# Robotic-assisted laparoscopic repair of isthmoceles: the feasibility of operative treatment and recommendations for patient selection

## TL;DR

Robotic-assisted surgery for uterine niches improves symptoms and fertility, with significant increases in uterine wall thickness and successful pregnancy outcomes.

## Contribution

Demonstrates the feasibility and effectiveness of robotic-assisted laparoscopic repair for uterine niches with detailed clinical and fertility outcomes.

## Key findings

- Robotic-assisted surgery significantly increased residual myometrial thickness from 1.75 mm to 4.9 mm.
- 71.4% of symptomatic patients reported symptom resolution after the procedure.
- 65.4% of patients who desired conception achieved live births post-surgery.

## Abstract

Uterine niches (isthmoceles) are myometrial defects commonly occurring after caesarean sections and may lead to abnormal uterine bleeding, pelvic pain and impaired fertility. Robotic-assisted surgical approaches have emerged as a minimally invasive option for their management, yet data on their efficacy remain limited.

To evaluate the efficacy of robotic-assisted laparoscopic repair of uterine niches in improving clinical symptoms and fertility outcomes.

A retrospective observational study conducted at a tertiary university hospital.

All patients who underwent robotic-assisted laparoscopic repair of uterine niches between 2013 and 2023 were included. Preoperative assessments included transvaginal ultrasound and hysterosalpingo-ultrasonography to evaluate residual myometrial thickness (RMT) and niche morphology. The surgical procedure entailed isthmocele resection followed by double-layer myometrial suturing using the Da Vinci Robotic System®. Pre- and postoperative RMT measurements were compared to assess myometrial restoration. Symptom resolution and postoperative fertility outcomes were also evaluated.

Fifty-one patients underwent robotic-assisted laparoscopic repair during the study period. The mean RMT significantly increased from 1.75 ± 1.4 mm preoperatively to 4.9 ± 3.4 mm postoperatively (p < 0.001). While niche diameter reduction was not statistically significant, the healing ratio demonstrated a significant improvement (p < 0.001). Among symptomatic patients with postoperative symptom assessment (n = 28), 20 (71.4%) reported complete or partial symptom resolution. Among patients desiring conception postoperatively (n = 36), 26 conceived; among pregnancies, 17/26 (65.4%) resulted in live birth, 1/26 (3.8%) was ongoing at last follow-up and 3/26 (11.5%) had an unknown outcome.

Robotic-assisted laparoscopic repair was associated with improvement in symptoms related to uterine niches. The technique significantly improves myometrial thickness and supports favourable reproductive outcomes. Further prospective studies are warranted to establish standardised treatment guidelines and assess long-term efficacy.

Not applicable.

Feasibility of robotic treatment of isthmoceles

This study looked at how effective robotic-assisted surgery is for treating uterine niche (also known as an isthmocele), which can cause symptoms like pelvic pain, abnormal bleeding, and difficulty getting pregnant. These niches often form after a cesarean section and can affect the thickness of the uterine wall. The researchers reviewed records from 51 women who had robotic-assisted laparoscopic surgery to repair a uterine niche between 2013 and 2023. Before surgery, all patients were assessed using ultrasound imaging to check the thickness of the uterine wall (residual myometrial thickness, or RMT, adjacent myometrial thickness, or AMT and their ratio, called healing ratio, or HR) and to examine the size and shape of the niche. During surgery, doctors used the DaVinci robotic system to remove the niche and then stitched the uterine wall back together in two layers. After surgery, imaging showed that the uterine wall became significantly thicker, going from an average of 1.75 mm to 4.9 mm. Most patients (71.4%) reported that their symptoms improved or disappeared after surgery. Among the women who wanted to get pregnant, 65.4% successfully gave birth after the procedure. The study concluded that robotic-assisted surgery is a promising option for women with uterine niches, especially for those experiencing symptoms or struggling with fertility. However, more research is needed to develop treatment guidelines and to understand the long-term outcomes.