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Does the Limitation of Haptic Feedback with Robotic-Assisted Laparoscopy Compromise Our Myomectomy Techniques?
Abstracts / Journal of Minimally Invasive Gynecology 20 (2013) S133–S181 Design: Retrospective Case Series. Setting: John Sealy Hospital at the University of Texas, Medical Branch in Galveston. Patients: All patients who underwent robotic retropubic urethropexy from 1/1/12 to 6/1/12 by a single gynecologic surgeon at the John Sealy Hospital of the University of Texas, Medical Branch in Galveston were included in the case series. The control cases consisted of the last five consecutive open retropubic urethropexies prior to 1/1/12, performed by the same surgeon. Intervention: Robotic retropubic urethropexy and open retropubic urethropexy. Measurements and Main Results: A total of 10 patients, 5 patients who underwent open retropubic urethropexy and 5 patients who underwent robotic retropubic urethropexy, were included. Mean hospital stay length and mean EBL were overall less for robotic cases than for open cases (1.2 days vs 2.6 days; 169cc vs 300cc). One of the 5 patients who underwent the open approach and 2 of the 5 patients who underwent the robotic approach sustained a minor intraoperative complication; however the intraoperative complications for the patients who underwent the robotic approach occurred during the hysterectomy portion of the robotic case. Postoperative follow-up was 3 months. All but one patient from each group experienced resolution of incontinence after the procedure. Two of the patients who underwent the open approach had postoperative complications: one had a wound separation and the other had a postoperative fever, which resolved by post-operative day 4. Conclusion: Robotic retropubic urethropexy may be a feasible alternative to open retropubic urethropexy. In addition, the robotic approach may have advantages including better visualization of the retropubic space, better ergonomics for the surgeon, shorter hospital stay, and less EBL. A larger study is necessary to support our observations.
573 Robotic Versus Laparoscopic Hysterectomy in the Elevated BMI Patient Prabakar C, Nimaroff ML, Raskin S, Masick K. Obstetrics & Gynecology, North Shore University Hospital, Manhasset, New York Study Objective: To investigate the hypothesis that there is a benefit in using the robotic platform in patients undergoing hysterectomy with an elevated BMI. Design: Retrospective analysis of outcome variables from 770 hospitals that were abstracted from the Premier national database over a three-year time period (2009-2012). Only cases that recorded the BMI were included in the study group. Setting: U.S hospitals participating in the Premier national database. Patients: A total of 4450 patients who underwent benign hysterectomy using either the conventional or robotic laparoscopic approach. Intervention: Hysterectomy. Measurements and Main Results: A total of 3450 laparoscopic and 1100 robotic hysterectomy patients were stratified into five categories based on BMI: normal (18.5-24.9), overweight (25-29.9), obese I (30-34.9), obese II (35-39.9), and obese III (>40). Study outcomes included cost, mortality, length of stay, readmission, and complications. Statistical analysis was conducted using t and chi square tests. Robotic hysterectomy cost more than the laparoscopic approach for all BMI classes except for class III. Robotic hysterectomy had higher readmission rates compared to the laparoscopic approach for all BMI subgroups. Length of stay was significantly higher for all BMI classes in the robotic group, except for classes I and II where patients who underwent the laparoscopic approach stayed longer. There was no significant difference in mortality rates between both surgical approaches. Complication rates were similar except for postoperative anemia and ileus which were significantly higher for the laparoscopic group across all BMI classes. Conclusion: In this review of 4550 patients who underwent hysterectomy for benign indications, there appears to be no significant advantage of using the robotic approach in patients with an elevated BMI. However, higher rates of postoperative anemia and ileus were observed in the laparoscopic group.
