Machines monitoring an elderly man's vital signs emit steady beeps while a surgeon uses one arm to grasp a dissector and deftly peel layers of tissue from the patient's cancerous bladder. Another arm snips at the base of the fleshy organ with a steel claw while a third manipulates a tiny camera that sends gorgeous images of glistening innards onto video screens all around the darkened room. Every now and then, a fourth arm cauterizes blood vessels shut with bloodless precision. It takes several hours to dissect and remove the bladder but those arms, working through abdominal holes no wider than a pen, never hesitate and never tire.

The eerily precise and silent surgeon hovering over the Madison patient last month in a UW Hospital operating room was a robot named da Vinci, after Leonardo Da Vinci, the 15th century Italian genius who made sketches and then a wooden model of the world's first human robot. Modern-day da Vincis have revolutionized the surgical world in the past few years, achieving a level of precision and visibility that once would have been unimaginable.

They have not, however, completely replaced human doctors. Every move of UW Hospital's 2,500-pound giant was being controlled at an operating room console by Dr. Jason Gee and Dr. David Jarrard. They were pioneering yet another new use of robotics - this time for a cystectomy, or bladder removal and reconstruction. "The technology is an extension of our hands," said Gee.

Last year 136,000 robotic procedures - quadruple the number in 2005 - were done worldwide. There are 825 da Vinci systems in use at U.S. hospitals, 21 of them in Wisconsin, two in Madison. The robots now perform most prostate removals in Madison and are poised to take over the majority of hysterectomies as well. Doctors like urologists Jarrard and Gee are constantly exploring what other kinds of minimally invasive surgery might be possible.

"Robotic surgery has become the standard of care," said Aleks Cukic, vice president of strategy for da Vinci's California manufacturer, Intuitive Surgical, which raked in a record $875 million in revenues last year and projects billions more in the years ahead.

Bladder cancer is an important new frontier for the robot. The disease afflicts nearly 70,000 people every year and killed more than 14,00 last year alone, according to the National Cancer Institute. It is the fourth most common cancer among men, and it can hit suddenly. Mike Martin, 60, a retired Verizon lineworker, said he went to the doctor because he "urinated blood." Martin's doctor in Brodhead sent him to a urologist in Janesville, who sent him to Madison for a second opinion. There Dr. Jarrard advised him to get rid of his cancerous bladder and replace it with one constructed from his own intestines.

That news was startling enough, but then Jarrard told Martin a robot would do part of the surgery. "I didn't know what to think," recalled Martin, who had never been in a hospital for any sort of health problem until last fall. "My idea of a robot was all made of steel, in a cartoon, or on an assembly line. I never had any idea they would be working on me."

Before he went into surgery, he filled out a will and gave it to his wife, Bonnie, his high school sweetheart. But he survived just fine. Within a few weeks he was riding his 4-wheeler and soon he was chopping wood and fishing with his grandkids again, too. "I feel great," he said. "I'm back to doing everything I did before." Martin and his doctors say that he has up to a 70 percent chance of complete recovery from the cancer. And within a year, he said, his reconstructed bladder should be working as good as his old one. "I'll be just like one of you," he said.

Jarrard and Gee have done only about 15 of the cystectomies so far in Madison, but they and other UW physicians have done hundreds of other robotic operations altogether, especially prostectomies, removal of the prostate gland. The doctors admit that in spite of their surgical skill, they have one flaw: they are human. The robot doesn't twitch or tremble. Its joints can turn 360 degrees, giving it greater flexibility than a mere mortal wrist. And its cameras allow physicians to see magnified 3-D images of even the deepest and darkest nooks and crannies of the human anatomy.

Robotic surgery offers other distinct advantages over the standard "open" surgeries of the past, they say, and even over other forms of minimally invasive surgery, or laparoscopy, which surgeons perform with long instruments through punctures in the human body. That spares patients the trauma of having their bodies cracked or cut open and spares surgeons the mess of having to work directly with blood and guts.

In robotic surgeries, small cameras are inserted through the holes, allowing surgeons to watch their work magnified up to 10 times on video screens. They can also see 3-D images through a binoculars-like viewer at their console, where they sit and press foot pedals and manipulate knobs to control the robot.

During the UW surgery the surgeons looked like they were playing a gory video game instead of operating on a live patient. They were a good 10 feet away from the patient, who was covered, except for his stomach, which protruded through all the sterile cloths and plastic covering the operating table and machines. The stomach had been "insufflated," or filled with carbon dioxide gas to make it expand, giving the surgical team better visibility and more space to work in, and helping staunch bleeding. The robot's arms were attached to steel instruments, which punctured the abdomen, occasionally lifting in and out while a doctor replaced one with another.

Once the robot dissected the bladder and pulled it out like a deflated balloon through one of the small access holes, Gee swung into action - the old-fashioned way. He cut a 10-centimeter incision into his patient's belly right below the naval, plucked out a section of intestine, and stitched it into a new reservoir, or neobladder. Then he sewed everything back together. "I basically hand-sewed a new bladder and reconfigured it to fit the patient's anatomy," he said. Some surgeons allow the robot to do even this delicate part of the operation, Gee said. But he enjoys the hands-on work and doesn't want to relinquish it, at least not yet.

For all its skill, this particular robot will probably never become a member of every Wisconsin hospital's surgical team. At around $1.65 million, it is prohibitively expensive for nearly all but the biggest metropolitan hospitals. And that price tag doesn't even include a basic inventory of instruments and scopes, which adds another $200,000 to the tab. (The instruments must be replaced after 10 operations or so.) Hospitals also sign an annual $150,000 service contract that allows them to call product support at 1-800-876-1310 if they run into problems. The robot is built with a number of safety checks and human surgeons are trained to step in quickly if there is any sort of problem and switch to an "open" operation. Gee said he has never had to do so.

Which brings up another obstacle for many local doctors - training required to use the robot is time-consuming and complex. "Any time there is a new technology, some surgeons will be reluctant to make a change, particularly when they have skills they have developed over decades," said Ellen Hartenbach, a gynecologic surgeon at UW who counted herself among the early skeptics but is now a convert. "It's less hands-on, but there are real advantages," she said. "You have much more precision, you can control the bleeding, and you can send patients home the next day."

Yet robots are evolving so quickly that soon the da Vinci might seem as primitive as the first surgeons of the 19th century, who dressed in street clothes and scooped out brain tumors with their bare hands. Israeli scientists are experimenting with miniature nano-robots that can navigate through the bloodstream. A California company headed by Frederic Moll, one of the founders of da Vinci's parent company, is marketing a robot that can pluck and transplant 1,000 individual hair follicles per hour from one part of the scalp to another to treat baldness.

And the military, whose research into remote-control technology helped inspire the da Vinci not long ago, is exploring the concept of a trauma pod for the battlefield. The team of robots would be lead by a robotic surgeon remotely controlled by an actual human surgeon, and a wounded soldier could lie in a robotic bed that could monitor his vital signs, give oxygen, and place an IV.

Does all this seem too futuristic to ever become medical reality? Well, just a year ago Martin would never have guessed that a real life robot would help to save his life. Now he is a grateful fan. "If I needed to do this over again," he said, "I'd want the same people. Yep. The same nurses. The same doctors. The same robot."

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