Significant progress has been achieved in the field of robotic surgery in recent years, revolutionizing various medical procedures. Robotic surgery is highly favored for its application in urologic, gynecologic, thoracic, cardiothoracic, and gastrointestinal surgeries. It has become a standard practice in numerous prominent hospitals worldwide, including those in the United States. This technological advancement has had a profound impact on the treatment of prostate cancer (PCa), particularly in the form of robotic-assisted radical prostatectomy (RARP), which has become the go-to procedure for localized PCa. Notably, the adoption of robotic surgery in Michigan hospitals has increased significantly over the span of six years, growing by 8.4 times from 2012 to 2018, indicating its increasing prevalence in common surgical practices.
The concept of remote robot-assisted surgery was first successfully demonstrated in 2001. However, due to technological challenges such as high latency, it has not been widely integrated into clinical practice. One of the significant challenges faced by various countries is the scarcity of surgical expertise in rural areas. Moreover, the presence of robotic surgeons predominantly in urban areas creates additional burdens for patients from distant locations, leading to potential delays in receiving robot-assisted surgical treatment, particularly for cancer patients. To address these issues, tele-surgery has emerged as a promising solution. By utilizing real-time communication and the exchange of digitized medical information, including images, audio, and video, tele-surgery allows surgeons located in urban areas to perform procedures in real-time, bridging the gap between medical expertise and remote patients.
Presently, the deployment of fifth-generation (5G) networks is underway in multiple countries worldwide. This expansion of advanced technology has enabled clinicians to conduct remote procedures, tele-mentored surgeries, and real-time interactive surgeries on animal models, cadavers, and human subjects. In this article, the authors delve into the history of robotic surgical systems, provide an overview of the internet and 5G networks, and discuss the current state of remote procedures utilizing the 5G network. The primary objective is to update readers on this novel technology, highlighting its efficacy, feasibility, and potential benefits for cancer patients in need of surgical interventions.
HISTORY OF SURGICAL ROBOTIC SYSTEMS
The field of robotic surgery has seen continuous development for over 40 years, marked by notable milestones. In 1983, the world witnessed the introduction of the first surgical robot called Arthrobot, which was developed and utilized in Vancouver. Meanwhile, the PUMA 200, originally designed for industrial purposes, emerged in 1985. Its improved version, the PUMA 560, gained attention in the medical field. Developed by Unimation Limited, the PUMA 560 was a programmable robot compatible with various imaging computers used in previous biomedical applications. Rigorous testing, including experiments with a chessboard and watermelons, was conducted to assess its accuracy. Notably, the PUMA 560 played a significant role in conducting a neurosurgical procedure for brain tissue sample biopsy under CT guidance. However, it had limitations such as lengthy setup times, accuracy concerns, and safety issues. In 1988, the PUMA 560 was used for transurethral resection of the prostate (TURP), marking its first application in urologic surgery.
Another noteworthy development came from England, where PROBOT was developed for prostate reconstruction and transurethral prostate resection surgeries. In 1992, the ROBODOC, created by Integrated Surgical Supplies, Inc., became the first surgical robot approved by the US Food and Drug Administration (FDA), specifically for performing hip replacements.
During the late 1980s and early 1990s, Computer Motion introduced their robotic system called AESOP (Automatic Endoscopic System for Optimal Positioning). AESOP provided steady positioning of laparoscopes, eliminating the need for fatigued or inexperienced scope holders. Initially controlled by a foot pedal, later versions of AESOP incorporated voice commands for laparoscope orientation. In 1994, AESOP received FDA approval for intra-abdominal surgeries, becoming the first FDA-approved robotic device for such procedures. Computer Motion’s second-generation robotic system, ZEUS, featured instrument and camera control with three robotic arms and a 2D video screen. The surgeon operated the arms using a remote console, and the camera could be controlled via voice commands. ZEUS made history in September 2001 when the first successful transatlantic robot-assisted telesurgery was performed, showcasing the potential for remote surgical support in rural and international areas. This groundbreaking procedure, a robot-assisted laparoscopic cholecystectomy on a porcine model, transmitted signals between Strasbourg, France, and New York.
