MINIMALLY INVASIVE HYSTERECTOMY PROGRAM

AT DESERT WOMEN’S CARE

Out-Patient Hysterectomy Program—

Desert Women’s Care is proud to have the first out-patient hysterectomy program in the State, doing surgery at Arizona Surgical Specialist’s Center in Tempe.  Being keenly aware of the costs and hazards associated with hospital-based surgery we have created this program to give patients access to the lowest impact continuum of care involving:

1. Surgical procedure in an Ambulatory Surgical Center (ASC);
2. Recovery at home with family and friends;
3. Daily home nursing visits;
4. Early post-operative physician office visits; and
5. Twenty-four hour telephone access to medical professionals.

We have developed this program on a foundation superb surgical outcomes.  Dr. Demir has performed more than eight hundred consecutive laparoscopic hysterectomies without resorting once to Laparotomy.  Whether Laparoscopic Supracervical Hysterectomy (LSH) or Total Laparoscopic Hysterectomy (TLH), we believe in keeping patients, to the extent practical, out of hospital and returning them to normal functioning as soon as possible.  With a track record of over 90% of patients spending one or fewer nights in the hospital over the last decade, out-patient hysterectomy with home nursing care is the next logical step.

Basis for Out-Patient Hysterectomy,  Same Day Discharge—

Same day discharge after Vaginal or Laparoscopic-Assisted Vaginal Hysterectomy was first described by Stovall and associates in  two publications in 1992.^1-2    A total of 56 patients underwent surgery in a teaching hospital and 53 (94.6%) were discharged home the evening of surgery (within twelve hours).  Taylor reported an even shorter post-operative stay of 4 – 6 hours in 1994 but this abstract involved only 7 patients.³   Also in 1994, Summitt published a larger series reporting 141 of 153 women undergoing VH and LAVH were successfully discharged the evening of surgery.⁴    Of the women discharged the same day, 3 were re-admitted with bleeding issues.

Chou and colleagues reported an Australian experience in which 27 of 30 patients selected prospectively for early discharge were in fact discharged within 24 hours of surgery.⁵  

Hoffman in 2005 presented data from Kaiser Permanente covering 81 patients with same day discharge. Their study did not report how many patients pre-operatively were planned for same day discharge.  Of the 81 patients discharged, nine were subsequently re-admitted.⁶

Gien, et al, in 2011 reported on same day discharge following Gynecologic Oncologic procedures not purely hysterectomies.⁷   Despite being widely cited this article’s results are not referable to our targeted population.

Also in 2011, Perron-Burdick reported on another Kaiser Permanente population discharged the night of surgery.⁸   There is no reported data on how many patients were planned to go home compared to those who actually were discharged.  The same day discharges accounted for 52% of the laparoscopic hysterectomies done in that time period. Within 48 hours only 0.6% of patients required re-evaluation. No injuries were ascribed to early discharge.

Most significantly, Schiavone and associates in late 2012 published a review of 128,634 women undergoing laparoscopic hysterectomy from 2000 to 2010.⁹    They demonstrated a clear trend toward same day discharge, going from 11.3% in 2000 up to 46.0% by 2010.  The rate of re-evaluation for same day discharge patients was 4%.  Even given costs associated with re-evaluation, same day discharge was more cost effective than 1 or 2 day post-operative stays.  No injuries were felt to have been caused by early discharge.

All of the foregoing reports have one thing in common, all surgeries were done in large hospitals.  Large hospitals have the security of emergency access to laboratory, blood transfusion and consultants in other fields if intra-operative complications occur.  Moreover, large hospitals come with an intrinsically high cost base which is probably not required for most of these procedures.    

The foundation for the safety and cost effectiveness of early discharge following minimally invasive hysterectomy is well established as is the trend toward same-day discharge following surgery.

Our program of laparoscopic hysterectomy in an Ambulatory Surgical Center, is simply the next logical step after thorough evaluation of the available information. 

