Robotic pyeloplasty using internet protocol and satellite network-based telesurgery

Technical and ethical considerations in telesurgery

Telesurgery, a cutting-edge field at the intersection of medicine and technology, holds immense promise for enhancing surgical capabilities, extending medical care, and improving patient outcomes. In this scenario, this article explores the landscape of technical and ethical considerations that highlight the advancement and adoption of telesurgery. Network considerations are crucial for ensuring seamless and low-latency communication between remote surgeons and robotic systems, while technical challenges encompass system reliability, latency reduction, and the integration of emerging technologies like artificial intelligence and 5G networks. Therefore, this article also explores the critical role of network infrastructure, highlighting the necessity for low-latency, high-bandwidth, secure and private connections to ensure patient safety and surgical precision. Moreover, ethical considerations in telesurgery include patient consent, data security, and the potential for remote surgical interventions to distance surgeons from their patients. Legal and regulatory frameworks require refinement to accommodate the unique aspects of telesurgery, including liability, licensure, and reimbursement. Our article presents a comprehensive analysis of the current state of telesurgery technology and its potential while critically examining the challenges that must be navigated for its widespread adoption.

Surgical tele-mentoring using a robotic platform: initial experience in a military institution

BACKGROUND

Surgical tele-mentoring leverages technology by projecting surgical expertise to improve access to care and patient outcomes. We postulate that tele-mentoring will improve surgeon satisfaction, procedural competence, the timeliness of operative intervention, surgical procedure efficiency, and key intra-operative decision-making. As a first step, we performed a pilot study utilizing a proof-of-concept tele-mentoring process during robotic-assisted surgery to determine the effects on the perceptions of all members of the surgical team.

METHODS

An IRB-approved prospective feasibility study to determine the safety and efficacy of remote surgical consultation to local surgeons utilizing robotic surgery technology in the fields of general, urology, gynecology and thoracic surgery was performed. Surgical teams were provided a pre-operative face-to-face orientation. During the operation, the mentoring surgeon was located at the same institution in a separate tele-mentoring room. An evaluation was completed pre- and post-operatively by the operative team members and mentor.

RESULTS

Fifteen operative cases were enrolled including seven general surgery, four urology, one gynecology and three thoracic surgery operations. Surveys were collected from 67 paired survey respondents and 15 non-paired mentor respondents. Participation in the operation had a positive effect on participant responses regarding all questions surveyed (p < 0.05) indicating value to tele-mentoring integration. Connectivity remained uninterrupted with clear delivery of audio and visual components and no perceived latency. Participant perception of leadership/administrative support was varied.

CONCLUSIONS

Surgical tele-mentoring is safe and efficacious in providing remote surgical consultation to local surgeons utilizing robotic surgery technology in a military institution. Operative teams overwhelmingly perceived this capability as beneficial with reliable audio-visual connectivity demonstrated between the main operative room and the Virtual Medical Center. Further study is needed to develop surgical tele-mentoring to improve patient care without geographic limitations during times of peace, war and pandemic outbreaks.

Telemedicine and Telementoring in Urology: A Glimpse of the Past and a Leap Into the Future

Telemedicine is the process of utilizing telecommunications and digital relay to perform, teach, or share medical knowledge. The digital era eased the incorporation of telemedicine to different areas of medical care, including the surgical care of Urologic patient mainly through telementoring, telesurgery, and telerobotics. Over the years, Telemedicine has played an integral part in a physicians' ability to provide high quality medical care to remote patients, as well as serve as an educational tool for trainee physicians, in the form of telementoring. During the COVID-19 pandemic, telemedicine has played a vital role in combatting the health implications of confinements. Challenges of telemedicine implementation include cost, ethical considerations, security, bandwidth, latency, legal, and licensure difficulties. Nevertheless, the future of telemedicine, specifically telementoring, promises several improvements and innovative advancements that aim to bridge the gap in technological divides of urologic care. In this review, we build on what is already known about telemedicine focusing specifically on aspects related to telementoring, telestration, and telesurgery. Furthermore, we discuss its historical role in healthcare with a special emphasis on current and future use in urology.