S173
574 Development of a Resident Training Curriculum for Robotic Gynecologic Surgery Ryan AR, Sheeder J, Arruda JS. Obstetrics and Gynecology, University of Colorado Denver, Aurora, Colorado Study Objective: To develop a training program for gynecology residents to learn the skills necessary for robotic surgery. Design: Robotic surgery teaching curriculum developed and applied to third and fourth year residents in gynecology. Setting: Western urban teaching hospital Obstetrics and Gynecology Residency Program. Intervention: Determine curriculum content and skills training and assessment needed to safely and proficiently perform robotic surgery with attending supervision. Measurements and Main Results: We developed a four phase clinical training pathway for residents. Phase I involved watching live surgical procedures followed by completion of the on-line da VinciÒ surgical modules course (the same course that is required of any attending surgeon). Phase II involved watching a procedure video, attending an onsite pre-procedural training (operating room set-up, port placement, docking, surgeon console overview, emergency procedures), acting as the bedside assistant, and being evaluated by the attending surgeon on the skills of the bedside assistant. Phase III involved approximately 3.5 hours of simulation training in a dry lab or on the MIMIC simulation system. Phase IV involved performing surgical procedures on the robotic console with attending supervision for increasing levels of difficulty. To date, 18 residents have completed the training program and an additional 9 will have completed the program by June 2013. Evaluation of confidence and skills is currently underway. Conclusion: A well-delineated clinical training pathway for gynecology residents can be helpful in preparing residents to perform robotic surgery at a teaching hospital. 575 Does the Limitation of Haptic Feedback with Robotic-Assisted Laparoscopy Compromise Our Myomectomy Techniques? Sasaki KJ,1 Cholkeri-Singh A,1 Sulo S,2 Steller C,1 Miller CE.1 1Obstetrics and Gynecology, Advocate Lutheran General Hospital, Park Ridge, Illinois; 2Patient Centered Outcomes Research, Russell Institute for Research & Innovation, Park Ridge, Illinois Study Objective: To determine if the lack of haptic-feedback in roboticassisted laparoscopic myomectomy affects the number of fibroids left in-situ versus traditional laparoscopic myomectomy. Design: Retrospective, 2:1 matched cohort study of 32 traditional laparoscopic myomectomies and 16 robotic-assisted laparoscopic myomectomies. The patients were matched for number of fibroids removed and time of post-operative ultrasound. Setting: High volume, minimally-invasive, gynecology referral practice in suburban Chicago. Patients: Forty-eight women aged 27-53 years old with symptomatic uterine fibroids who underwent a laparoscopic or robotic-assisted myomectomy between September 2009-December 2012, by one expert laparoscopic surgeon. Intervention: Laparoscopic or robotic-assisted laparoscopic myomectomy with a post-operative ultrasound. Measurements and Main Results: The laparoscopic and robotic cohorts were similar in terms of age at time of surgery, gravida and parity, number of ports used, average number of fibroids removed, and history of prior pelvic surgery (all p values >0.05). There was no difference in postoperative number of fibroids (p=0.52) or size of fibroids (all p values >0.05) between the two groups. There was also no difference in complication rates, operative time or blood loss between the laparoscopic and robotic cohorts. None of the procedures in either group required conversion to a different surgical approach. The only difference noted was a higher admission rate in the robotic group (33%) compared to the laparoscopic group (7%) (p=0.02).
S174
Abstracts / Journal of Minimally Invasive Gynecology 20 (2013) S133–S181
Conclusion: Although robotic-assisted surgery is often cited for lacking haptic feedback, it did not affect our myomectomy technique, as there was no difference in number of fibroids identified post-operatively.
Conclusion: There was a steep learning curve to master robotic hysterectomy, and the docking process did not have a significant negative influence on the overall operating time.