Benefits of Minimally Invasive Hysterectomy—

Minimally invasive hysterectomy has long been demonstrated to be the preferable route for hysterectomy.  Dating to the 1960’s, vaginal hysterectomy was the preferred route for hysterectomy with superior results compared with abdominal hysterectomy.^10-13 Vaginal hysterectomy is the original Minimally Invasive Hysterectomy and, according to the American College of Obstetricians and Gynecologists, remains the gold standard by which other procedures and outcomes are judged.¹⁴ Newer laparoscopic variants (LAVH, TLH and LSH) are shown to have faster recovery, less post-operative pain and similar complication rates when compared with total abdominal hysterectomy.^{10, 15-17}

Dr. Demir has a long record of assuring women requiring surgery have access to the most advanced, Minimally Invasive procedures to ensure minimization of post-operative discomfort, better cosmetic results, quicker return to normal functioning and less time away from work. 

At Desert Women’s Care we have carefully monitored our outcomes over many years. Dr. Demir recently completed evaluation of data for 1125 consecutive hysterectomies performed for benign disease. Of those, 1120 have been successfully completed using minimally invasive techniques (well over 99%). Within that series are over 800 consecutive Minimally Invasive hysterectomies.  

Many Gynecologists believe there are three de-selectors for patients’ candidacy for Minimally Invasive hysterectomy—elevated weight, increasing uterine size and increasing number of prior abdominal surgeries.  Oppositely, we believe all benign hysterectomies should be scheduled as laparoscopic surgeries because these de-selectors are not statistically associated with increased chance of intra-operative conversion to Laparotomy (Abdominal Hysterectomy). Our initial data was presented at the American College of Surgeons Meeting, 2011, and again in 2012 at the Society of Laparoendoscopic Surgeons Annual Meeting in Boston.^18-19

Risks with Elevated Weight (Body Mass Index)

Careful examination of our data showed no statistical association between increasing BMI and failure to successfully complete any listed hysterectomy type:

                                     Total              Laparoscopic            Total                           Grand   

                                    Vaginal           Supracervical            Laparoscopic           Total

Patient Wt (BMI)—

< 18.5                          0 /    6              0 /   18                         0 /   10                         0 /   34

18.5 – 24.9                  0 /  44              1 / 160                         1 /   93                         2 / 297

25.0 – 29.9                  0 /  78              0 / 159                         1 / 211                         1 / 448

30.0 – 34.9                  0 /    8              0 / 130                         1 /   80                         1 / 218

> 35.0                          0 /    4              1 /   37                         0 /   87                         1 / 128

Grand Total               0 / 140             2 / 504                         3 / 481                         5 /1125

Risks with Previous Cesarean Section

The same statistical evaluation of our data showed no relationship between increasing number of prior Cesarean Sections and MIH failure with any listed hysterectomy type or overall.

                                     Total              Laparoscopic            Total                           Grand   

                                    Vaginal           Supracervical            Laparoscopic            Total  

Prior C-Sections—  

0                                  0 / 102             1 / 345                         1 / 289                         2 / 736

1                                  0 /   24             0 / 110                         2 /   86                         2 / 220

2                                  0 /    6              1 /   22                         0 /   65                         1 /   93

3                                  0 /    5              0 /   15                         0 /   11                         0 /   31

>4                                0 /    3              0 /   12                         0 /   30                         0 /   45

Grand Total               0 / 140             2 / 504                         3 / 481                         5 /1125

Risks with Increasing Uterine Size (Specimen Weight)

Gynecologists also commonly believe the larger a uterus the more necessary abdominal hysterectomy becomes.  Our data does not bear this conclusion out:

                                     Total              Laparoscopic            Total                           Grand   

Specimen                   Vaginal           Supracervical            Laparoscopic           Total

Weight (grams)—     

0       -    227                0 /   86             0 / 342                         0 / 121                         0 / 549

228   -    454                0 /   38             1 /   85                         1 /   77                         2 / 200

455   -    681                0 /   10             1 /   47                         1 / 141                         1 / 198

682   -    908                0 /     3             0 /   19                         0 /   81                         0 / 103

>  908                          0 /     3             0 /   11                         1 /   61                         1 /   75

Grand Total               0 / 140             2 / 504                         3 / 481                         5 /1125

Dr. Demir is capable of doing the largest uteri without resorting to laparotomy.  In 2008 he received a Guinness World Record for avoiding laparotomy in a 3200 gram (7 pound) fibroid uterus. 