While ZEUS gained popularity, the da Vinci robotic system, developed by Intuitive Surgical, Inc., emerged as a leading player in the field. It showcased a shorter learning curve and more intuitive technical movements compared to ZEUS. The da Vinci system received FDA approval in 2000 for general laparoscopic procedures. Comprising a surgeon master console, a four-armed surgical robot on a patient trolley, and an imaging system, it became widely approved for various surgical procedures. In 2008, using the da Vinci system, surgeons in the United States successfully performed four transcontinental telesurgical nephrectomies on porcine models. The surgeries took place with the animal subjects in Sunnyvale, California, and the surgeon located in either Cincinnati, Ohio, or Denver, Colorado, utilizing a wired internet connection to study the effectiveness and reliability of remote surgery.
The field of robotic-assisted surgical devices continues to expand rapidly with the development and availability of various systems such as Ion (Intuitive Surgical), Mako (Stryker), NAVIO (Smith & Nephew), Monarch (Auris Health), and many others. These systems have been utilized in real-time remote procedures, which will be discussed in subsequent sections.
BACKGROUND OF THE INTERNET AND 5G
Over the years, advancements in mobile networks, including 2G, 3G, and 4G, have significantly enhanced wireless internet services. According to resource, 5G networks offer an impressive data transfer rate of 10 GB/s. In contrast to 4G networks, which operate as a unified system, 5G networks employ a network splicing/slicing approach. This scheme divides the network architecture into specialized networks, each dedicated to a specific function. By utilizing network splicing, the 5G network optimizes resources based on the specific functions in use. Consequently, 5G networks deliver superior performance in terms of data transfer speed, communication, reliability, and ultra-low latency compared to their 4G counterparts.
Understanding the concept of latency is crucial, as it directly affects the response time between devices and can impact remote surgery outcomes. Latency refers to the delay in response between a device and the server or target device it communicates with. This delay is influenced by the data transfer rate of the network and the volume of data being transmitted. In the context of remote surgery, these factors play a vital role in enabling the surgeon to respond effectively to changing conditions and rely on high-quality video streams for accurate decision-making. Insufficient time or poor video quality can result in surgical complications and potential harm to the patient.
An early example of remote surgery conducted by Dr. Marescaux and colleagues in the early 2000s demonstrates the limitations they faced. They achieved a maximum resolution of 1024 pixels by 768 pixels with a data transfer rate of 10 Mbps. successful surgery was conducted at a maximum latency of 330 ms, with most procedures performed at an average latency of 155 ms. However, there is a need for better video quality and faster data transfer speeds to improve the success rate of remote surgery. As resolution increases, more data must be transmitted, but it also enhances the video quality available to the surgeon, enabling more accurate surgical procedures.
Likewise, faster data transfer speeds contribute to reduced latency, allowing surgeons to respond more quickly. The DaVinci robot, for instance, supports a resolution of at least 1920 pixels by 1080 pixels (approximately 2.6 times larger than Dr. Marescaux’s setup). With the advent of 5G networks, both latency and video stream quality can be improved due to their maximum transfer rate of 10 Gbps. In a study conducted by Zheng and colleagues, the average response time of endoscopic surgeons to complex scenarios was found to be 397 ms ± 19 s. Successful remote surgeons typically operated at average latencies ranging from 76 to 150 ms, resulting in an estimated response time of 475-660 ms. Therefore, it can be speculated that a maximum safe latency period is around 150 ms, representing a roughly 37.5% increase compared to a normal surgeon’s response time. Consequently, advancements in data transfer speeds through improved mobile networks can lead to lower latencies or enhancements in resolution, facilitating more efficient remote surgical procedures.
CURRENT SCENARIO OF THE USE OF 5G IN ROBOTIC SURGERY
The adoption of 5G networks is gradually increasing in many countries. This, coupled with the advancements in surgical robot technologies, has facilitated the implementation of remote robotic procedures utilizing 5G technology. In one notable case, a remote hepatectomy was performed in a porcine model in December 2018 in Fujian, People’s Republic of China (PRC). The procedure utilized the Kangduo robotic surgery system and the 5G network infrastructure provided by Huawei Technologies Company and China Unicom.
The control equipment for the surgery was situated at the Fujian Branch of China Unicom, while the operating theater was located in the Mengchao Hepatobiliary Hospital in Fujian, Fuzhou, PRC, which was approximately 48 km (30 miles) away. During the procedure, the surgeon remotely controlled two robotic arms, specifically the bipolar coagulation and electrocoagulation hooks, as well as the lens. Their objective was to resect a portion of the liver measuring 2 cm x 2 cm x 3 cm. The surgery lasted approximately 60 minutes, with minimal blood loss of around 5 ml. Notably, the reported average latency during the procedure was less than 150 ms.
