500 km between the surgeon (V.P.) in Beijing,
China, and the surgical assistant (M.C.M.) in Harbin, China.
The procedure was performed flawlessly in 60 min, with
real-time latency on a fiber-optic network of 30–60 ms
and no loss of frames, drops in signal, or miscoordination
during the case. These experiences highlight the technolog-
ical evolution of telesurgery in recent years and the poten-
tial for expansion of minimally invasive surgery.
Another significant advantage of telesurgery is its ability
to connect multiple consoles simultaneously to perform a
single procedure. This technology is especially beneficial
for patients with complex medical conditions that require
a multispecialty approach. Experts from different areas
can connect from different locations and collaborate to per-
form surgeries on the same patient in real time. We could
remotely connect from Beijing to Hunan and Haikou, China,
over a distance of 2500 km using the Kang Duo robot. This
Please cite this article as: V. Patel, J. Marescaux and M. Covas Moschovas, The Humanitarian Impact of Telesurgery and Remote Surgery in Global
Medicine, Eur Urol (2024), https://doi.org/10.1016/j.eururo.2024.04.029
was the first demonstration of a triple console connection
using 5G transmission and fiber optic cables. This was
unique because the surgeon (V.P.) was in Beijing, the surgi-
cal team with the assistant (M.C.M.) was with the patient in
Hainan, China, and the surgeon being proctored was at a
separate location in Hunan, China. A robotic radical prosta-
tectomy was performed by both experts and the proctored
trainee surgeon. Audiovisual communication between the
surgical teams was seamless throughout, and the procedure
had no complications.
Since the groundbreaking Lindberg operation, connec-
tion and feasibility issues for surgeries between different
countries reduced traction, with connectivity the major lim-
itation [1]. To test the concept of long-distance telesurgery
connectivity between different countries, we set up a
Microport Toumai robotic console in Orlando, Florida, and
established connectivity with the Arab Health conference
in Dubai, UAE, facing challenges with telecom complexity
and significant delays. Despite a round trip distance of
26 000 km and latency of 480 ms, we demonstrated proof
of concept with perceptible delays. We then improved the
network between Orlando and Shanghai, reducing latency
to 240 ms after several tests. With this enhanced setup,
we successfully performed multiple nephrectomies in por-
cine models across the Pacific Ocean, managing the percep-
tible latency via slower movements.
Telesurgery holds significant humanitarian promise in
terms of addressing health care challenges, fostering collab-
oration, and ensuring that advanced surgical care is accessi-
ble to all, irrespective of geographical constraints. It has the
potential to expand the minimally invasive benefits of
robotic surgery to underserved areas. There are still some
challenges regarding wide-scale implementation and opti-
mal applications in different countries. However, telesur-
gery has the potential to minimize health disparities by
ensuring that individuals in remote or economically disad-
vantaged areas can access the same quality of surgical care
as those in more urban or affluent regions. This would help
in promoting equity and optimal delivery of health care.
Conflicts of interest: The authors have nothing to disclose.
References
[1] Marescaux J, Leroy J, Rubino F, et al. Transcontinental robot-assisted
remote telesurgery: feasibility and potential applications. Ann Surg
2002;235:487–92.
[2] Zheng J, Wang Y, Zhang J, et al. 5G ultra-remote robot-assisted
laparoscopic surgery in China. Surg Endosc 2020;34:5172–80.
[3] Meara JG, Leather AJM, Hagander L, et al. Global Surgery 2030:
evidence and solutions for achieving health, welfare, and economic
development. Int J Obstet Anesth 2016;25:75–8.
[4] Patel V, Saikali S, Moschovas MC, et al. Technical and ethical
considerations in telesurgery. J Robot Surg 2024;18:40.
[5] Shrank WH, Rogstad TL, Parekh N. Waste in the US health care
system. JAMA 2019;322:1501–9.
[6] Ju YW, Lee JS, Choi YA, Kim YH. Causes and trends of disabilities in
community-dwelling stroke survivors: a population-based study.
Brain Neurorehabil 2022;15:e5.