We do not believe elevated BMI, increasing number of prior C-Sections or bigger uteri require abdominal hysterectomy.  We believe all women having hysterectomy for benign indications should be offered Minimally Invasive Hysterectomy.  Our outcome data confirms our ability to offer these outcomes in a highly reproducible manner.  In our hands every patient is scheduled for a minimally invasive hysterectomy and it is successfully achieved 99.6 % of the time.

Hysterectomy Trends—

To get an idea of the prevalence of various hysterectomy routes locally, Intellimed data for the State of Arizona was examined for the years 2008 - 2010. Changing trends are clearly demonstrated.

The total number of Minimally Invasive Hysterectomies (Vaginal and All Laparoscopic variants including Robot Assisted) is represented by a bar for the years 2008 - 2010. The percentage of all hysterectomies done Minimally Invasively is depicted by the line. For the first time in 2010, the percentage of Minimally Invasive Hysterectomies (Vaginal and all Laparoscopic Hysterectomies) actually exceeded 50%. Although a positive trend toward minimally invasive hysterectomy, much work remains to be done. 

Nationally, Wright and colleagues recently completed a review of changing routes for benign hysterectomy from 2007 through 2010.²⁰  Combined with older data a clear trend away from Abdominal Hysterectomy toward Minimally Invasive Hysterectomy is observed.^21-23

In 2009, ACOG published a Committee Opinion encouraging Minimally Invasive Hysterectomy for most cases of benign uterine disease. ²⁴  The AAGL followed with its endorsement in 2011.²⁵   Despite the opinion of normative bodies, every year in the U.S.A. almost half of hysterectomies are still done via the traditional abdominal route.  In general, benefits of Minimally Invasive Hysterectomy include: 1.) less post-procedure pain, 2.) decreased duration of post-operative admission and recuperation, 3.) decreased loss of productivity in the work place, 4.) improved cosmetic result, and 5.) enhanced patient satisfaction. The recognized superiority of minimally invasive hysterectomy, whether vaginal ^26-30  or laparoscopic, ^{2,16-17,26,29-30}  is well documented in the medical literature and is affirmed by the American College of Obstetricians & Gynecologists.

Despite advantages, the transition to minimally invasive hysterectomy remains slow. The most common reasons cited by Gynecologists forsaking Minimally Invasive Hysterectomy for Abdominal Hysterectomy include large uterine size, previous abdominal surgeries and elevated BMI. In the most skilled hands these common de-selectors are not true barriers to access to Minimally Invasive Hysterectomy. Among physicians skilled in minimally invasive surgery, prior largest uteri removed included a 2421 gram uterus removed vaginally, ³¹  a 2418 gram uterus removed via hand-assisted laparoscopic hysterectomy, ³²  and a 3200 gram uterus removed via laparoscopic assisted hysterectomy. ³³  Prior abdominal surgery has also been shown to have no significant influence on failure rate of Minimally Invasive Hysterectomy.³⁴  Finally, elevated BMI confers no greater risk of morbidity in women undergoing laparoscopic versus abdominal hysterectomy.^35-36

Intent To Treat Cost Analysis—

In order to effectively demonstrate the cost saving achievable in our program of Out Patient Laparoscopic Hysterectomy, an Intent To Treat analysis is presented.  It is not fair to only look at a group of patients who would have laparoscopic hysterectomy in the Ambulatory Surgical Center (ASC) vs. those performed in a hospital.  To properly appreciate the savings we can offer in our program, one must look at a cohort of women to be treated with hysterectomy for benign disease in the general population and then compare costs to those of our program.

