Reproductive and clinical outcomes after minimally invasive isthmocele repair: a comparison of robotic-assisted and laparoscopic approaches

PURPOSE: Caesarean scar defect (CSD), also known as an isthmocele or niche, is a common consequence of caesarean delivery, associated with chronic inflammation, abnormal uterine bleeding, pelvic pain, and infertility, though some patients remain asymptomatic. Minimally invasive isthmocele repair (MIIR) has emerged as a promising therapeutic option for symptomatic women and those seeking fertility, yet evidence guiding optimal surgical management remains limited. In particular, data on reproductive outcomes are scarce and largely based on small, heterogeneous case series. To our knowledge, there are no data from direct comparisons between robotic-assisted (RAIR) and conventional laparoscopic (LIR) isthmocele repairs. METHODS: This monocentric retrospective study included patients undergoing RAIR and LIR at the University Hospital Bonn between December 2019 and March 2026. The primary objective was to determine the live-birth rate after MIIR in women attempting conception. Secondary objectives included evaluating patient-reported outcomes, such as symptom relief, and objective outcomes, including changes in niche length, niche depth, and residual myometrial thickness, as well as obstetric outcomes in subsequent pregnancies, and comparisons between RAIR and LIR. RESULTS: Twenty-eight patients underwent CSD surgery, including 21 RAIR and 7 LIR procedures. Follow-up was available in 82% of patients (median 4 months). No intraoperative or postoperative complications occurred. Among women attempting conception (n = 8), the live-birth rate was 75% (6/8), with equal distribution between groups. In the RAIR group, a significant decrease in niche length and niche depth as well as a significant increase in myometrial thickness were observed between pre- and postoperative. In the LIR group, similar trends were noted that did not reach statistical significance. Between-group comparisons showed no significant differences in postoperative imaging outcomes. Symptom improvement was reported in the majority of patients, particularly regarding abnormal uterine bleeding and pelvic pain. Obstetric outcomes included one uterine scar dehiscence and one placenta accreta spectrum disorder (each 3.6%), both occurring after RAIR. CONCLUSION: MIIR and especially RAIR represent a promising fertility-preserving and symptom-improving option for patients with CSD. REGISTRATION: This study was registered in the German Clinical Trials Register (DRKS) under the number DRKS00038857 on April 15th 2026.