Improving Precision and Safety in Uterine Isthmocele Repair by Utilizing the KOH Cup and Firefly Guidance

Multiple surgical modalities are currently used for uterine isthmocele repair. Identifying defects intraoperatively remains challenging, and guidelines for optimal repair techniques are still evolving. Here, we present a case of safe and precise uterine isthmocele repair using the KOH Cup (Cooper Surgical Inc., Trumbull, USA) in combination with the Firefly technology of the Da Vinci Xi robotic system (Intuitive Surgical Inc., Sunnyvale, USA). A 30-year-old woman, para 1 living 1, with a history of previous cesarean section, presented with secondary infertility for the past seven years. A suspicion of a uterine isthmocele was revealed by ultrasonography. Magnetic resonance imaging (MRI) confirmed the diagnosis of a bulky uterus with a thinned-out anterior wall myometrium at the utero-cervical junction and an isthmocele of collection measuring 7.6 x 3.0 mm. The KOH Cup was used alongside Firefly-guided complete isthmocele repair and bladder adhesiolysis, with the patient being discharged within 24 hours. By using the KOH Cup with the Firefly imaging system, surgical accuracy can be improved through real-time feedback, making it a safe approach for uterine isthmocele repair. While the KOH Cup and Firefly combination appear to be a novel and promising approach, a direct comparison with traditional laparoscopic methods (without robotic guidance) is necessary to establish its clear advantages. Without supporting data or references, the claim of superiority remains speculative.