Issues impacting this Intent To Treat analysis for benign hysterectomy are as follows:

1. To be credible this analysis must have a scientific foundation;
2. This evaluation requires actual costs of all of the various hysterectomy alternatives calculated in the contemporary time frame and in the same study population (TAH- Total Abdominal, VH- Vaginal, LH- Laparoscopic and RH- Robotic).  Taking the cost of an abdominal hysterectomy from one paper and comparing it to that of a laparoscopic or robotic hysterectomy from another paper from another institution in another year would not yield a fair analysis.  Only eight papers in the literature have some of the information required for this analysis.^37-44   Two are from different countries where reimbursement systems and currencies are not comparable.^37-38  Three are significantly dated.^42-44 The contemporary study with the largest numbers only compares two types of hysterectomies.³⁹  The remaining two studies are from the same investigators at Brigham and Women’s Hospital.^40-41  The only paper that evaluates differential costs of each type of hysterectomy in a single time period is used as the basis of this Intent To Treat analysis.⁴⁰ 
3. Examination of this review will demonstrate the merit of our proposal;
4. Any insurance company can substitute their “actual” claims experience into the “General Hysterectomy Population” analysis to calculate their cost for providing 100 benign hysterectomies;
5. Any insurance company can compare their cost, calculated above, to the price in our proposal to demonstrate the benefit of working with us.

Surgeon’s Performance Guarantee—

Consistent with what we have done in the past with our “shared risk” program in Reproductive Medicine (Center for Human Reproduction in Chicago) and in an effort to show our commitment to achieving Minimally Invasive outcomes, we will waive the surgeon’s fee if laparoscopic hysterectomy is converted to abdominal hysterectomy (TAH).  

Why Not Use The Robot—

A general rule in medicine is that for a new procedure to gain wide-ranging acceptance it must first demonstrate its superiority over the procedure it is replacing.  Years of publications now conclusively demonstrate benign Robotic Hysterectomy takes longer, offers no improvement in outcome and is more costly.^39,45-47

The only benefit to robotic hysterectomy in benign gynecology has been its significant penetrance amongst GYN surgeons not previously performing vaginal or laparoscopic hysterectomy resulting in a significant decrease in abdominal hysterectomy rate in the U.S.   In a population-level discussion, a cogent argument can be made that although no verifiable quality benefits are achieved in robotic compared with conventional laparoscopic hysterectomy for benign disease, that the additional cost of robotic assisted laparoscopy is negated by the benefit of more patients actually achieving a minimally invasive hysterectomy outcome.

We are not, however, debating population-level access to Minimally Invasive Hysterectomy; we are offering a program dedicated to providing successful Laparoscopic Hysterectomy to referred patients.  Because of our superb outcome data with conventional Laparoscopis Hysterectomy, we simply do not need to add the additional cost associated with robotics to perform Minimally Invasive Hysterectomy.

Why Every Insurance Is Not Accepted at ASSC, or The Difference Between Fair Cost and What Insurance Actually Pays—

In a typical business the “price” for a service is usually determined by the actual “cost”
of delivering that service plus a reasonable “profit” for the entity.

Medicine is not a typical business.  Because the government compels hospitals to care for anyone without regard for their ability to pay, costs must be shifted from those individuals to those who can pay for their services so the hospital stays open.  Hospitals must take in more from paying customers.  A free standing Ambulatory Surgical Center (ASC) does not share the governmental mandate to take all comers.  Therefore, the cost of offering a service is invariably lower in an ASC.   This is why for patients personally financing their procedure, an ASC is the most cost effective choice.

This distinction does not always apply when insurance companies are involved.  Unlike a restaurant that expects to get 100% of your check plus a gratuity for the wait staff, medical facilities and physicians are often paid what the insurance wants to pay.  This is a novel concept.  Although you are not able to pay 50% of your dinner bill and walk away, this is exactly what insurance companies often do.