576
578
Is Uterine Weight Associated with Length of Stay and Complication Rate in Robotic Assisted Laparoscopic Hysterectomy? A Retrospective Chart Review Schiff L, Toubia T, Sangha R. Women’s Health Services, Department of Obstetrics and Gyencology, Henry Ford Hospital, Detroit, Michigan
Cost Comparison Review of Robotic Surgery Sich NM, Dandolu V. University of Nevada School of Medicine, Las Vegas, Nevada
Study Objective: To investigate whether uterine weight is associated with prolonged length of stay and operative outcomes following robotic assisted laparoscopic hysterectomy. Design: Retrospective chart review of all robotic-assisted laparoscopic hysterectomies performed at one institution between 2011 and 2012. Setting: Henry Ford Health System, an urban, midwestern academic teaching hospital and its suburban affiliates. Patients: Two hundred and forty one consecutive patients who underwent robotic assisted laparoscopic hysterectomy for a benign indication, with or without salpingo-oophorectomy. Intervention: Medical record review of patient charts following roboticassisted laparoscopic hysterectomy. Measurements and Main Results: Of the 241 patients meeting inclusion criteria, 83 (34.4%) had a uterine weight 400 grams or greater. Uterine weight was positively correlated with procedure time (Spearman correlation=0.45, p\0.0001) and estimated blood loss (Spearman correlation=0.37, p\0.0001). Uterine weight was statistically significantly higher among those who received transfusion (p=0.04) with mean uterine weight in the transfusion group being 578.5 grams versus 361.2 grams in the no transfusion group. Uterine weight was statistically significantly greater among patients who required a length of stay greater than one day. Uterine weight was not correlated with BMI, age, or complications. Conclusion: Uterine weight is significantly correlated with prolonged procedure time, estimated blood loss, need for transfusion, and prolonged length of stay in robotic-assisted laparoscopic hysterectomy. Pre-operative estimation of uterine weight may help surgeons predict for which patients robotic technique retains its advantages as a minimally invasive surgical approach. Further study with a larger patient and surgeon population is advised to establish if a predictive model exists. 577 Learning Robotic Hysterectomy: An Analysis of Setup, Docking and Operating Times Sendag F,1 Zeybek B,2 Akdemir A,1 Ozgurel B,3 Oztekin K.1 1Obstetrics and Gynecology, Ege University School of Medicine, Izmir, Turkey; 2 Obstetrics and Gynecology, Universal Ege Saglik Hospital, Izmir, Turkey; 3 Business Administration, Yasar University, Izmir, Turkey Study Objective: The objective was to evaluate the learning curve for performing a robotic hysterectomy to treat benign gynecological disease. Design: Retrospective analyses of 36 consecutive cases of robotic hysterectomy. Setting: University hospital. Patients: Thirty six women (ages 39-65 yrs) with benign indications of hysterectomy. Intervention: Robotic hysterectomy with/without BSO. Measurements and Main Results: The mean age and BMI of the patients were 50.3 6.2 years and 31.3 7.8 kg/m2, respectively. The mean operating, setup and docking times were 169 54.5, 52.9 12.4 and 7.8 7.6 minutes, respectively. The estimated blood loss was 56.6 84.5 cc, and the mean uterine weight was 256 190.1 g. There were no intraoperative complications or conversions to laparotomy. There was only 1 (2%) patient with a postoperative complication, and the average hospital stay was 2 0.16 days. The learning curve analysis revealed a decrease in both docking time and operating time, with both curves plateauing after the 9th case. The operating time correlated with uterine weight (p=0.003) but did not correlate with BMI or the number of prior operations.
Study Objective: Robotic surgery is becoming increasingly popular for a large variety of surgical procedures that were formally approached either through laparotomy or laparoscopy. This review analyzes studies comparing the use of robotic assisted surgery across a variety of surgical procedures against traditional laparoscopy and laparotomy to assess cost efficiency through direct costs as well as indirect costs such as length of stay (LOS), complications, learning curves, and outcomes. Design: A systematic review was performed using the pubmed database using relevant search terms and authors independently reviewed manuscripts included in the study. Procedures reviewed include Sacrocolpopexy, Hysterectomy, Prostatectomy, Cystectomy, Partial/Complete Nephrectomy, Rectal Cancer Resection, Thyroidectomy, Gastrectomy and Pyeloplasty. Measurements and Main Results: Direct costs of robotic surgery were consistently higher than either laparoscopic surgery or open surgery in all procedures, often even when purchase and maintenance of the robotic system was excluded. The primary factors of this increased cost were increased operative time, instrument cost, purchase, and maintenance of the robotic system. Indirect costs varied greatly by procedure but in general there were roughly equivalent LOS, blood loss, and complications between robotic and laparoscopic surgery and were significantly decreased over open surgery Procedure
