Twenty-five years ago, robotic surgery was an experimental technology available in only a handful of centres worldwide. Today, it has become the standard approach for many urological procedures, helping surgeons operate with a level of precision that was previously difficult to achieve.
The technology is now entering a new phase. Competition is increasing, costs are beginning to fall, and surgeons have already demonstrated the ability to operate on patients thousands of kilometres away through tele-surgery.
Urologist Dr. Png Keng Siang discusses how robotics transformed urology, why the field embraced the technology before many others, and where the next generation of robotic surgery may take patient care.
The pelvis is an unforgiving terrain, with organs and structures located close together in a narrow space. As such, precision matters enormously when operating in the pelvis. In prostatectomy, the final step involves joining the bladder to the urethra — an anastomosis over an opening roughly the diameter of a urinary catheter, sutured with fine thread in a confined space deep in the body.
"With laparoscopy, it was a very difficult task," Dr. Png explains. "We used to commonly encounter anastomotic leakages after surgery because of the poor anastomosis. With robotic surgery, anastomotic leak is almost zero these days."
The wristed instruments that robotic systems provide are capable of turning at tight angles that straight laparoscopic tools cannot. When combined with three-dimensional visualisation and tremor filtration, this results in a level of precision that laparoscopy cannot consistently replicate in the deep pelvis.
Robotic prostatectomy is now established as superior to open surgery on both oncological and functional outcomes. Virtually every radical prostatectomy in Singapore is done robotically.
Beyond prostate surgery, robotic partial nephrectomy has become the standard of care for small renal tumours. Rather than removing the entire kidney, the surgeon excises only the tumor and repairs the organ, preserving as much kidney function as possible.
The challenge in such a surgical procedure is time. To operate safely, the surgeon must clamp the kidney's blood supply, rendering it temporarily ischemic. The shorter time the surgeon takes to operate, the less damage will be done to the remaining kidney tissue.
Dr. Png co-authored a study analysing nearly 5,000 patients, finding robotic partial nephrectomy superior to laparoscopic partial nephrectomy in conversion rates, complications, ischemia time, and surgical margins. The Ministry of Health subsequently approved robotic partial nephrectomy as the standard of care for complex renal tumors, patients with a solitary kidney, and those with impaired renal function, where minimising ischaemia time is especially critical.
FireFly, the near-infrared imaging technology also discussed by his colleague Dr. Eugene Yeo, has particular utility here. By injecting Indocyanine Green (ICG) dye and activating the fluorescent camera, a surgeon can identify which artery supplies blood to a tumor and selectively clamp only that vessel, thus sparing the rest of the kidney from ischemia entirely while the tumour is removed.
"The artery I clamped is supplying the tumor," Dr. Png explains, describing a case where two separate arteries supplied blood to a single kidney. "Therefore, I can safely proceed with excising the tumour, repairing the kidney and sparing the rest of the kidney from total ischemia."
For the better part of 25 years, the da Vinci system from Intuitive Surgical was effectively the only clinical robotic platform available. Its patents have now expired, and the field has changed.
Over the past five years, a new generation of robotic systems has entered clinical practice. The CMR Versius from Cambridge, the Hinotori from Japan, the Hugo system from Medtronic, India's SSI Mantra, and several platforms from Chinese manufacturers have all come to market. Some are already Health Sciences Authority (HSA)-approved and in clinical use in Singapore.
"For the last 10 to 15 years, we were just stuck with da Vinci," Dr. Png says. "However, in the last five years, competitors have been knocking on our doors asking us to try their systems. It's very exciting times."
Dr. Png admits to having tried most of the new platforms. Two are now present in Singapore, in clinical or training settings. The Hinotori is in use at Singapore General Hospital, with a training unit at Academia. The Hugo system, which uses a modular design — each robotic arm on its own mobile unit rather than a central cart — is HSA-approved and under review at several public hospitals. The Edge Medical system from China, backed by major institutional investors including Temasek, was recently trialled at Farrer Park Hospital.
"If I didn't tell you it was Edge Medical, you would think it was a da Vinci Xi," Dr. Png notes. "It's just like a da Vinci. That's good, it means we can replicate our surgery exactly the same way."
The most striking development in robotic surgery Dr. Png described is not a new instrument or a new platform; it is tele-surgery. Through the technology, a surgeon will be able to operate using a console in one country while the robot and patient are in another.
In 2023, researchers at the National University of Singapore — led by Professor Jimmy So and Professor Kim Khoi — demonstrated robotic surgery over a 5G network, with the console in Singapore and the robotic cart in Japan. The latency of 107 to 132 milliseconds was short enough that the operating surgeon could not perceive any lag. The procedure was performed on a live porcine model and published in 2024.
Before the paper was published, Professor Zhang Xu from Beijing's PLA Hospital had already performed tele-surgery on four human patients — two prostatectomies and two nephrectomies — while attending a conference in Rome. He was over 8,000 kilometres away from his patients in Beijing and the Edge Medical robot he controlled, with no reported complications arising from the procedures.
American Professor Vipul Patel from Florida subsequently performed tele-surgery on patients in Angola — 11,000 kilometres away — using the MedBot system, another Chinese-manufactured platform.
"It's been shown to be repeatable and feasible," Dr. Png says. "The technology is there."
For patients, robotic surgery may still seem like a futuristic technology. In reality, it has already become routine for many urological procedures, delivering measurable improvements in precision, recovery, and organ preservation.
What is changing now is not whether robotic surgery works, but how accessible it becomes. As new platforms enter the market and competition increases, more hospitals and more patients are likely to benefit from technologies that were once available only in specialised centres.
The idea of a surgeon operating from another country may still sound extraordinary. Yet if the past two decades have shown anything, it is that what seems futuristic in robotic surgery has a habit of becoming standard practice sooner than expected.
The question for the next decade is not a matter of whether robotic surgery works, but how far it can reach.