Because insurance companies are able to dictate what they will pay for a surgery, many facilities and surgeons will actually provide some services below their costs hoping to achieve a profit on other types of procedures or services.  This is why we do not have contracts for Out-Patient Hysterectomy with every insurance plan.

Conclusion—

ASSC’s program of out-patient laparoscopic hysterectomy represents the evolution of hysterectomy care.  Our program has been developed after a thorough review of the literature, a reasoned assessment of the trends in post-operative hysterectomy care and is based on a solid foundation of consistently positive outcomes achieved over many years.  ASSC and Dr. Demir want to provide out-patient hysterectomy services and other complex gynecologic procedures for your patients.

To view our 2014, AAGL abstract on the first 100 cases in our Out-Patient Hysterectomy program, click the meeting icon, below:

To view our 2013, AAGL abstract on preliminary data from our Out-Patient Laparoscopic Hysterectomy program, click the meeting icon, below:

To view the AAGL 2011 position paper on Minimally Invasive Hysterectomy, click the Left icon, below. To view the AAGL 2013 position paper on Robotic Hysterectomy, click the Right icon, below.

To read our publication, "Safe Laparoscopic Removal of a 3200 grams Fibroid Uterus," click on the SLS icon below. Click on the Guinness logo to see our World Record Certificate for "Largest Uterus Ever Removed Without Resorting to Laparotomy." The award was given for the case described in the associated article in JSLS.

To view DWC's Video Poster from the 2012 Society of Laparoendoscopic Surgeons (SLS) Annual Meeting, De-Selectors for Minimally Invasive Hysterectomy, click on the icons below.

To view DWC's two Abstracts from the 2011 Clinical Congress of the American College of Surgeons on Traditional De-Selectors for Minimally Invasive Hysterectomy, click on the icons below.