5G Use in Healthcare: The Future is Present

Background:

Most healthcare providers are unaware of the extraordinary opportunities for implementation in healthcare which can be enabled by 5G wireless networks. 5G created enormous opportunities for a myriad of new technologies, resulting in an integrated through 5G ‘ecosystem’. Although the new opportunities in healthcare are immense, medicine is slow to change, as manifest by the paucity of new, innovative applications based upon this ecosystem. Thus, emerges the need to “avoid technology surprise” - both laparoscopic and robotic assisted minimally invasive surgery were delayed for years because the surgical community was either unaware or unaccepting of a new technology.

Database:

PubMed (Medline) and Scopus (Elsevier) databases were searched and all published studies regarding clinical applications of 5G were retrieved. From a total of 40 articles, 13 were finally included in our review.

Discussion:

The important transformational properties of 5G communications and other innovative technologies are described and compared to healthcare needs, looking for opportunities, limitations, and challenges to implementation of 5G and the ecosystem it has spawned. Furthermore, the needs in the clinical applications, education and research in medicine and surgery, in addition to the administrative infrastructure are addressed. Additionally, we explore the nontechnical challenges, that either support or oppose this new healthcare renovation. Based upon proven advantages of these innovative technologies, current scientific evidence is analyzed for future trends for the transformation of healthcare. By providing awareness of these opportunities and their advantages for patients, it will be possible to decrease the prolonged timeframe for acceptance and implementation for patients.

5G mobile communication applications for surgery: An overview of the latest literature

Fifth-generation wireless network, 5G, is expected to bring surgery to a next level. Remote surgery and telementoring could be enabled and be brought into routine medical care due to 5G characteristics, such as extreme high bandwidth, ultra-short latency, multiconnectivity, high mobility, high availability, and high reliability. This work explores the benefits, applications and demands of 5G for surgery. Therefore, the development of previous surgical procedures from using older networks to 5G is outlined. The current state of 5G in surgical research studies is discussed, as well as future aspects and requirements of 5G in surgery are presented.

5G ultra-remote robot-assisted laparoscopic surgery in China

BACKGROUND

5G communication technology has been applied to several fields in telemedicine, but its effectiveness, safety, and stability in remote laparoscopic telesurgery have not been established. Here, we conducted four ultra-remote laparoscopic surgeries on a swine model under the 5G network. The aim of the study was to investigate the effectiveness, safety, and stability of the 5G network in remote laparoscopic telesurgery.

METHODS

Four ultra-remote laparoscopic surgeries (network communication distance of nearly 3000 km), including left nephrectomy, partial hepatectomy, cholecystectomy, and cystectomy, were performed on a swine model with a 5G wireless network connection using a domestically produced "MicroHand" surgical robot. The average network delay, operative time, blood loss, and intraoperative complications were recorded.

RESULTS

Four laparoscopic telesurgeries were safely performed through a 5G network, with an average network delay of 264 ms (including a mean round-trip transporting delay of 114 ms and a 1.20% data packet loss ratio). The total operation time was 2 h. The total blood loss was 25 ml, and no complications occurred during the procedures.

CONCLUSIONS

Ultra-remote laparoscopic surgery can be performed safely and smoothly with 5G wireless network connection using domestically produced equipment. More importantly, our model can provide insights for promoting the future development of telesurgery, especially in areas where Internet cables are difficult to lay or cannot be laid.

Is remote live urologic surgery a reality? Evidences from a systematic review of the literature

INTRODUCTION AND OBJECTIVES

The possibility of performing remote-surgery has been the goal to achieve, since the early development of the first surgical robotic platforms. This systematic review aims to analyse the state of the art in the field and to provide an overview of the possible growth of this technology.

METHODS

All English language publications on Telementoring and Telesurgery for minimally invasive urologic procedures were evaluated. We followed the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) statement to evaluate PubMed^®, Scopus^®, and Web of Science™ databases (up to June 2019).

RESULTS

Our electronic search identified a total of 124 papers in PubMed, Scopus, and Web of Science. Of these, 81 publications were identified for detailed review, which yielded 22 included in the present systematic review. Our results showed that remote surgery has been under-utilised until today, mostly due to the lack of appropriate telecommunication technologies.

CONCLUSION

Remote live surgery is a growing technology that is catalyzing incremental interest. Despite not being yet reliable today on a regular basis in its most advanced applications, thanks to the advent of novel data-transmission technologies, telepresence might become a critical educational methodology, highly impacting the global healthcare system.

Improving access to urologists through an electronic consultation service

INTRODUCTION

Access to specialist services is limited by wait times and geographic availability. Champlain Building Access to Specialist Advice (BASE) has been implemented in our service region to facilitate access to specialists by primary care providers (PCPs). Through a secure web-based system, PCPs are able to send eConsults instead of requesting a formal in-office consultation.

