While these advantages are important, a minimally invasive approach is sellectchem not warranted if it compromises the oncologic outcome. This is best demonstrated in patients with endometrial cancer. In these cases, adjuvant therapy is dictated by histologic grade, depth of myometrial invasion, and lymphovascular space invasion. Morcellating or fragmenting a hysterectomy specimen during retrieval not only limits the pathologic evaluation but it can also lead to seeding the abdominal and pelvic peritoneum [4]. In cases where malignancy is not a primary concern, alternative methods of retrieval when the uterine manipulator become dislodged such as using a tenaculum or ring forceps have been described [5]. Although occurrences are rare, aggressive attempts to deliver a difficult specimen through the colpotomy incision can lead to unintended injury to the rectum or small bowel [5].

Lastly, surgeons that perform minimally invasive hysterectomies on a routine basis know that precious time is wasted with fruitless attempts to deliver a uterus that is too large to fit through a small and narrow vagina as the case above demonstrates. Since the routine adoption of this technique at our institution, we have successfully used the technique in approximately 100 cases and have found specimen retrieval is less time consuming and less frustrating during minimally invasive hysterectomy. In addition, the incidence of conversion to mini-laparotomy for specimen retrieval has been impacted. Since adoption of this technique, there has not been one instance where conversion was preformed solely for specimen retrieval.

Data to support our observations are difficult to quantify as the time required to remove a specimen after completion of the vaginal colpotomy has not been routinely recorded at our institution. Nonetheless, over the last 30 cases preformed by one author, the average time to retrieve specimens that could not be spontaneously removed with the uterine manipulator was less than 2 minutes, ranging from 44 seconds to 3 minutes and 25 seconds. Since the introduction of this novel technique, we have found less time is required to remove large specimens. Total operative time is shorter which, in theory, can lead to a decrease of overall cost of robotic hysterectomy.

Despite numerous publications on the cost effectiveness of laparoscopic and robotic surgery, there is an equally valid argument that, in terms of dollars spent per case, conventional surgery is considerably less expensive. This issue will become more important as healthcare reimbursement becomes increasingly limited. Multiple papers have addressed the higher cost for robotic hysterectomy and conventional laparoscopic hysterectomy [2, 3]. Any new surgical technique that is cost effective Carfilzomib and has the potential to decrease the overall cost of these procedures warrants further investigation.