To the Editor: The concept of telesurgery was first realized in 2001 with the groundbreaking “Lindbergh Operation”, during which a surgeon in New York successfully performed a cholecystectomy on a patient in Strasbourg, France.1 This landmark achievement demonstrated the potential of integrating robotics with telecommunication technologies to overcome geographical barriers in healthcare delivery. Since then, telesurgery has been increasingly explored and applied across various medical disciplines, particularly in urology.2 Despite these advances, the widespread adoption of remote robotic surgery has faced persistent challenges. Key obstacles include transmission latency, limited bandwidth, and the need for highly stable communication networks. However, recent technological breakthroughs have renewed interest in this field. The integration of fifth generation (5G) technology, artificial intelligence, and advanced robotics has helped address many of these barriers, enabling real-time data transmission with minimal latency and improved reliability. Previous studies have demonstrated the safety and feasibility of telesurgery over distances of approximately 3000 km.3 These achievements highlight the potential of telesurgery to bridge disparities in medical resource distribution, particularly in remote and underserved areas. However, the literature remains limited regarding whether telesurgery can be safely and effectively extended beyond 3000 km. In this study, we conducted a clinical trial to evaluate the safety and efficacy of telesurgery over a distance of approximately 5000 km (5038 km). This study aimed to push the boundaries of telesurgical applications and expand access to high-quality surgical care for patients in geographically isolated regions. This study was approved by the institutional ethics committees of Sun Yat-sen Memorial Hospital (No. SYSKY-2024-220-01) and Kashgar First People’s Hospital (2024-09), and was registered at ChiCTR.org (No. ChiCTR2400088750). All participants provided written informed consent after a detailed discussion with the operating surgeon regarding the risks and benefits of the procedure. Inclusion criteria: (1) age of 18–80 years, irrespective of gender; (2) body mass index between 18 and 30 kg/m2; (3) indications for urological surgery; (4) willingness to cooperate and complete research follow-up and related examinations; and (5) voluntary provision of informed consent. Exclusion criteria: (1) severe cardiovascular or circulatory diseases precluding surgery; (2) pregnancy or lactation; (3) history of epilepsy or psychiatric illness; (4) severe allergies or suspected/diagnosed alcohol or drug dependence; (5) inability to understand the study requirements or complete follow-up; and (6) determination by the research team that participation was unsuitable. A dedicated telesurgery team was assembled, consisting of an administrator, a remote surgeon, a local surgeon, two surgical assistants, three nurses, two anesthesiologists, and two engineers from Shenzhen Edge Medical Co., Ltd (China). The remote surgeon operated the robotic console at the Sun Yat-sen Memorial Hospital, whereas the patient underwent surgery at Kashgar First People’s Hospital. A local surgeon remained in the operating room to ensure patient safety and provide immediate assistance if necessary. A backup console was available locally, enabling seamless transition of control in case of complications. All participating surgeons had more than 15 years of robotic surgery experience. The administrator oversaw network connectivity and team communication, resolving unexpected issues and determining whether control should be transferred locally. Two robotic engineers (one stationed remotely and one locally) managed technical malfunctions. Port placement and operative steps followed standard protocols, consistent with conventional robot-assisted surgery. Telesurgeries were performed using the Edge MP1000 surgical system (Shenzhen, Guangdong, China), consisting of two consoles: (1) a remote surgeon console and (2) a local bedside console. Surgical signals were transmitted through a commercial 5G network (100 Mb/s, China Union Company, Guangzhou, Guangdong, China) and a dedicated data line. All transmissions were encrypted, and a next-generation firewall protected against cyberattacks. Engineers verified network speed and stability 1 h before each operation. Real-time monitoring was conducted, with automatic switching to a backup line if latency occurred. Control transfer from the remote to the local console took less than 1 s. To minimize video latency, the system used a network jitter-smoothing algorithm, maintaining jitter within 4 ms. The remote and local teams communicated through a telesurgery demonstration platform with a split-screen interface showing the endoscopic view, operating room views from both hospitals, and a network monitoring panel. This allowed the remote surgeon to simultaneously monitor the surgical field and the patient’s vital signs. Primary outcome: Successful completion of telesurgery without conversion to the local console. Secondary outcomes:Clinical: Operative duration, anesthesia duration, blood loss, early complications (within 14 days), and late complications (within 3 months), classified according to the Clavien–Dindo system.4Technical: Network latency metrics, including round-trip time (RTT), video encoding/decoding latency, and frame loss. RTT was defined as the time for a data packet to travel from the source to the destination and back. Continuous variables were reported as medians with interquartile ranges and categorical variables as frequencies and percentages. Six patients (four men and two women; aged 48–79 years) were enrolled. The telesurgery success rate was 100%, with all procedures completed without conversion to the local console. Procedures included: robotic-assisted partial nephrectomy for kidney cancer (tumor, node, and