METHODS

Urology eConsults completed through the Champlain BASE service from March 2013 to January 2015 were analyzed. Each consult was characterized in regard to the type of question asked by the referring physician and the clinical content of the referral. Using the mandatory close-out surveys, we analyzed rates of referral avoidance, physician satisfaction, and overall impact on patient care.

RESULTS

Of 190 eConsultations, 70% were completed in less than 10 minutes. The most common clinical questions related to the interpretation of imaging reports (16%) and tests to choose for investigating a condition (15%). The most common diagnoses were hematuria (13%) and renal mass (8%). In 35% of cases, referral to a urologist had originally been contemplated and was avoided. In 8% of cases, a PCP did not believe a consultation was initially needed, but a referral was ultimately initiated after the eConsultation.

CONCLUSIONS

Our study shows that although certain clinical presentations still require a formal in-person urological consultation, eConsultations can potentially reduce unnecessary clinic visits while identifying patients who may benefit from early urological consultation. Through both these mechanisms, we may improve timely access to urologists.

Telementoring and Telesurgery for Minimally Invasive Procedures

PURPOSE

Tremendous interest and need lie at the intersection of telemedicine and minimally invasive surgery. Robotics provides an ideal environment for surgical telementoring and telesurgery given its endoscopic optics and mechanized instrument movement. We review the present status, current challenges and future promise of telemedicine in endoscopic and minimally invasive surgery with a focus on urological applications.

MATERIALS AND METHODS

Two paired investigators screened PubMed^®, Scopus^® and Web of Science^® databases for all full text English language articles published between 1995 and 2016 using the key words "telemedicine," "minimally invasive surgical procedure," "robotic surgical procedure," "education" and "distance." We categorized and included studies of level of interaction between proctors and trainees. Research design, special equipment, telecommunication network bandwidth and research outcomes of each study were ascertained and analyzed.

RESULTS

Of 65 identified reports 38 peer-reviewed studies qualified for inclusion. Series were categorized into 4 advancing levels, ie verbal guidance, guidance with telestration, guidance with tele-assist and telesurgery. More advanced levels of surgical telementoring provide more effective and experiential teaching but are associated with increased telecommunication network bandwidth requirements and expenses. Concerns regarding patient safety and legal, financial, economic and ethical issues remain to be reconciled.

CONCLUSIONS

Telementoring and telesurgery in minimally invasive surgery are becoming more practical and cost effective in facilitating teaching of advanced surgical skills worldwide and delivery of surgical care to underserved areas, yet many challenges remain. Maturity of these modalities depends on financial incentives, favorable legislation and collaboration with cybersecurity experts to ensure safety and cost-effectiveness.

Telemedicine in Urology: State of the Art

Whereas telemedicine is recognized as one of the fastest-growing components of the healthcare system, the status of telemedicine use in urology is largely unknown. In this narrative review, we detail studies that investigate the use of televisits and teleconsultations for urologic conditions. Moreover, we discuss current regulatory and reimbursement policies. Finally, we discuss the significant barriers to widespread dissemination and implementation of telemedicine and reasons why the field of urology may be positioned to become a leader in the provision of telemedicine services.

Telemedicine in Surgery: What are the Opportunities and Hurdles to Realising the Potential?

Since the first telegraphic transmission of an electrocardiogram in 1906, technological developments have allowed telemedicine to flourish. It has become a multi-billion pound industry encompassing many areas of medical practice and education. Telemedicine is now widely used in surgery from performing operations to teaching and can be divided into three main components; telesurgery, telementoring and teleconsultation. Developments across these fields have led to remarkable achievements such as intercontinental telesurgery and telementoring. However, barriers to the further implementation of telemedicine remain. In this review, the developments and recent advances of telemedicine across the three domains are discussed together with the challenges and limitations that need to be overcome.

Impact of delay on telesurgical performance: study on the robotic simulator dV-Trainer

PURPOSE

To determine the impact of communication latency on telesurgical performance using the robotic simulator dV-Trainer®.

METHODS

Surgeons were enrolled during three robotic congresses. They were randomly assigned to a delay group (ranging from 100 to 1000 ms). Each group performed three times a set of four exercises on the simulator: the first attempt without delay (Base) and the last two attempts with delay (Warm-up and Test). The impact of different levels of latency was evaluated.