In 2019, a study was conducted in Munich, Germany, to assess the performance of 5G in two different medical applications, specifically focusing on camera positioning. The study involved evaluating the video streaming rate, robotic control command rate, and latency associated with the transmission.
The video streaming rate ranged from 900 KB to 1 Mbps (equivalent to 7.2 to 8 Mbps), indicating the speed at which video data was transferred. On the other hand, the robotic control command rate varied from 2.4 to 7.2 KB/s (equivalent to 19.2 to 57.6 KB/s), reflecting the rate at which commands to control the robotic system were transmitted. The latency, which represents the delay between data transmission and reception, ranged from 2 to 60 ms and was influenced by the length of the transmitted data packets.
In addition to the technical evaluation, a Delphi study was conducted as part of the research. The study involved gathering opinions and insights from experts in the field, who collectively agreed that 5G holds significant potential in the healthcare domain and warrants further exploration.
In March 2019, a significant advancement in medical technology occurred as clinicians utilized 5G networks to remotely control deep brain stimulation (DBS) implants for the treatment of Parkinson’s disease and other brain ailments. The study involved three patients, two with Parkinson’s disease and one with essential tremor, who underwent on-site procedures including headframe installation, craniotomy, and microelectrode puncture in Beijing, China. The remote-control group, situated approximately 2400 km away at Hainan Hospital of Chinese PLA General Hospital in Sanya City, controlled the microelectrode recording and imaging to ensure proper electrode implantation. Huawei and China Mobile facilitated the 5G network utilized in this study. During the procedures, the reported peak download speed reached 119 Mbps, and the average latency was 76 ms. At the 3-month follow-up, significant improvements of 43.6%, 84.9%, and 90.5% were observed in the patients, respectively, based on the Unified Parkinson’s Disease Rating Scale (MDS).
In February 2019, another milestone was achieved with the first tele-mentored surgery performed over a 5G network in Barcelona, Spain. The laparoscopic procedure, using a medial-to-lateral approach, took place between the Mobile World Congress (MWC) Barcelona 2019 at Fira Gran Via and the Hospital Clinic de Barcelona, with a distance of approximately 4 km between the two locations. Vodafone provided the 5G connection for this telementored surgery, and the Advances in Surgery (AIS) Channel, an online education portal, played a crucial role. The procedure lasted approximately 118 minutes, with an average latency of 202 ms and a mean data upload speed of 98 Mbps. Notably, there were no issues such as signal loss, image buffering, or pixelation. Three surgeons rated the image quality as 9.67 out of 10 and the audio exchange as a perfect 10.
In June 2019, a remote tele-assisted surgery took place between MWC Shanghai 2019 at Shanghai New International Expo Center (SNIEC) and Shanghai East Hospital, which were approximately 6 km apart. Surgeon 1 provided live guidance to Surgeon 2 using the 5G connection provided by China Mobile. The surgery lasted around 138 minutes, with an average latency of 148 ms. The mean data upload speed reached 101 Mbps, and no signal loss was observed. The image quality was rated as 9.5 out of 10, and the audio exchange received a perfect score of 10.
In June and August 2019, two surgeries involving orthopedic telerobotic spinal placements were performed on a total of 12 patients. The first procedure, known as “one-to-two” simultaneous remote orthopedic pedicle screw placement, took place between Beijing Jishuitan Hospital, Shandong Yantaishan Hospital, and Zhejiang Jiaxing Second Hospital in June 2020. The second procedure, called “one-to-three” simultaneous remote orthopedic pedicle screw placement, was conducted in August 2020 between Beijing Jishuitan Hospital, Tianjin First Central Hospital, Second Hospital of Zhangjiakou City, and Karamay Central Hospital. In both surgeries, the master control room and the responsible surgeon were located at Beijing Jishuitan Hospital, while the other hospitals served as the surgery locations. The 5G network utilized in these surgeries was provided and established by China Telecom and Huawei Technologies. The TiRobot system was used as the surgical robot. The distances between the master room and the various operating theaters ranged from 114 to 3154 km. The average surgery time was 142.5 ± 46.7 minutes, with guide pin insertion taking 41.3 ± 9.8 minutes. A total of 62 screws were implanted, and the average difference in screw placement was 0.76 ± 0.49 mm. No intraoperative adverse events were observed, except for one complication in a lumbar spondylolisthesis patient who experienced a cerebrospinal fluid (CSF) leak the day after surgery, possibly related to a nerve decompression procedure.