References—

1. Stovall TG, Summitt RL, Bran DF, Ling FW. Outpatient vaginal hysterectomy: a pilot study. Obstet Gynecol  1992;80:145-9.
2. Summitt RL, Stovall TG, Lipscomb GH, Ling FW. Randomized comparison of laparoscopy-assisted vaginal hysterectomy and standard vaginal hysterectomy in an outpatient setting. Obstet Gynecol  1992;80:895-901.
3. Taylor RH. Outpatient laparoscopic hysterectomy with discharge in 4 to 6 hours. J Am Assoc Gynecol Laparosc 1994;1:S35.
4. Summitt RL, Stovall TG, Lipscomb GH, Washburn SA, Ling FW. Outpatient hysterectomy: determinants of discharge and rehospitalization in 133 patients. Am J Obstet Gynecol 1994;171:1480-7.
5. Chou DC, Rosen DM, Cario GM, et al. Home within 24 hours of laparoscopic hysterectomy. Aust N Z J Obstet Gynaecol 1999;39:234-8.
6. Hoffman CP, Kennedy J, Borschel L, Burchette R, Kidd A. Laparoscopic hysterectomy: the Kaiser Permanente San Diego experience. J Minim Invasive Gynecol 2005;12:16-24.
7. Gien LT, Kupets R, Covens A. Feasibility of same-day discharge after laparoscopic surgery in gynecologic oncology. Gynecol Oncol 2011;121:339-43.
8. Perron-Burdick M, Yamamoto M, Zaritsky E. Same-day discharge after laparoscopic hysterectomy. Obstet Gynecol 2011;117:1136-41.
9. Schiavone MB, Herzog TJ, Ananth CV, Wilde ET, Lewin SN, et al. Feasibility and economic impact of same-day discharge for women who undergo laparoscopic hysterectomy. Am J Obstet Gynecol  2012;207:382.e1-9.
10. Garry R, Fountain J, Mason S, Hawe J, Napp V, Abbott J, et al. The eVALuate study; two parallel randomized trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy. BMJ 2004;328:129.
11. Harki P, Kurki T, Sjoberg J, TitinenA. Safety aspects of laparoscopic hysterectomy. Acta Obstet Gynecol Scand  2001;80:383-391.
12. Schwartz RO. Complications of laparoscopic hysterectomy. Obstet Gynecol 1993;81:1022-1024.
13. Summitt RL, Stovall TG, Lipscomb GH, Ling FW. Randomized comparison of laparoscopy-assisted vaginal hysterectomy with standard vaginal hysterectomy in an outpatient setting. Obstet Gynecol 1991;80:895-901.
14. Choosing the route of hysterectomy for benign disease.  ACOG Committee Opinion No. 444. American College of Obstetricians and Gynecologists.  Obstet Gynecol  2009;114:1156-58.
15. Summitt RL, Stovall TG, Steege JF, Lipscomb GH. A multi-center randomized comparison of laparoscopically-assisted vaginal hysterectomy and abdominal hysterectomy in abdominal hysterectomy candidates. Obstet Gynecol 1998;92:321-326.
16. Olsson JH, Ellstrom M, Hahlin A.  A randomized prospective trial comparing laparoscopic and abdominal hysterectomy. Br J Obstet Gynaecol 1996;103:345-350.
17. Falcone T, Paraiso MF, Mascha E. Prospective randomized clinical trial of laparoscopically assisted vaginal hysterectomy versus total abdominal hysterectomy. Am J Obstet Gynecol 1999;180:955-962.
18. Demir R, Marchand G. Outcome of 783 consecutive hysterectomies for benign indication—likelihood of completing a minimally invasive hysterectomy based on patient’s body mass index. American College of Surgeons. October, 2011, San Francisco.
19. Demir R, Marchand G. Irrelevance of traditional de-selectors for minimally invasive hysterectomy. Society of Laparoendoscopic Surgeons. October, 2012, Boston.
20. Wright JD. Robotically assisted vs laparoscopic hysterectomy among women with benign gynecologic disease. JAMA  2013;309:689-698.
21. Farquahar CM. Hyserectomy rates in the United States 1990 - 1997. Obstet Gynecol. 2002;99:229-234.
22. Wu JM. Hysterectomy rates in the United States, 2003.  Obstet Gynecol. 2007;110:1091-1095.
23. Jacoby VL. Nationwide use of laparoscopic hysterectomy compared with abdominal and vaginal approaches. Obstet Gynecol 2009; 114:1041-1048.
24. Choosing the route of hysterectomy for benign disease.  ACOG Committee Opinion No. 444. American College of Obstetricians and Gynecologists.  Obstet Gynecol  2009;114:1156-58.
25. AAGL. Advancing minimally invasive gynecology worldwide. AAGL position statement: route of hysterectomy to treat benign uterine disease. J Minim Invasive Gynecol. 2011;18:1-3.