RESULTS

Thirty-seven surgeons were involved. The different latency groups achieved similar baseline performance with a mean task completion time of 207.2 s (p > 0.05). In the Test stage, the task duration increased gradually from 156.4 to 310.7 s as latency increased from 100 to 500 ms. In separate groups, the task duration deteriorated from Base for latency stages at delays ≥300 ms, and the errors increased at 500 ms and above (p < 0.05). The subjects' performance tended to improve from the Warm-up to the Test period. Few subjects completed the tasks with a delay higher than 700 ms.

CONCLUSION

Gradually increasing latency has a growing impact on performances. Measurable deterioration of performance begins at 300 ms. Delays higher than 700 ms are difficult to manage especially in more complex tasks. Surgeons showed the potential to adapt to delay and may be trained to improve their telesurgical performance at lower-latency levels.

Virtual Interactive Presence in Global Surgical Education: International Collaboration Through Augmented Reality

BACKGROUND

Technology allowing a remote, experienced surgeon to provide real-time guidance to local surgeons has great potential for training and capacity building in medical centers worldwide. Virtual interactive presence and augmented reality (VIPAR), an iPad-based tool, allows surgeons to provide long-distance, virtual assistance wherever a wireless internet connection is available. Local and remote surgeons view a composite image of video feeds at each station, allowing for intraoperative telecollaboration in real time.

METHODS

Local and remote stations were established in Ho Chi Minh City, Vietnam, and Birmingham, Alabama, as part of ongoing neurosurgical collaboration. Endoscopic third ventriculostomy with choroid plexus coagulation with VIPAR was used for subjective and objective evaluation of system performance.

RESULTS

VIPAR allowed both surgeons to engage in complex visual and verbal communication during the procedure. Analysis of 5 video clips revealed video delay of 237 milliseconds (range, 93-391 milliseconds) relative to the audio signal. Excellent image resolution allowed the remote neurosurgeon to visualize all critical anatomy. The remote neurosurgeon could gesture to structures with no detectable difference in accuracy between stations, allowing for submillimeter precision. Fifteen endoscopic third ventriculostomy with choroid plexus coagulation procedures have been performed with the use of VIPAR between Vietnam and the United States, with no significant complications. 80% of these patients remain shunt-free.

CONCLUSION

Evolving technologies that allow long-distance, intraoperative guidance, and knowledge transfer hold great potential for highly efficient international neurosurgical education. VIPAR is one example of an inexpensive, scalable platform for increasing global neurosurgical capacity. Efforts to create a network of Vietnamese neurosurgeons who use VIPAR for collaboration are underway.

Narrative review of telemedicine consultation in medical practice

BACKGROUND

The use of telemedicine has grown across several medical fields, due to the increasing number of "e-patients".

OBJECTIVE

This narrative review gives an overview of the growing use of telemedicine in different medical specialties, showing how its use can improve medical care.

METHODS

A PubMed/Medline, Embase, Web of Science, and Scopus search was performed using the following keywords: telemedicine, teleconsultation, telehealth, e-health, and e-medicine. Selected papers from 1996 to 2014 were chosen on the basis of their content (quality and novelty).

RESULTS

Telemedicine has already been applied to different areas of medical practice, and it is as effective as face-to-face medical care, at least for the diagnosis and treatment of some pathological conditions.

CONCLUSION

Telemedicine is time- and cost-effective for both patients and health care professionals, encouraging its use on a larger scale. Telemedicine provides specialist medical care to patients who have poor access to hospitals, and ensures continuity of care and optimal use of available health resources. The use of telemedicine opens new perspectives for patients seeking a medical second opinion for their pathology, since they can have remote access to medical resources that would otherwise require enormous costs and time.

Virtual interactive presence for real-time, long-distance surgical collaboration during complex microsurgical procedures

OBJECT

The shortage of surgeons compels the development of novel technologies that geographically extend the capabilities of individual surgeons and enhance surgical skills. The authors have developed "Virtual Interactive Presence" (VIP), a platform that allows remote participants to simultaneously view each other's visual field, creating a shared field of view for real-time surgical telecollaboration.