In October 2019, transoral laser microsurgery procedures, including ventriculotomy, type 1 cordectomy, and type 4 cordectomy, were conducted on an adult human cadaver. The otolaryngologist was located at Vodafone Village in Milan, Italy, while the cadaver was situated at San Raffaele Hospital in Milan, approximately 15 km away. The surgical system involved the use of a computer-assisted laser microsurgery system (CALM) controlling a medical CO2 laser (SmartXid2 C60 DEKA), a Panda robot (robotic surgical forceps by Frank Emika), and a VITOM 3D stereo exoscope (Karl Storz). Support staff assisted with cadaver setup and laser settings. The 5G network utilized in this study was the 5G Radio Access Network with a bandwidth of 1 Gbps provided by Vodafone. Throughout the procedure, the average latency observed for 3D high-definition video was 102 ± 9 ms, with a maximum latency of 280 ms. The mean round trip delay between devices was estimated at 40 ms. The surgical evaluation concluded that the procedures were highly precise.
In November 2019, a remarkable live interaction surgery utilizing 5G technology took place. Surgeon 1, located in Rome, Italy, had the opportunity to observe a laparoscopic gastrectomy performed by Surgeon 2 and his team at Santa Maria Hospital in Terni, Italy. Surgeon 1 viewed the procedure through a visual-reality visor, which provided access to the patients’ biometrics captured by three cameras, including a super high-definition 360° camera, in the operating room. The live surgery was showcased at the 30th International Congress of Digestive Surgery and was broadcasted to over 30,000 surgeons worldwide through online video streaming platforms, in addition to the surgeons present at the Congress.
Moreover, in 2020, four laparoscopic procedures consisting of left nephrectomy, partial hepatectomy, cholecystectomy, and cystectomy were performed on 25 kg porcine models. The surgeons were located in Qingdao, PRC, while the porcine models were situated in Anshun, PRC, with a distance of approximately 3000 km between them. The “MicroHand” surgical robot, assisted by the Hisense computer-assisted system (CAS) for remote access, was utilized for these procedures. A comparison was made between a wired 100 Mbps connection provided by China Unicom and a 5G 1 Gbps connection, also provided by China Unicom, during the surgeries. The 5G network exhibited an average latency of 264 ms, a round trip delay of 114 ms, and a 1.2% packet loss ratio. In contrast, the “control” wired connection demonstrated an average latency of 206 ms and a round trip delay of 56 ms. The total duration of the procedures was 120 min, with a total blood loss of 25 ml.
Stable 5G networks have enabled the realization of robotic surgeries and telementoring through 5G technology in several countries. Surgeons in countries such as PRC, Germany, Spain, and Italy have successfully showcased the feasibility and effectiveness of conducting robotic procedures using 5G networks. Importantly, the duration of these surgeries using 5G technology has been comparable to non-5G robotic surgeries.
These cases of 5G-powered robotic surgery have also implemented backup measures to address potential issues with unstable connections. For instance, onsite surgeons and surgical support staff have been involved to provide partial control and support during the operations. European clinicians have expressed their support for the use of 5G networks in facilitating robotic telesurgery. They have quantified the image and audio quality of 5G procedures and have reaffirmed that the maximum latency threshold for effective robotic surgery is within 300 ms.
These studies present evidence contrary to the claim made by Ullah and colleagues, who suggested that a highly reliable connection with ultra-low latency of less than 10 ms is required for robotic surgery. The successful implementation of robotic surgeries using 5G networks demonstrates that while low latency is desirable, it is not an absolute prerequisite for achieving safe and efficient remote surgical procedures. The availability of stable 5G connections, even with slightly higher latency, has proven sufficient for conducting successful robotic surgeries and ensuring patient safety.
POSSIBLE CHALLENGES AND LIMITATIONS
The COVID-19 pandemic has highlighted the importance and urgency of telemedicine, and the integration of 5G technology in healthcare can bring numerous benefits. By utilizing 5G, virtual check-ins, mobile waiting rooms, and secure high-definition medical image transfers can be facilitated. Furthermore, 5G-enabled virtual reality scenarios can be created to alleviate pain and anxiety for terminally ill, immunocompromised, or elderly patients.
