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

Background: 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.Objective: To evaluate the efficacy of robotic-assisted laparoscopic repair of uterine niches in improving clinical symptoms and fertility outcomes.Design: A retrospective observational study conducted at a tertiary university hospital.Methods: 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.Preand postoperative RMT measurements were compared to assess myometrial restoration.Symptom resolution and postoperative fertility outcomes were also evaluated.Results: 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.Conclusion: 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.