METHODS

The authors demonstrate the capability of VIP to facilitate long-distance telecollaboration during cadaveric dissection. Virtual Interactive Presence consists of local and remote workstations with integrated video capture devices and video displays. Each workstation mutually connects via commercial teleconferencing devices, allowing worldwide point-to-point communication. Software composites the local and remote video feeds, displaying a hybrid perspective to each participant. For demonstration, local and remote VIP stations were situated in Indianapolis, Indiana, and Birmingham, Alabama, respectively. A suboccipital craniotomy and microsurgical dissection of the pineal region was performed in a cadaveric specimen using VIP. Task and system performance were subjectively evaluated, while additional video analysis was used for objective assessment of delay and resolution.

RESULTS

Participants at both stations were able to visually and verbally interact while identifying anatomical structures, guiding surgical maneuvers, and discussing overall surgical strategy. Video analysis of 3 separate video clips yielded a mean compositing delay of 760 ± 606 msec (when compared with the audio signal). Image resolution was adequate to visualize complex intracranial anatomy and provide interactive guidance.

CONCLUSIONS

Virtual Interactive Presence is a feasible paradigm for real-time, long-distance surgical telecollaboration. Delay, resolution, scaling, and registration are parameters that require further optimization, but are within the realm of current technology. The paradigm potentially enables remotely located experts to mentor less experienced personnel located at the surgical site with applications in surgical training programs, remote proctoring for proficiency, and expert support for rural settings and across different counties.

Determination of the latency effects on surgical performance and the acceptable latency levels in telesurgery using the dV-Trainer(®) simulator

BACKGROUND

The primary limitation of telesurgery is the communication latency. Accurate and detailed data are lacking to reveal the latency effects on surgical performance; furthermore, the maximum acceptable latency in telesurgery remains unclear.

METHODS

Sixteen medical students performed an energy dissection exercise and a needle-driving exercise on the robotic simulator dV-Trainer(®), and latencies varying between 0 and 1,000 ms with a 100-ms interval were randomly and blindly presented. Task completion time, instrument motion, and errors were automatically recorded. The difficulty, security, precision, and fluidity of manipulation were self-scored by subjects between 0 and 4 (0 the best, 2 moderate, and 4 the worst).

RESULTS

Task completion time, motion, and errors increased gradually as latency increased. An exponential regression was fit to the mean times and motions (R (2) > 0.98). Subjective scorings of the four items were similar. The mean scores were less than 1 at delays ≤200 ms, then increased from 1 to 2 at 300-700 ms, and finally approached 3 at delays above. In both exercises, latencies ≤300 ms were judged to be safe by all and 400-500 ms were accepted by 66-75 % of subjects. Less than 20 % of subjects accepted delays ≥800 ms.

CONCLUSIONS

The surgical performance deteriorates in an exponential way as the latency increases. The delay impact on instrument manipulation is mild at 0-200 ms, then increases from small to large at 300-700 ms, and finally becomes very large at 800-1,000 ms. Latencies ≤200 ms are ideal for telesurgery; 300 ms is also suitable; 400-500 ms may be acceptable but are already tiring; and 600-700 ms are difficult to deal with and only acceptable for low risk and simple procedures. Surgery is quite difficult at 800-1,000 ms, telementoring would be a better choice in this case.

Novel telementoring system for robot-assisted radical prostatectomy: impact on the learning curve

OBJECTIVE

To develop a Web-based audiovisual telementoring system for robot-assisted radical prostatectomy (RARP) and to assess the utility of this system.

METHODS

A telementoring system for RARP, consisting of a 3-dimensional high-definition view of the operating field, overview of the operating room, annotation function, and 2-channel audio feed with bidirectional connectivity between 2 institutions, was developed. The outcome of RARP performed for the initial 30 patients by 2 surgeons with telementoring was compared with that for 2 surgeons who received direct mentoring.

RESULTS

This system was shown to function properly with an acceptable latency. There were no significant differences in several parameters reflecting surgical outcomes, including the operating time, complication rate, early continence status, and positive margin rate between the telementoring and direct mentoring groups.

CONCLUSION

These findings suggest the usefulness of the telementoring system for promoting the spread of precise surgical techniques associated with RARP. To our knowledge, this is the first report concerning telementoring for robot-assisted surgery.

Telemedical technologies in urological cancer care: past, present and future applications

Since the initial development of telegraphy by Sir Charles Wheatstone in 1837 and the telephone by Alexander Graham Bell in 1875, doctors have been able to convey medical information across great distances. The exchange and sharing of medical information has evolved and adapted to suit the vast array of today's medicine. Early adopters of telemedicine within clinical practice have gained significant health economic benefits. The arrival of wireless connections has further enhanced the possibilities for all clinical work with focus on diagnosis, treatment and management of urological cancers, as highlighted in this article.

