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. 2025 Jun 14;19(1):293.
doi: 10.1007/s11701-025-02459-2.

Uterine isthmocele: obstetric outcomes after robotic-assisted laparoscopic repair

Sierra J Seaman  1 , Arnold P Advincula  2 , Natalia S Parra  2 , Sherelle Laifer-Narin  3 , Chetna Arora  2
Affiliations

Uterine isthmocele: obstetric outcomes after robotic-assisted laparoscopic repair

Sierra J Seaman et al. J Robot Surg. .

Abstract

An isthmocele, also called a cesarean scar defect or niche, is a defect in the lower uterine segment myometrium that occurs as a result of a cesarean delivery. This study aims to review our institution's comprehensive data following robotic-assisted laparoscopic isthmocele repair (RA-IR) including birth outcomes and changes in the dimensions of the isthmocele. This was a retrospective case series at a single high-volume tertiary medical center in the United States with over 2500 gynecologic surgeries performed yearly. All women with an identified isthmocele who underwent RA-IR between 9/2015 and 12/2022 were included. Detailed chart review, imaging review with a pelvic radiologic specialist, and post-operative questionnaire were utilized in our analysis. Our primary outcome was post-operative live births. Secondary outcomes included post-operative fertility rate, radiologic changes, and symptom improvement. Twenty-eight patients underwent RA-IR during the study period. Of the 17 patients who attempted pregnancy, 94.1% were able to conceive status post-repair including 7 patients with a pre-operative diagnosis of primary or secondary infertility. Of these, 12 who continued their pregnancies achieved their goal of a live birth (n = 12 of 15, 80.0%). There were a total of 20 pregnancies post-repair, resulting in 12 live births, 6 miscarriages, 1 cesarean scar pregnancy, and 1 termination, which corresponds to a live birth rate per pregnancy of 60.0% (n = 12 of 20). There was a statistically significant improvement in myometrial depth, width, and residual myometrial thickness postoperatively (p < 0.1). The greatest difference was seen in the depth of the isthmocele. The residual myometrial thickness improved from mean of 0.63 mm before to 5.13 mm after surgery. Twelve patients completed a questionnaire regarding symptoms and obstetric outcomes. Symptom improvement was reported by 100% of patients, with 66.7% experiencing complete resolution. RA-IR results in improved defect width, depth, and residual myometrial thickness with preservation of fertility and good obstetric outcomes with a live birth yield of 80.0%.

Keywords: Cesarean scar; Fertility; Isthmocele; Uterine niche.

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Conflict of interest statement

Declarations. Conflict of interest: Drs. Advincula and Arora are consultants to Intuitive. Drs. Advincula and Seaman are consultants for Cooper Surgical. Consent to participate: Retrospective data use was exempt from consent per the IRB. Informed consent was obtained from all individual participants included in the questionnaire component of the study. Prior presentation: This study was presented as an abstract at the 2023 Global Conference for the American Association of Gynecologic Laparoscopists in Nashville, Tennessee. Registration: Not applicable. IRB approval: This study was approved by the University of Sample IRB on January 13, 2021. Approval number: AAAT5566.

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