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E. David Crawford: Hi, everyone. My name is E. David Crawford. I'm a professor of urology at the University of California, San Diego. Joining me for today's Crawford's Corner is an innovative and outstanding clinician, Dr. Dave Albala, from Syracuse, New York. Dave has always been on the cutting edge of so many things, and today we're going to discuss a topic that he's very familiar with and involved in, and that's telesurgery. It's something I think that's going to have a major impact on our practice, not only in the U.S. but around the world. Dave, you know there's no question that telesurgery is a cutting-edge field at the intersection of medicine and technology. And there's a lot of promise for enhancing surgical capabilities, extending medical care, and so forth.

You and I grew up and we learned how to do surgery by looking over somebody's shoulder. Then we got some video cameras and things like that. There's been a lot of that around, but this opens up a whole new arena, and I know you just published an article several weeks ago in the Journal of Robotic Surgery with a number of your colleagues internationally on it. I wonder if you could just give our audience an overview of what you said, and we'll get into some discussion about it. Thanks.

David Albala: Sure. And Dave, thanks again for inviting me. It really is an honor to sit down and talk about what I think is going to shape the future. I think you and I, as you mentioned, trained in urology by seeing a procedure done, doing a procedure, and then passing it on to our fellow residents and colleagues. Then I think robotic surgery came along, and that was a game-changer. That really brought technology and medicine together. It intersected. What we found is that using a robot, we could be more proficient, and we could get the same outcomes or even better outcomes in some respects compared to what we would do with open surgery. And I think now, with the changes in technology that have taken place, we can perform telesurgery, where a surgeon can sit in one place and perform a surgical procedure in another place.

E. David Crawford: We sort of do that right now with robots. They're just at a different part of the operating room, right? You've just got a long extension cord you're putting out there.

David Albala: Exactly. But I think what we're doing now is pushing the envelope. Back in 1998, Jacques Marescaux did the first telesurgery operation when he was in New York City and operated on a patient in Strasbourg, France, and did gallbladder surgery. That was called the Lindbergh operation. We started to see our Canadian colleagues from McMaster University operate in remote portions of Canada. But then there was a stop. There was no real telesurgery that took place. Then in 2020-2023, we started to see a revival, partly because of advancements in technology. We started to see better telecommunication systems with 5G. In the past year, we've seen surgeons in China operate across the country, and in Japan, we've seen the same thing. So there's been a real groundswell, if you will, on the technology aspect, not only from the telecommunications standpoint but also with the robotic platforms.

We've only had one robotic platform to speak of, which is the da Vinci. Today, we just had our robotic society meeting in Orlando back in June. Forty different robotic systems are now introduced around the world, and the majority of these are coming from China, and these are systems that have telesurgery capabilities available to them. The da Vinci, at the present time, doesn't have that. So actually, what we're seeing is this groundswell, not only of advancements in telecommunication systems but also with the surgical robotic systems. And it's this marriage between the two that really is going to propel this subspecialty forward. We're seeing it not only in urology, but we've also seen it in cardiac stent placement, we've seen it in neurosurgery. So all subspecialties are starting to jump on board with this new technology and this excitement that really is sort of a game changer in the surgical specialty.

E. David Crawford: Opening up Pandora's box there. I mean, I just start thinking about this. It is going to have some major impact. I would think like in third-world countries, we could have Dave Albala operating, and things like that. And then also, I guess there's going to be a concern: Is this going to happen in the U.S., where somebody wants Dave Albala to operate on someone in Tallahassee, Florida, or something like that? What are your thoughts about that?

David Albala: Well, I think we're going to see some of that. There's a lot of health inequality that exists around the world. We do about 310 million surgeries per year. So that's a lot of surgery. Less than 5% of those are done with a minimally invasive approach, either robotically or laparoscopically. But underdeveloped countries don't have access to healthcare. In remote parts, not only in Africa and Asia but also in the United States, there are many areas that don't have cutting-edge surgical technology.

So what this does is allow us to do telementoring for local surgeons, and it allows expertise for complicated cases to be done by expert surgeons. So it does broaden the playing field, if you will. It opens it up to... But there have to be guardrails put in place with regulations, guardrails about policy, about funding, insurance companies. All of those guardrails have to be considered. This past year in February, we had the first telesurgery meeting in Orlando. The FDA, the White House, Health and Human Services (HHS), and CMS came to this meeting because they see the value of this. How it needs to be put in place has to be done in a very systematic and quality-controlled environment. We're not just jumping in. Just because we can do it doesn't mean we should do it. There has to be a good reason to do it and a plan for how we're implementing these programs, not only in the United States but all over the world.

E. David Crawford: We saw a little bit of this with COVID and telemedicine. That was felt to be impossible for a whole bunch of reasons, like interstate practice of medicine, and so forth. And that seems to have calmed down now and settled. There's a real advantage to it, and I can see that happening with this. But I wonder, things that go through my mind, like we just had this issue with airlines and other things, when the cloud went out and Microsoft had issues. It would worry me that you're doing that surgery from Syracuse to Sudan, and the electricity goes out. I'm sure there will be ways to deal with that, but [inaudible].

David Albala: Well, you bring up important concerns. There have to be safeguards put in place. There have to be backup systems, but the communication systems have to be reliable. There has to be a low latency period. In other words, when I do a maneuver, what is the time that it actually happens in the patient? And you have to have high-quality video feeds for all of this to work. So there are structural things that need to be put in place. But when you think about 1998, taking a gallbladder out, surgeons in New York—that was all done through fiber optic cables that were laid under the Atlantic Ocean. So you can imagine the cost of what this was back then. But now with 5G technology, it's better than what we have with satellites. It's better than what we have with fiber optic. This technology is here, but we have to make sure that patient safety is number one. And what happens if something does go wrong? We need to have safeguards in place.

E. David Crawford: Just to finish, Dave, I've got a great interesting discussion here. We should probably schedule this once a year to see how it goes over the next five years. But put on your future hat: Where do you think this is going to be in five years?

David Albala: I think in five years you're going to see robotic systems in areas that would not have had the opportunity to have those types of systems. Obviously, healthcare programs need to be developed that funnel into areas of excellence. In underdeveloped countries—I spent time in Nepal and India and other third-world countries—we can bring this technology to these patients so that they can benefit from it. But there are going to be policy implications, regulatory implications that need to be ironed out. We're just at the tip of the iceberg right now in 2023. But in five years, when I finished my fellowship with Ralph Clayman and we did the first laparoscopic nephrectomy, I always thought I would be able to wake up, get my cup of coffee, go to my computer console, and do a surgical procedure. I believe that will happen before I die.

E. David Crawford: Well, you were really thinking ahead there. I think there's no question there are going to be a lot of issues with super surgeons with great reputations going around to various places in the U.S. There's going to be a lot of backlash, but that's the same thing we saw with telemedicine. People felt threatened, and that all got ironed out. Dave, it's great having you on. You're a very innovative person and always on the cutting edge of things. I hope we can get back with you soon to follow up on this. Congratulations on the publication of your paper and your new one coming out. Stay in touch. Thanks.

David Albala: Dave, thank you. It's been an honor to participate, and thanks for having me on.