Robotic renal surgery: The future or a passing curiosity?

The development, advancement and clinical integration of robotic technology in surgery continue at a staggering pace. In no other discipline has this rapid evolution occurred to a greater degree than in urology. Although radical prostatectomy has grown to become the prototypical application for the robot, the role of the robot in renal surgery remains controversial. Herein we review the literature on robotic renal surgery. A comprehensive PubMed literature search was performed to identify all published reports relating to robotic renal surgery. All clinically related articles involving human participants were critically appraised in this review. Fifty-one clinical articles were included, encompassing robot-assisted pyeloplasty, nephrectomy, nephroureterectomy, living-donor nephrectomy and partial nephrectomy. Feasibility has been shown for each of these procedures. Robot-assisted techniques have been described for almost all renal-related procedures. However, the intersect between feasibility and necessity as it pertains to robotic renal surgery has yet to be defined. Also, the high cost of surgical robotic technology mandates critical appraisal before adoption, especially in a publicly funded health care system, such as the one present in Canada.

Remote monitoring and supervision of urology residents utilizing integrated endourology suites-a prospective study of patients' opinions

PURPOSE

To report on integrated endourology suites (IES), remote monitoring and supervision (RMS) of urology residents and to evaluate patients' opinions, acceptance, and satisfaction level with IES and RMS.

PATIENTS AND METHODS

Patients undergoing flexible cystoscopy in the IES with RMS were surveyed using a questionnaire. All procedures were performed by junior urology residents (UR-1 level) using RMS. Patients were studied using a nine-question survey to evaluate their comfort level, acceptance, and level of satisfaction with RMS. Six questions used a scale of 1 to 10 (1=strongly disagree; 10=strongly agree), and the remaining three questions solicited a "yes" or "no" response.

RESULTS

100 patients were studied (59% Caucasians, 40% African Americans, and 1% Hispanic). Median age was 63 years. The highest level of education was middle school in 2% of patients, high school in 55%, undergraduate in 33%, and postgraduate in 10%. Patients scored a mean of 9.50/10 (highly satisfactory) regarding their comfort with RMS; 96% scored ≥ 7, 4% scored 5 to 6, and none scored <5. Patients were satisfied having a urology resident perform the procedure (9.48/10), other residents and medical students watch the procedure (9.41/10), a video camera in the room (9.40/10), and two-way sound communication (9.40/10). None perceived compromise to their privacy or quality of care.

CONCLUSIONS

RMS in IES is highly acceptable to patients undergoing endoscopic procedures. RMS has the potential to positively impact residency training, efficiency, regulatory compliance, safety, and productivity.

Telementoring and telerobotics in urological surgery

For more than 150 years, doctors have had the ability to transmit medical information to advise and assist their colleagues in remote locations via teleconsultation using a variety of communication modalities. In surgery this has evolved into the telementoring of minimally invasive procedures, particularly, robotic surgery, which have become relatively commonplace in urology. The ultimate progression to true telerobotic surgery, in which remote surgeons independently perform complex and fundamental parts of procedures at long range, is starting to occur. This article discusses the current state of telementoring and telerobotics in urology and examines the pros and cons of this technology at the present time.

Pre-clinical remote telesurgery trial of a da Vinci telesurgery prototype

BACKGROUND

The objective of this study was to perform a pre-clinical remote telesurgery trial of a da Vinci telesurgery prototype on a surgical-grade virtual private network.

METHODS

A da Vinci telesurgery-enabled prototype was used to conduct surgical trials across a 17 MB/s bandwidth VPNe network spanning 2848 km round-trip landline distance from London, Ontario, to Halifax, Nova Scotia, Canada. The outcomes measured during the trial were surgical times and quality of anastomoses.

RESULTS

Network configuration resulted in observed latencies of 370 ms with 140 ms due to transport delay. The da Vinci telesurgery prototype performed well subjectively and average porcine pyeloplasty anastomotic times were 20.7 +/- 4.7 min.

CONCLUSIONS

This work constitutes an early evaluation of the da Vinci telesurgery prototype for conceptually remote telesurgical operations. This study clearly demonstrated the feasibility of remote telesurgery using the da Vinci platform to perform a complex surgical task.