Doc: ‘I Forgot I Was 7000 Miles Away' During Surgical First
On a cold Wednesday morning in January, Ruben Olivares, MD, sat down at a computer workstation in Cleveland to perform surgery on a man with prostate cancer. Olivares, a urologist at Cleveland Clinic, Cleveland, directed a robot to send high-intensity, focused ultrasound waves to the tumor. But this time, the patient was not in a nearby operating room, or in the same building — or even the same country. Instead, the man was in a facility more than 7000 miles away, at Cleveland Clinic's hospital in Abu Dhabi.
Ruben Olivares, MD, a urologist in the Glickman Urological Institute at Cleveland Clinic in Ohio, worked remotely with Waleed A. Hassen, MD, the chair of urology at Cleveland Clinic, Abu Dhabi, who managed the on-site procedure in which a man with prostate cancer underwent high-intensity focused ultrasound therapy to ablate his tumor.
In what is believed to be the world's first remotely-conducted, transcontinental robotic-assisted focal therapy for prostate cancer, Waleed Hassen, MD, MBA, department chair of urology for the Abu Dhabi hospital, sat near the patient to launch the software program and transferred to Olivares control of the robotic arm used to deliver the therapy.
'During the procedure, I forgot I was 7000 miles away,' Olivares told Medscape Medical News . 'I did a case in a regular fashion and, with all the people interested, I started doing teaching and educated everyone. The case was seamless,' thanks in part to an imperceptible video lag of less than 120 milliseconds, he added. The patient, expected to have a life expectancy of at least 10 more years, is now cancer-free, Olivares said.
The procedure was intended to serve as proof that this type of remote surgery was possible using a regular landline. The achievement was the result of 2 years of planning, Olivares said, including testing the equipment and finding an appropriate patient who was agreeable.
Olivares traveled to the Abu Dhabi location in 2023; he has since established a tumor board for which colleagues at Cleveland Clinic's various locations — including outposts in Florida, Canada, Nevada, and the United Arab Emirates — send him MRIs, biopsies, and other test results, and they discuss who is an appropriate candidate for focused ultrasound for prostate cancer.
Olivares and his colleagues incorporate MRI images and a robotic platform that scans the prostate in real-time to determine exactly where to aim the ultrasound to ablate the tumor while sparing nearby healthy tissue. If a patient moves, Olivares can adjust the robotic arm accordingly.
'The future looks very promising,' Olivares said. 'We have to be able to offer new alternatives, new ways to solve all problems, regardless of where the patient lives.' He foresees a time when he could help guide physicians performing the procedure elsewhere while staying connected in real time: 'If a problem happens, I can take over and do the case from here.'
Accelerating Adoption
Teleinterventions between physical locations have occurred since the 1990s, but the field is gaining momentum, said Louis Kavoussi, MD, MBA, chairman of urology and director of Teleintervention at Northwell Health in New Hyde Park, New York. The first widely known telesurgery occurred in 2001, when surgeons at Mount Sinai Medical Center in New York City performed a remote, robotic gallbladder removal on a patient in Strasbourg, France. While successful, the procedure, supported by French Telecom, was determined to be too expensive for the transatlantic cable to be done on any regular basis, and garnered little interest, he said.
With recent advances in technology, surgeons in China, Japan, and India have been performing robotic urological telesurgeries in remote locations, said Vipul Patel, MD, medical director of the Global Robotics Institute at AdventHealth in Celebration, Florida, and director of Urologic Oncology at the AdventHealth Cancer Institute.
'There's just a huge interest' in the technology, Patel said. 'All the societies, all the countries, all the robotic companies — I think we're starting to realize that we can truly help healthcare equity globally with telesurgery, and everyone's just jumping on board now.'
Patel said the COVID-19 pandemic gave the field an important push. 'Patients could be seen virtually for medical issues but not for surgery. Telesurgery was born out of the need to treat patients remotely,' he said. A small number of medical schools, including Duke University, Durham, North Carolina, and McMaster University in Hamilton, Ontario, Canada, have started training programs in telesurgery.
In 2023, Patel and colleagues from AdventHealth traveled to China, Japan, and India to see their equipment and work with companies there to develop telesurgery applications. As part of the visit, they were given licenses to operate in China, where Patel performed five robotic prostatectomies on patients located up to 5000 km (about 3106 miles) away to test the capabilities, with surgical colleagues at the patients' bedsides in case the equipment malfunctioned or another problem arose. The surgeons present locally never had to intervene.
'It was the same as if the patient was in our home OR [operating room],' Patel said. 'It was amazing that we could operate at such distances, and it was if the patient was in the room with us.'
Patel's training facility in Florida is now connected to robotic systems in Brazil, Kuwait, Angola, China, and Morocco to teach and coach surgeons through telesurgeries in those countries.
'The global implications in terms of humanitarian healthcare equity are massive,' said Patel, who gave a plenary talk on telesurgery for the American Urological Association (AUA) 2025 Annual Meeting in Las Vegas last month. 'If we could teach remotely from here to underserved areas of the world, we could actually advance healthcare. Obviously, it helps patient care as well, But I think first, if you could teach remotely, you can help so many more people.'
Conquering Lag
Some hurdles still to be worked through are determining how far apart surgeons can be from the patient to perform operations safely, achieving a lag of < 155 milliseconds in some areas, and ensuring secure connections that cannot be breached. Still, telesurgeries could become more mainstream in the United States and other areas within 2-5 years, Patel and Kavoussi said.
Legal and patient care issues also must be worked out, he said. Patel is executive director of the Society for Robotic Surgery, where he is working on guidelines for telesurgeries to ensure the patient is protected and clinicians conduct procedures in an ethical, orderly manner.
Device manufacturers are working on designs for 'several hundred' new robots with different capacities, Kavoussi said. For example, some could be employed in telestroke programs where experts in one hospital can use them remotely to guide a wire through a patient's body to the site of a clot for the delivery of clot-busting drugs or devices to remove a blockage, in any emergency room.
'This is something that's coming,' he said. 'This is just the tip of the iceberg is what we're beginning to see now.'
Kavoussi is on the board of Sovato. Olivares and Patel reported no relevant financial conflicts of interest.
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