Zachary Klaassen: Hi, UroToday. My name is Zach Klaassen, Urologic Oncologist at the Georgia Cancer Center in Augusta, Georgia. I'm really excited to have on UroToday Dr. Vip Patel, who is the Director of the Advent Health Global Robotics Institute in Celebration, Florida. Vip, thanks for joining us on UroToday.

Vipul Patel: Thank you for having me.

Zachary Klaassen: So you recently performed the first telesurgery, basically cross-continent robotic prostatectomy. And just we're going to get your thoughts on that. But before we get into it, I just want to talk a little bit about your practice. What sort of led up to this big day? I know you've got a phenomenal setup down there. I was fortunate to see it as a resident. So, maybe just tell us about your setup before we get into it.

Vipul Patel: Yeah, 23 years in practice now, and I'm almost at 20,000 robotic prostatectomies, getting close. And so obviously, robotics and prostate cancer is something that we feel very passionately about. But I've always had this interest in remote teaching and education. And as you came to us with a resident, we've been teaching for 23 years, residents, attendings, and all over the world. I think I have operated in 40 countries. But there was always kind of that healthcare inequity between places that could buy a da Vinci and a robot and places that couldn't. And so, there was definitely a big diversity between who we could and couldn't reach. And I think this is where the whole telesurgery concept really helps.

Zachary Klaassen: Yeah, absolutely. I can imagine, this was in Angola, and I can imagine just from a logistics standpoint, even just real time, what was the logistics leading up to that day? You had a team in place in Angola. Just tell us about all the planning that went into it.

Vipul Patel: Yeah, it took about two years to plan. First we actually went to China, Japan, India. Kind of saw the technology, the concepts. We flew out there multiple times. We actually got a license in China to actually operate remotely to see how it would be. And so, we did multiple cases out there and then we brought it back and we got different technologies on non-da Vinci technology. And there's multiple robots from India, China, Japan that are telesurgically capable.

And I think then we decided to do trials in the lab. And the key to the trials in the lab was basically the fact that we were able to work on the latency and the delay of the signal. Because that was the issue, right? Is at such a distance, what would be the latency and would it hinder the surgeon?

Zachary Klaassen: Yeah. And I think when just reading about your surgery, there was just the fiber optic technology to go to Brazil and then over. Just the whole process was really fascinating, how the ability to technologically do it in real time like we're sitting in the room. Tell us a little bit about the day. How was it? How was the time difference, the optics? Was it similar to being next door?

Vipul Patel: Yeah, it was an FDA approved IDE trial, clinical trial. So, we had to do it very strategically and properly. Our team flew out there to Africa. I had actually just been there and operated the week before and trained. And so, we sent our team back after being on the ground maybe 12 hours. And basically we had spent probably three months checking the connectivity, what's the fastest route, what had the least latency. And we had a latency of about 146 milliseconds. So when I was there, actually a week before, I met the patient. I talked to him, made sure that he understood what we were going to do. And then it was just a matter of waiting for the FDA to approve, and then our team was on site. So for me, it felt like we were operating in the room next door. It was the same. There were no issues with any of the audio, video, or the signal, so it went very well.

Zachary Klaassen: Wonderful. I think the reason we talked offline a little bit about the lay media picking up on this, there's such a fascinating... The public has a fascination with robots in general, but just the ability to do a big operation like this, 7,000 to 8,000 miles away. How do you see, as we go forward, what the potential impact of this technology taking skilled surgery to underserved areas such as you guys have shown with the Angola patient?

Vipul Patel: Yeah, I think the whole concept really was humanitarian. It's not just internationally that's underserved, we have huge underserved areas in the United States, our rural areas. Our system is a large hospital system and we have a lot of hospitals that are out there and they don't have certain specialties, neuro, cardiac, cancer. And to be able to potentially reach those areas has huge humanitarian implications. And I think what we did is kind of the next step in surgery, is to democratize it. The robots are cheaper, telecom is better. That's why since the Lindbergh operation, it's been 24 years, no one ever did it again because it was too expensive, telecom wasn't ready, technology wasn't ready, we weren't ready. Now everybody's ready.

But there is a lot of caution there. It's very difficult to do. There are a lot of stakeholders that have to approve. There's a lot of checks and balances, and I don't think people realize how difficult it was to actually pull off. And so, this is not something that you can just start doing tomorrow. This is something that takes an engineering team, takes a hospital team, takes a clinical team, and then an oversight team to make sure everyone's in coordination.

Zachary Klaassen: Absolutely. Any take-home messages for anything we haven't hit on that you want to highlight from today for our listeners?

Vipul Patel: No. I think this was a huge step forward for surgery. I think this is the next evolving frontier where we can operate and teach remotely. And I think the humanitarian implications, and not just the ability to teach, but to help. You're a residency director and if your residents leave, wouldn't it be great to monitor them for their first 10 cases? I think they would all sign up for that and you could do it from your home. Let them operate and just in case there's a problem, you just fix it and give it back.

I mean, imagine the complication reduction you would have. Imagine the people who would actually adopt the technology because they got through the learning curve. This is huge. I think every company would like to use their technology and train remotely if they could. Because it would save them money and it would have huge adoption implications.

I think for neuro and cardiac, these are probably the first two frontiers. Telestroke, remote cardiac intervention. This is the biggest healthcare inequity where people don't have access. And so if we can do those two things remotely, that's probably the first thing we need to do.

Zachary Klaassen: Absolutely. Vip it was great having you on UroToday. Congratulations on just an enormous day for, like you said in your article, not just surgery, but for the future. I think this has so many implications. Appreciate you taking time out of your busy day.

Vipul Patel: Awesome. Thank you so much.