Robotic-assisted laparoscopic niche repair (RALNR): technique development and pregnancy-associated outcomes

Uterine scar defects after cesarean sections are increasingly common and elevate the risk of life-threatening complications in subsequent pregnancies. From various sonomorphological measurement parameters, the residual myometrial thickness (RMT) is crucial for predicting an obstetric complication in a subsequent pregnancy. A low RMT can be improved by surgical correction. The purpose of this paper is to present our technique for robotic-assisted laparoscopic niche repair (RALNR), to sonomorphologically characterize the niches pre- and postoperatively and to surveil subsequent symptoms and pregnancies. A cohort study of 35 patients with a niche and the wish to conceive, who had undergone RALNR between 05/2019 and 09/2023 at the university hospital of Zurich, was conducted. Sonomorphological parameters before and 6 weeks after surgery, as well as surgical, clinical and obstetrical outcomes were assessed. The mean widths and depths of the niche were significantly reduced (p < 0.001), width from 10.0 ± 3.5 mm preoperatively to 2.6 ± 3.4 mm postoperatively, and depths from 9.1 ± 3.7 mm preoperatively to 1.8 ± 2.6 mm postoperatively. RMT was significantly improved after RALNR (p < 0.001) with mean 1.5 ± 1.5 mm preoperatively compared to 8.3 ± 2.9 mm postoperatively. The pregnancy rate was 13 of 18 (77%), and 7 re-cesarean sections were performed at term. Following surgery, RMT is improved, and subsequent pregnancy rates are high. Larger prospective studies with different long-term obstetric outcomes are needed to determine the clinical significance of RALNR in subsequent pregnancies. This effort advances the field`s state of the art by demonstrating a successful technique for RALNR and its clinical feasibility in a symptomatic cohort.