However, the successful integration of 5G into healthcare relies heavily on the widespread coverage provided by existing telecommunications companies. In the United States, several telecom companies have already started expanding 5G coverage in rural areas. For instance, in December 2020, OpenSignal reported that T-Mobile 5G users in rural locations were experiencing download speeds of up to 53.4 Mbps. It is expected that both the speed and coverage of 5G networks will continue to improve across the country as multiple telecom companies expand their networks. T-Mobile, for example, has expressed its goal of covering 90% of rural Americans within the next six years. Additionally, the availability of 5G-compatible devices such as laptops, cell phones, and robotic surgical systems is crucial for the successful implementation of 5G-powered healthcare applications.
In the context of 5G-powered robotic surgeries, it is important to consider the potential limitations and challenges. One such consideration is the need for a backup surgical team to be present on-site in case of any hindrance or loss of connection during the procedure. This ensures that the safety and well-being of the patient are not compromised.
Before implementing 5G-powered robotic surgery in rural areas that lack access to surgeons, a comprehensive cost-benefit analysis is necessary. The number of surgeons per 100,000 population in rural counties has been declining, emphasizing the need for innovative solutions. The financial cost to patients in the US remains an area where minimal data has been collected. Studies conducted in Canada have shown an increase in procedure costs with robotic surgery, but they did not take into account the potential decrease in hospitalization duration. Further research is needed to determine the economic feasibility of 5G-powered robotic surgery for both healthcare institutions and patients. Additionally, as remote surgery is not yet widely practiced, there is an opportunity to better understand and assess the training and learning curve associated with this approach.
The advancements in 5G networks have shown promising solutions to overcome the latency and reliability challenges faced in remote surgeries during the 2000s. By leveraging 5G technology, it may be possible for surgeons to perform robot-assisted procedures remotely, thereby addressing the need for surgical expertise in rural locations. Studies have indicated that cancer patients, including those with prostate cancer and bladder cancer, often face delays in treatment due to increased travel distances. Leveraging 5G technology could help bridge this gap by enabling robot-assisted surgical management for patients who require it.
The development of improved robotic surgical devices and techniques, such as robotic-assisted radical prostatectomy (RARP), has revolutionized the surgical management of prostate cancer. As technology continues to advance, we can expect further developments in the field of robotic surgery and tele-surgery. Real-time virtual reality-based surgeries and three-dimensional models of cancer lesions and organs during surgeries could become a reality. Additionally, with high-speed data transfer enabled by 5G, the incorporation of artificial intelligence into robotic surgical systems is also anticipated.
During the initial implementation of 5G networks, performance may vary depending on the user’s location. This is because 5G utilizes different frequency bands, including high band 5G (mmWave/24-39 GHz), mid-band 5G (2.5/3.5 GHz), and low band 5G (600-700 MHz). High band 5G offers the fastest data transfer speeds but has a shorter range and limited ability to penetrate obstacles or buildings. In contrast, mid-band and low-band 5G can provide extended coverage at the expense of some performance capabilities. To ensure optimal performance for remote and live-interactive surgeries, telecom companies would need to install base stations and antennas in close proximity to each other, particularly for high band wave connections.
Remote tele-mentored collaboration facilitated by 5G networks has the potential to enhance knowledge sharing among clinicians in real-time, thereby increasing medical assistance in areas where 5G infrastructure is established. The high-speed data transfer capability of 5G enables the seamless exchange of large volumes of research and data, fostering real-time collaboration and innovation. These technological advancements can pave the way for novel therapeutic applications and interventions.
However, it is important to acknowledge and address the limitations and challenges associated with 5G infrastructure, including factors such as the learning curve for healthcare professionals, cost analysis, and device compatibility. Extensive research and development efforts are needed to overcome these limitations and fully comprehend the potential benefits of integrating 5G technology into cancer management practices. Before widespread implementation, it is crucial to conduct further research to evaluate the feasibility, effectiveness, and safety of remote and tele-mentored 5G-powered procedures.
Nevertheless, the integration of 5G technology holds significant promise as a tool for improving the care of patients who require robot-assisted surgical management, such as prostate cancer patients. By harnessing the capabilities of 5G networks, healthcare providers can enhance their expertise, access real-time guidance and mentoring, and deliver high-quality care to patients regardless of geographical constraints.