metastasis TNM stages T1bN0M0 and T3aN0M0); robotic-assisted radical nephrectomy for a nonfunctional kidney due to ureteric stricture; robotic-assisted ureteral reimplantation for ureteric stricture; and robotic-assisted radical prostatectomy with pelvic lymph node dissection for prostate cancer (TNM stage T3bN1M0). Operative times and blood loss varied according to procedure complexity Supplementary Table 1, https://links.lww.com/CM9/C810. All patients recovered without major complications and were discharged within one week. By discharge, all had Clavien–Dindo grade I outcomes. No readmissions or adverse events occurred during follow-up. At three months, all patients showed satisfactory recovery, confirming the safety and feasibility of telesurgery. At the latest review (>6 months postoperatively), no major complications, relapse, or progression were observed. Network performance: The mean RTT across >10,000 km was 77.38 ms (standard error = 0.636 ms), well below the 100–300 ms latency threshold that compromises synchrony between surgeon and patient. Video encoding/decoding latency averaged approximately 20 ms Figure 1. No frame loss occurred, and all remote console commands were accurately executed by the robotic arms. Surgeons reported no perceptible video delay. Detailed per-patient latency data are provided in Supplementary Table 2, https://links.lww.com/CM9/C811.Figure 1: Safety of telerobotic surgery in patients with indications for urological surgery. (A) The operation scene photos of Guangzhou and Xinjiang; (B) Frame loss of six cases enrolled in this study; (C) Video delay of the six cases enrolled in this study. ms: Millisecond.Since the pioneering Lindbergh Operation in 2001, substantial progress has been made in refining telesurgery systems. Key advancements include reducing system latency to 120 ms and optimizing image encoding and decoding algorithms to achieve delays as low as 17 ms, thereby ensuring real-time visual feedback. Additional innovations such as tremor-mitigation algorithms, forward error correction, and automatic repeat-request mechanisms have further enhanced the stability and reliability of data transmission. Moreover, the system’s adaptability to different network conditions—whether broadband, 5G, or Wi-Fi—allows for seamless operation even in challenging environments. Collectively, these technological improvements have addressed many historical barriers to telesurgery and paved the way for its broader adoption. Our study focused on urological procedures, including partial and radical nephrectomy, ureteral reimplantation, and radical prostatectomy, which represent the majority of urological surgeries. Robotic-assisted radical cystectomy was excluded due to the complexity of urinary diversion, which often requires open surgery and carries a higher risk of complications if the assisting team lacks sufficient expertise. Operative time, clinical outcomes, and recovery profiles in our telesurgeries were comparable to those of conventional robotic surgeries. For example, in partial nephrectomy cases, renal artery clamping times were kept within safe limits (12 min in Case 1 and 20 min in Case 3), with no significant postoperative rise in serum creatinine levels. Similarly, the high-risk patient with prostate cancer (Case 6, TNM stage T3bN1M0) achieved negative surgical margins and had no anastomotic leakage, as confirmed by cystography 1 week postoperatively. Intraoperative blood loss was minimal across all cases, further supporting the safety and precision of telesurgery. Despite these promising results, several challenges remain before telesurgery can be widely adopted in clinical practice. First, standardized laws and regulations are needed to govern telesurgery, ensuring patient’s safety and legal accountability. Second, specialized training programs must be developed to prepare local surgical teams to manage unexpected complications, particularly in the case of network failures. Effective communication and collaboration between remote surgeons and local assistants are also critical, as surgical techniques and preferences vary among individuals. Third, the high costs associated with telesurgery—including robotic systems, network infrastructure, and specialized personnel—must be reduced to make this technology accessible to low-income populations, who may benefit the most from remote surgical care. Finally, the expansion of high-speed network coverage to rural and underserved regions is essential for large-scale implementation. This study has several limitations. First, all patients enrolled were in good general health aside from their urological conditions. The applicability of telesurgery to patients with significant comorbidities or poor baseline health remains to be evaluated. Second, the small sample size (six patients) limits the generalizability of our findings. Larger, multicenter studies are needed to validate the safety and efficacy of telesurgery over extended distances. In conclusion, our study demonstrates the feasibility and safety of telesurgery in urology at distances exceeding 5000 km, with a 100% success rate and no significant complications. All patients recovered quickly and were discharged within one week. These findings highlight the potential of telesurgery to transform surgical care, particularly for remote and underserved populations. However, coordinated efforts are required to establish standardized protocols, expand training, reduce costs, and enhance network infrastructure to fully realize the promise of telesurgery in the near future. Funding This study was supported by the National Natural Science Foundation of China (No. 82573724), Guangdong Provincial Clinical Research Center for Urological Diseases (No. 2020B1111170006), and the Science and Technology Planning Project of Guangdong Province (No. 2023B1212060013). Conflicts of interest None.
Dong et al. (Fri,) studied this question.