OR Time
PostOP $
Total $
P. Nephrectomy Prostatectomy Cystectomy Sacrocolpopexy Hysterectomy
[ [ Y [ [
Y/Y/-/Y Y/Y/-
[/[/[[ / - / [ [[ / - / [ -/-/- / - /-
/ / / / /
[/-/-/-/-/-
/ / / / /
[ -
Results show Robotic/Laparoscopic/Open. Instrumentation significantly increased cost of RPN and moderately increased cost of laparoscopic in all procedures. Conclusion: Robotic surgery tends to offer similar outcomes to laparoscopic surgery regardless of procedure type but at a significantly higher cost. Robotic surgery consistently has a decrease on morbidity over most open procedures, again, at a significantly higher cost. Studies specifically analyzing robotic use between various departments and subspecialties at a given institution are lacking and may help to better clarify the impact of volume on the cost of implementation of robotic assisted surgery. 579 Robotic Myomectomy in Large Myomas: A Single Center Experience of 10 Cases Vanni DGBS,1 Neme RM,2 Gomes MTV,1 Kaufmann OG,2 Brudniewski HF.2 1Albert Einstein Israeli Hospital, S~ao Paulo, SP, Brazil; 2 Centro de Endometriose S~ao Paulo, S~ao Paulo, SP, Brazil Study Objective: To describe operative and immediate postoperative outcomes of robotically assisted myomectomy (RAM) in cases of large myomas. Design: Prospective study. Setting: Gynecology group in Albert Einstein Israeli Hospital in Sao Paulo, Brazil. Patients: We conducted a retrospective review of 10 cases of RAM performed in women of reproductive age with symptomatic large uterine
573 Robotic Versus Laparoscopic Hysterectomy in the Elevated BMI Patient Prabakar C, Nimaroff ML, Raskin S, Masick K. Obstetrics & Gynecology, North Shore University Hospital, Manhasset, New York Study Objective: To investigate the hypothesis that there is a benefit in using the robotic platform in patients undergoing hysterectomy with an elevated BMI. Design: Retrospective analysis of outcome variables from 770 hospitals that were abstracted from the Premier national database over a three-year time period (2009-2012). Only cases that recorded the BMI were included in the study group. Setting: U.S hospitals participating in the Premier national database. Patients: A total of 4450 patients who underwent benign hysterectomy using either the conventional or robotic laparoscopic approach. Intervention: Hysterectomy. Measurements and Main Results: A total of 3450 laparoscopic and 1100 robotic hysterectomy patients were stratified into five categories based on BMI: normal (18.5-24.9), overweight (25-29.9), obese I (30-34.9), obese II (35-39.9), and obese III (>40). Study outcomes included cost, mortality, length of stay, readmission, and complications. Statistical analysis was conducted using t and chi square tests. Robotic hysterectomy cost more than the laparoscopic approach for all BMI classes except for class III. Robotic hysterectomy had higher readmission rates compared to the laparoscopic approach for all BMI subgroups. Length of stay was significantly higher for all BMI classes in the robotic group, except for classes I and II where patients who underwent the laparoscopic approach stayed longer. There was no significant difference in mortality rates between both surgical approaches. Complication rates were similar except for postoperative anemia and ileus which were significantly higher for the laparoscopic group across all BMI classes. Conclusion: In this review of 4550 patients who underwent hysterectomy for benign indications, there appears to be no significant advantage of using the robotic approach in patients with an elevated BMI. However, higher rates of postoperative anemia and ileus were observed in the laparoscopic group.
S173
574 Development of a Resident Training Curriculum for Robotic Gynecologic Surgery Ryan AR, Sheeder J, Arruda JS. Obstetrics and Gynecology, University of Colorado Denver, Aurora, Colorado Study Objective: To develop a training program for gynecology residents to learn the skills necessary for robotic surgery. Design: Robotic surgery teaching curriculum developed and applied to third and fourth year residents in gynecology. Setting: Western urban teaching hospital Obstetrics and Gynecology Residency Program. Intervention: Determine curriculum content and skills training and assessment needed to safely and proficiently perform robotic surgery with attending supervision. Measurements and Main Results: We developed a four phase clinical training pathway for residents. Phase I involved watching live surgical procedures followed by completion of the on-line da VinciÒ surgical modules course (the same course that is required of any attending surgeon). Phase II involved watching a procedure video, attending an onsite pre-procedural training (operating room set-up, port placement, docking, surgeon console overview, emergency procedures), acting as the bedside assistant, and being evaluated by the attending surgeon on the skills of the bedside assistant. Phase III involved approximately 3.5 hours of simulation training in a dry lab or on the MIMIC simulation system. Phase IV involved performing surgical procedures on the robotic console with attending supervision for increasing levels of difficulty. To date, 18 residents have completed the training program and an additional 9 will have completed the program by June 2013. Evaluation of confidence and skills is currently underway. Conclusion: A well-delineated clinical training pathway for gynecology residents can be helpful in preparing residents to perform robotic surgery at a teaching hospital. 575 Does the Limitation of Haptic Feedback with Robotic-Assisted Laparoscopy Compromise Our Myomectomy Techniques? Sasaki KJ,1 Cholkeri-Singh A,1 Sulo S,2 Steller C,1 Miller CE.1 1Obstetrics and Gynecology, Advocate Lutheran General Hospital, Park Ridge, Illinois; 2Patient Centered Outcomes Research, Russell Institute for Research & Innovation, Park Ridge, Illinois Study Objective: To determine if the lack of haptic-feedback in roboticassisted laparoscopic myomectomy affects the number of fibroids left in-situ versus traditional laparoscopic myomectomy. Design: Retrospective, 2:1 matched cohort study of 32 traditional laparoscopic myomectomies and 16 robotic-assisted laparoscopic myomectomies. The patients were matched for number of fibroids removed and time of post-operative ultrasound. Setting: High volume, minimally-invasive, gynecology referral practice in suburban Chicago. Patients: Forty-eight women aged 27-53 years old with symptomatic uterine fibroids who underwent a laparoscopic or robotic-assisted myomectomy between September 2009-December 2012, by one expert laparoscopic surgeon. Intervention: Laparoscopic or robotic-assisted laparoscopic myomectomy with a post-operative ultrasound. Measurements and Main Results: The laparoscopic and robotic cohorts were similar in terms of age at time of surgery, gravida and parity, number of ports used, average number of fibroids removed, and history of prior pelvic surgery (all p values >0.05). There was no difference in postoperative number of fibroids (p=0.52) or size of fibroids (all p values >0.05) between the two groups. There was also no difference in complication rates, operative time or blood loss between the laparoscopic and robotic cohorts. None of the procedures in either group required conversion to a different surgical approach. The only difference noted was a higher admission rate in the robotic group (33%) compared to the laparoscopic group (7%) (p=0.02).
S174
Abstracts / Journal of Minimally Invasive Gynecology 20 (2013) S133–S181
Conclusion: Although robotic-assisted surgery is often cited for lacking haptic feedback, it did not affect our myomectomy technique, as there was no difference in number of fibroids identified post-operatively.
Conclusion: There was a steep learning curve to master robotic hysterectomy, and the docking process did not have a significant negative influence on the overall operating time.
576
578
Is Uterine Weight Associated with Length of Stay and Complication Rate in Robotic Assisted Laparoscopic Hysterectomy? A Retrospective Chart Review Schiff L, Toubia T, Sangha R. Women’s Health Services, Department of Obstetrics and Gyencology, Henry Ford Hospital, Detroit, Michigan
Cost Comparison Review of Robotic Surgery Sich NM, Dandolu V. University of Nevada School of Medicine, Las Vegas, Nevada
Study Objective: To investigate whether uterine weight is associated with prolonged length of stay and operative outcomes following robotic assisted laparoscopic hysterectomy. Design: Retrospective chart review of all robotic-assisted laparoscopic hysterectomies performed at one institution between 2011 and 2012. Setting: Henry Ford Health System, an urban, midwestern academic teaching hospital and its suburban affiliates. Patients: Two hundred and forty one consecutive patients who underwent robotic assisted laparoscopic hysterectomy for a benign indication, with or without salpingo-oophorectomy. Intervention: Medical record review of patient charts following roboticassisted laparoscopic hysterectomy. Measurements and Main Results: Of the 241 patients meeting inclusion criteria, 83 (34.4%) had a uterine weight 400 grams or greater. Uterine weight was positively correlated with procedure time (Spearman correlation=0.45, p\0.0001) and estimated blood loss (Spearman correlation=0.37, p\0.0001). Uterine weight was statistically significantly higher among those who received transfusion (p=0.04) with mean uterine weight in the transfusion group being 578.5 grams versus 361.2 grams in the no transfusion group. Uterine weight was statistically significantly greater among patients who required a length of stay greater than one day. Uterine weight was not correlated with BMI, age, or complications. Conclusion: Uterine weight is significantly correlated with prolonged procedure time, estimated blood loss, need for transfusion, and prolonged length of stay in robotic-assisted laparoscopic hysterectomy. Pre-operative estimation of uterine weight may help surgeons predict for which patients robotic technique retains its advantages as a minimally invasive surgical approach. Further study with a larger patient and surgeon population is advised to establish if a predictive model exists. 