26. Fountain GR, Mason J, Hawe J, NappV, Abbott J, et al. The eVALuate study: two parallel randomized trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy. BMJ 2004;328:129.
27. Harkki P, Kurki T, Sjoberg J, Titinen A. Safety Aspects of laparoscopic hysterectomy. Acta Obstet Gynecol Scand 2001;80:383-391.
28. Schwartz RO. Complications of laparoscopic hysterectomy. Obstet Gynecol 1993;81:1022-1024.
29. Supracervical hysterectomy. ACOG Committee Opinion No. 388. American College of Obstetricians and Gynecologists.  Obstet Gynecol 2007;110:1215-1217.
30. Summit RI, Stowall TG, Steege JF, Lipscomb GH. A multicenter randomized comparison of laparoscopically-assisted vaginal hysterectomy and abdominal hysterectomy in abdominal hysterectomy candidates. Obstet Gynecol 1998;92:321-326.
31. TwoKiloClub.Com. 24 Feb. 2006. The Two Kilo Club ™. 12 Jan 2009. http://twokiloclub.com/member.htm.
32. Pelosi M. "Should uterine size alone require laparoscopic assistance?" J Laparoendosc Adv Surg Tech A. 1998 Apr;8(2):99-103.
33. Demir RH, Marchand GJ. Safe Laparopscopic Removal of a 3200 grams Fibroid Uterus. JSLS. 2010;14:600-602.
34. Boggess, John F.; Gehrig, Paola A.; Cantrell, Leigh; Shafer, Aaron; Mendivil, Alberto; Rossi, Emma; Hanna, Rabbie. Perioperative Outcomes of Robotically Assisted Hysterectomy for Benign Cases With Complex Pathology. Obstetrics & Gynecology. 114(3):585-593, September 2009.
35. O'Hanlan, Katherine A.; Lopez, Lisbeth; Dibble, Suzanne L.; Garnier, Anne-Caroline; Huang, Gloria Shining; Leuchtenberger, Mirjam. Total Laparoscopic Hysterectomy: Body Mass Index and Outcomes. Obstetrics & Gynecology. 102(6):1384-1392, December 2003.
36. Heinberg, Eric M.; Crawford, Benjamin L. III; Weitzen, Sherry H.; Bonilla, David J. Total Laparoscopic Hysterectomy in Obese Versus Non-obese Patients. Obstetrics & Gynecology. 103(4):674-680, April 2004.
37. Rhou YJ, Pather S, Loadsman JA, Campbell N, Philip S, Carter J. Direct hospital costs of total laparoscopic hysterectomy compared with fast-track open hysterectomy at a tertiary hospital: a retrospective case-controlled study. Aust N Z J Obstet Gynaecol. 2013;
38. Graves N, Janda M, Merollini K, Gebski V, Obermair A. The cost-effectiveness of total laparoscopic hysterectomy compared to toal abdominal hysterectomy for the treatment of early stage endometrial cancer. Br Med J.  2013;18:4.
39. Wright JD, Ananth CV, Lewin SN, Burke WM, Lu YS, Neugut AI, Herzog TJ, Hershman DL. Robotically assisted vs laparoscopic hysterectomy among women with benign gynecologic disease.  JAMA  2013;3099:689-698.
40. Wright KN, Jonsdottir GM, Jorgensen A, Shah N, Einarsson JI. Costs and outcomes of abdominal, vaginal, laparoscopic and robotic hysterectomies. JSLS  2012;16:519-524.
41. Jonsdottir GM, Jorgensen S, Cohen SL, Wright KN, Shah NT, Chavan N, Einarsson JI. Increasing minimally invasive hysterectomy. Am J Obstet Gynecol  2011;117:1142-1149.
42. Simon NV, Laveran RL, Cavanaugh S, Gerlach DH, Jackson JR. Laaparoscopic Supracervical hysterectomy vs. abdominal hysterectomy in a community hospital. A cost comparison. J Reprod Med.  1999;44:339-345.
43. Dorsey JH, Holtz PM, Griffiths RI, McGrath MM, Steinberg EP. Costs and charges associated with three alternative techniques of hysterectomy. NEJM  1996;335:476-482.
44. Nezhat C, Bess O, Admon D, Nezhat CH, Nezhat F. Hospital cost comparison between abdominal, vaginal, and laparoscopic-assisted vaginal hysterectomies. Obstet Gynecol  1994;83:713-716.
45. AAGL. Advancing minimally invasive gynecology worldwide. AAGL position statement: robotic-assisted laparoscopic surgery in benign gynecology. J Minim Invasive Gynecol. 2013;20:2-9.
46. Liu H, Lu D, Wang L, Shi G, Song H, Clarke J. Robotic conventional laparoscopic surgery for benign gynaecological disease. Cochrane Database Syst Rev. 2012;(2):CD008978.
47. Paraiso MF, Ridgeway B, Park AJ, Jelovsek JE, Barber MD, Falcone T, Einarsson JI. A randomized trial comparing conventional and robotically assisted total laparoscopic hysterectomy. Am J Obstet Gynecol  2013;208:368.e1-7.

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