The problem with surgery is our humanness. Fitting a pair of surgeon's hands deep inside a patient's body requires a large incision, and even with a magnifying loupe the surgeon can't see the tiniest of nerves, especially a surgeon with "45-year-old eyeballs," as Dr. James C. Jensen puts it.
That's the beauty of robotic surgery, says Jensen, one of the first Utah surgeons to use a device known as the da Vinci robot. On a recent afternoon, Jensen used the da Vinci to remove a patient's prostate while sitting about 10 feet away.
Because robotic surgery doesn't require a large incision and because the da Vinci allows the surgeon to magnify the surgical field up to 10 times its normal size, the operation is less invasive, more precise and heals faster, Jensen says.
That's good news in Utah, which has the highest prevalence of prostate cancer of a predominantly white population in the world.
Jensen is one of the few surgeons locally who perform robotic prostatectomies, and Salt Lake Regional Medical Center is the only hospital currently using the machine.
Even after completing more than 50 such prostatectomies, he is still awed by the device. "It's like being back at the invention of anesthesia," says Jensen. "We stand at the confluence of new trends and treatment. . . . It's like a cloud of stardust, a nebula. We're seeing a new world form."
The new trend that has coincided with this new treatment, he says, is the discovery that more and more younger men are developing cancer of the prostate, the male secretory gland that produces semen. Jensen recently found the disease in a 35-year-old man.
The "discovery incidence" of prostate cancer has also increased for older men, in part due to the "coming of age" of baby boomers, and the realization that cancer can exist even at very low levels of PSA (prostate specific antigen).
The treatment used to boil down to "watch and wait," Jensen says, because the disease was found more often in older men. But even for younger men, doctors were cautious about removing the prostate, he says.
Since 1987, doctors have been able to measure the levels of PSA in the blood higher levels can indicate the presence of cancer or some other problem with the prostate. If cancer is diagnosed, doctors continue to monitor the levels of PSA, and for years it was believed that if the PSA was rising slowly it meant that the cancer was growing slowly, too. "But it's an assumption that is frequently wrong," Jensen said.
And efforts to cure prostate cancer with radiation, he says, have not been as successful as originally hoped.
"Prostate cancer has in it an inherent mechanism free radical scavengers that resist radiation," says Jensen.
Because Jensen is one of the pioneers in robotic prostate surgery fewer than 100 doctors in the world have done more than 20 cases he keeps meticulous notes of his progress and the lessons he learns from each surgery. Although his first operations took eight tedious hours, they now routinely last between three and four.
In typical radical prostatectomies, an incision is made from the navel to the public bone. But robotic surgery requires only six puncture wounds in the abdominal area. "Do you remember Pythagoras?" Jensen asks, as he and nurses Adriana Montgomery, Alice Cooke and Connie Gourdian measure the exact spots where these puncture wounds will be placed on the abdomen of the 70-year-old man sedated on the operating table. The six spots form a triangle that must line up exactly with the arms of the robot that will soon be positioned overhead.
The six puncture wounds serve as ports for the robot's arms and eyes. A camera is inserted in the hole above the navel; the other holes provide access for the miniaturized, finely articulated electric knife, cauterizing tool and telescope that are threaded down into the patient's body.
While the nurses position the instruments, Jensen sits at a console across the room. He takes off his shoes, then positions his head and gloveless hands into the machine. Unlike laparoscopic surgery, which provides only a two-dimensional view, the da Vinci is 3-D, and all movements are made just as they would be if he actually had his hands in the patient's body. (Laparoscopy requires a reverse, counter-intuitive manipulation of the instruments.)
Moving his hands inside the console, Jensen begins his remote-control slicing into the patient's abdomen, through each thin layer of tissue, blood vessels and fat, deeper and deeper, heading for the walnut-sized prostate.
"The blood loss is less because you can see the fine blood vessels so much better," Jensen explains. "I can see millimeters. I can see nerves. I can see the things I couldn't see with standard surgery." And he's able to do things not possible with standard surgery: use a needle and suture a third the size of normal, tie knots faster and better, position staples he couldn't otherwise, he says.
Robotic surgery, he reports, reduces the hospital stay from two days to one; reduces acute recovery from two weeks to three days, and chronic recovery from four weeks to two weeks. Fifty percent of men having robotic surgery are "pad free" within one month, compared to six months with conventional surgery. And 50 percent have erectile function within six months, compared to one year for conventional surgery.
The most-asked question by men about to have their prostates removed, though, is, "When will I be able to golf again?" Jensen reports.
"Chip and putt in four days, drive in two weeks." Driving straight, though, that's different, he says.Even robotic surgery has its limitations.