577 Learning Robotic Hysterectomy: An Analysis of Setup, Docking and Operating Times Sendag F,1 Zeybek B,2 Akdemir A,1 Ozgurel B,3 Oztekin K.1 1Obstetrics and Gynecology, Ege University School of Medicine, Izmir, Turkey; 2 Obstetrics and Gynecology, Universal Ege Saglik Hospital, Izmir, Turkey; 3 Business Administration, Yasar University, Izmir, Turkey Study Objective: The objective was to evaluate the learning curve for performing a robotic hysterectomy to treat benign gynecological disease. Design: Retrospective analyses of 36 consecutive cases of robotic hysterectomy. Setting: University hospital. Patients: Thirty six women (ages 39-65 yrs) with benign indications of hysterectomy. Intervention: Robotic hysterectomy with/without BSO. Measurements and Main Results: The mean age and BMI of the patients were 50.3 6.2 years and 31.3 7.8 kg/m2, respectively. The mean operating, setup and docking times were 169 54.5, 52.9 12.4 and 7.8 7.6 minutes, respectively. The estimated blood loss was 56.6 84.5 cc, and the mean uterine weight was 256 190.1 g. There were no intraoperative complications or conversions to laparotomy. There was only 1 (2%) patient with a postoperative complication, and the average hospital stay was 2 0.16 days. The learning curve analysis revealed a decrease in both docking time and operating time, with both curves plateauing after the 9th case. The operating time correlated with uterine weight (p=0.003) but did not correlate with BMI or the number of prior operations.
Study Objective: Robotic surgery is becoming increasingly popular for a large variety of surgical procedures that were formally approached either through laparotomy or laparoscopy. This review analyzes studies comparing the use of robotic assisted surgery across a variety of surgical procedures against traditional laparoscopy and laparotomy to assess cost efficiency through direct costs as well as indirect costs such as length of stay (LOS), complications, learning curves, and outcomes. Design: A systematic review was performed using the pubmed database using relevant search terms and authors independently reviewed manuscripts included in the study. Procedures reviewed include Sacrocolpopexy, Hysterectomy, Prostatectomy, Cystectomy, Partial/Complete Nephrectomy, Rectal Cancer Resection, Thyroidectomy, Gastrectomy and Pyeloplasty. Measurements and Main Results: Direct costs of robotic surgery were consistently higher than either laparoscopic surgery or open surgery in all procedures, often even when purchase and maintenance of the robotic system was excluded. The primary factors of this increased cost were increased operative time, instrument cost, purchase, and maintenance of the robotic system. Indirect costs varied greatly by procedure but in general there were roughly equivalent LOS, blood loss, and complications between robotic and laparoscopic surgery and were significantly decreased over open surgery Procedure
OR Time
PostOP $
Total $
P. Nephrectomy Prostatectomy Cystectomy Sacrocolpopexy Hysterectomy
[ [ Y [ [
Y/Y/-/Y Y/Y/-
[/[/[[ / - / [ [[ / - / [ -/-/- / - /-
/ / / / /
[/-/-/-/-/-
/ / / / /
[ -
Results show Robotic/Laparoscopic/Open. Instrumentation significantly increased cost of RPN and moderately increased cost of laparoscopic in all procedures. Conclusion: Robotic surgery tends to offer similar outcomes to laparoscopic surgery regardless of procedure type but at a significantly higher cost. Robotic surgery consistently has a decrease on morbidity over most open procedures, again, at a significantly higher cost. Studies specifically analyzing robotic use between various departments and subspecialties at a given institution are lacking and may help to better clarify the impact of volume on the cost of implementation of robotic assisted surgery. 579 Robotic Myomectomy in Large Myomas: A Single Center Experience of 10 Cases Vanni DGBS,1 Neme RM,2 Gomes MTV,1 Kaufmann OG,2 Brudniewski HF.2 1Albert Einstein Israeli Hospital, S~ao Paulo, SP, Brazil; 2 Centro de Endometriose S~ao Paulo, S~ao Paulo, SP, Brazil Study Objective: To describe operative and immediate postoperative outcomes of robotically assisted myomectomy (RAM) in cases of large myomas. Design: Prospective study. Setting: Gynecology group in Albert Einstein Israeli Hospital in Sao Paulo, Brazil. Patients: We conducted a retrospective review of 10 cases of RAM performed in women of reproductive age with symptomatic large uterine