Highlights of the TeleS Trial
The TeleS Research Group has published a landmark multicentre randomized controlled trial in the BMJ, providing high-level evidence for the reliability of remote robotic surgery. The key findings include:
- Telesurgery achieved a surgical success rate non-inferior to traditional local robotic surgery, with a success probability difference of only 0.02.
- The Bayesian posterior probability for non-inferiority was calculated at 0.99, far exceeding standard thresholds for clinical confidence.
- Technical performance remained stable across distances ranging from 1000 km to 2800 km, with mean round-trip network latency staying below 50 ms.
- Clinical outcomes, including perioperative complications, early recovery metrics, and oncological results, showed no substantial differences between remote and local cohorts.
Background: The Long-Distance Ambition of Modern Surgery
For decades, the concept of telesurgery—performing an operation on a patient located at a different site from the surgeon—has been a cornerstone of medical futurism. While the first transcontinental robotic operation, known as the Lindbergh Operation, was successfully performed in 2001, the widespread adoption of telesurgery was long hindered by technical limitations. Issues such as prohibitive network latency, signal instability, and the lack of high-bandwidth, low-latency infrastructure like 5G or dedicated fiber optics created a ‘safety gap’ that many clinicians felt was insurmountable for routine practice.
In the field of urology, robotic-assisted surgery has become the gold standard for procedures like radical prostatectomy and partial nephrectomy. However, access to highly skilled robotic surgeons is often concentrated in major metropolitan academic centers. Telesurgery offers a potential solution to this geographical disparity, allowing expert surgeons to provide care to patients in remote or underserved areas without requiring the patient to travel. The TeleS trial was designed to rigorously evaluate whether modern network infrastructure can support these complex operations with the same reliability as local intervention.
Study Design: A Multicentre Non-Inferiority Framework
The TeleS trial was a multicentre, non-inferiority, randomized controlled trial conducted across five hospitals in China between December 2023 and June 2024. The study enrolled 72 patients scheduled for radical prostatectomy or partial nephrectomy—two procedures requiring high precision and complex reconstruction.
Participants were randomly assigned in a 1:1 ratio to either the telesurgery group or the local surgery group. In the telesurgery arm, the surgeon operated from a console located between 1000 km and 2800 km away from the patient. The local surgery arm involved the surgeon and the patient being in the same operating room. The primary outcome measure was the probability of surgical success, defined by a medical team using pre-established criteria including the completion of the planned procedure without conversion to open surgery and the absence of major intraoperative technical catastrophes. The non-inferiority margin was set at an absolute reduction in success probability of 0.1.
Primary Outcome: Redefining Surgical Success
The results of the intention-to-treat analysis confirmed that telesurgery is non-inferior to local surgery. The success probability difference was 0.02 (95% credible interval -0.03 to 0.15). Utilizing a Bayesian statistical model to account for clustering by surgeon, the study found a 0.99 posterior probability that telesurgery met the non-inferiority criteria. This high probability underscores the robustness of the surgical outcomes despite the immense geographical distance between the surgeon and the patient.
Critically, the success of the surgery was not just a measure of whether the operation was finished, but whether it was performed to the same standard. The lack of significant difference between the two groups suggests that the spatial separation does not inherently degrade the quality of the surgical intervention when supported by appropriate technology.
Secondary Outcomes: Clinical Recovery and Operational Safety
Beyond the primary success rate, the trial scrutinized 13 clinical secondary outcomes and four technical parameters. Key findings in the clinical domain included:
Operative and Recovery Data
There were no significant differences in operative time, estimated blood loss, or the rate of intraoperative complications. Postoperatively, the early recovery metrics—such as time to first flatus, duration of hospital stay, and pain scores—were comparable between the two groups. Follow-up at four and six weeks postoperatively revealed no significant differences in the incidence of complications or oncological markers (e.g., surgical margin status).
Medical Team Workload
One concern regarding telesurgery is the potential for increased cognitive load or stress on the surgical team. However, the study found that the workload of the medical team, assessed through standardized metrics, did not differ substantially between the remote and local settings. This suggests that the current interface for telesurgery is intuitive enough that it does not impose an undue burden on the operator or the local assisting staff.
Technical Performance: Overcoming the Latency Barrier
The technical success of telesurgery hinges on the quality of the network connection. The TeleS trial utilized advanced network solutions to connect the five participating hospitals. The data showed:
- Network Latency: The mean round-trip network latency ranged from 20.1 ms to 47.5 ms. In the context of robotic surgery, latency below 100 ms is generally considered imperceptible to most surgeons, and the TeleS trial stayed well within this ‘safety zone’.
- Frame Loss: Video stability is crucial for depth perception and tissue handling. Frame loss during the procedures was minimal, ranging from 0 to 1.5 per telesurgery, ensuring a smooth and continuous visual field for the surgeon.
- System Stability: There were no recorded system malfunctions that compromised patient safety or necessitated a transition to local control during the telesurgery sessions.
Expert Commentary and Limitations
The TeleS trial represents a significant step forward, but experts note several areas for consideration. First, the sample size of 72 patients, while sufficient for a non-inferiority trial of this nature, is relatively small. Larger, global studies will be needed to confirm these findings across different healthcare systems and network infrastructures. Second, the trial was conducted in a highly controlled environment with specialized network support; the reliability of telesurgery in regions with less stable internet infrastructure remains to be seen.
Furthermore, while urological procedures like prostatectomy are well-suited for robotic platforms, the application of telesurgery to emergency trauma or highly vascular cardiac procedures may present different challenges regarding latency tolerance and the need for immediate physical intervention. The role of the ‘bedside assistant’ (the local surgeon) remains vital, as they must be capable of taking over the operation instantly should a technical failure occur.
Conclusion: The Dawn of the Global Operating Room
The reliability of urological telesurgery is no longer a matter of speculation. This multicentre randomized controlled trial provides the highest level of evidence to date that remote robotic surgery is as safe and effective as local surgery for complex urological procedures. By proving non-inferiority across distances of up to 2800 km, the TeleS Research Group has demonstrated that the ‘Global Operating Room’ is a clinical reality.
As network technology continues to evolve with 6G and improved satellite communications, the barriers to surgical expertise will continue to fall. This study paves the way for a future where a patient’s access to life-saving surgical precision is determined by clinical need rather than their proximity to a major medical center.
Funding and Trial Registration
This study was supported by various national medical research funds in China. The trial is registered at ChiCTR.org under the identifier ChiCTR2300077721.
References
Wang Y, Xia D, Xu W, et al. Reliability of urological telesurgery compared with local surgery: multicentre randomised controlled trial. BMJ. 2026 Jan 28;392:e083588. doi: 10.1136/bmj-2024-083588. PMID: 41605542.
