Robot-assisted metroplasty

Loginova E.A., Ponomareva Yu.N., Davydova I.Yu., Ivanova L.B., Valiev R.K.

1) A.S. Loginov Moscow Clinical Research and Practical Center, Moscow Healthcare Department, Moscow, Russia; 2) Academician V.I. Kulakov National Medical Research Center of Obstetrics, Gynecology, and Perinatology, Ministry of Health of Russia, Moscow, Russia
The rate of surgical delivery, such as caesarean section, has substantially increased globally in recent decades. One of the adverse consequences of caesarean section is the formation of an inconsistent uterine scar that can become a cause of uterine rupture during pregnancy and childbirth or that of menstrual irregularities and pain syndrome. The excision of scar tissue and the formation of a new scar are an effective treatment for inconsistent uterine scar in patients when planning pregnancy and in the presence of clinical symptoms.
The paper presents a literature review on possible methods for surgical correction of uterine scar. It also describes a rare clinical case of reconstructive plastic surgery for inconsistent uterine scar in a patient with complete uterine duplication. A 36-year-old female patient was diagnosed having a scar myometrial thickness of up to 2.5 mm and a niche measuring 10*8 mm in the left uterine body. Hysteroscopic coagulation of a uterine wall defect produced no expected positive effect; the woman still complained of her long-term disrupting quality of life and postmenstrual bleeding. The patient underwent reconstructive plastic surgery, namely, excision ofpathologically altered tissues in the isthmus of the left uterine body to form a new scar using the da Vinci robotic surgery system. Robotic metroplasty yielded positive results: there was no niche in the scar area; the myometrial thickness was 9.3 mm; prolonged postmenstrual bleeding was stopped.
Conclusion: Thus, in our observation, robot-assisted metroplasty could create conditions for the formation of an adequate uterine scar, improve quality of life in a woman and reduce the risk of life-threatening complications of pregnancy and childbirth, such as uterine scar rupture, placental growing into the scar, and maternal and intranatal mortality.


caesarean section
postmenstrual bleeding
complete uterine duplication
robotic correction of uterine scar
uterine scar


1. Dosedla E., Calda P. Outcomes of laparoscopic treatment in women with Cesarean scar syndrome. Med. Sci. Monit. 2017; 23: 4061-6.

2. Крамарский В.А., Мащакевич Л.И., Дудакова В.Н. Основные факторы риска развития неполноценности рубца на матке после кесарева сечения. Российский вестник акушера-гинеколога. 2003; 2: 37-9. [Kramarskiy V.A., Mashchakevich L.I., Dudakova V.N. Major risk factors for the development of low-grade uterine scar after cesarean section. Rossiyskiy vestnik akushera- ginekologa/ Russian Bulletin of Obstetrician-Gynecologist. 2003; 2: 37-9 (in Russian)].

3. Фаткуллин И.Ф., Габидуллина Р.И., Галимова И.Р., Гурьев Э.Н., Азанова Д.Б., Шайхутдинова Л.Р. Сравнительный анализ результатов кесарева сечения: выбор шовного материала и метода наложения шва на матку. Российский вестник акушера-гинеколога. 2001; 1: 83-5. [Fatkullin I.F., Gabidullina R.I., Galimova I.R., Gur'ev E.N., Azanova D.B., Shaykhutdinova L.R. Comparative analysis of results of caesarean section: choice of suture material and methods of uterine closure. Rossiyskiy vestnik akushera-ginekologa/ Russian Bulletin of Obstetrician-Gynecologist. 2001; 1: 83-5 (in Russian)].

4. Габидуллина Р.И., Фаткуллин И.Ф., Киясов А.П., Азанова Д.Б., Резвяков П.Н. Клинико-морфологические параллели в оценке состояния рубца на матке после кесарева сечения. Казанский медицинский журнал. 2002; 6: 424-9. [Gabidullina R.I., Fatkullin I.F., Kiyasov A.P., Azanova D.B., Rezvyakov P.N. Clinical and morphological parallels in evaluation of status of a post-caesarean uterine scar. Kazanskiy meditsinskiy zhurnal/ Kazan Medical Journal. 2002; 6: 424-9 (in Russian)].

5. Густоварова Т.А., Иванян А.Н., Коржуев С.И. Ведение беременности и родов у пациенток с рубцом на матке после кесарева сечения. Российский вестник акушера-гинеколога. 2007; 4: 45-9. [Gustovarova T.A., Ivanyan A.N., Korzhuev S.I. Management of pregnancy and labor in patients with an uterine scar after cesarean section. Rossiyskiy vestnik akushera-ginekologa/ Russian Bulletin of Obstetrician-Gynecologist. 2007; 4: 45-9 (in Russian)].

6. Павлова Т.Ю., Филиппова Р.Д., Крамарский В.А., Аргунов В.А. Комплексная оценка характера репаративных процессов в области разреза матки после кесарева сечения. Якутский медицинский журнал. 2008; 4: 37-40. [Pavlova T.Yu., Filippova R.D., Kramarskiy V.A., Argunov V.A. Complex assessment of pattern of reparative processes at the place of uterine incision after caesarean section. Yakutskiy meditsinskiy zhurnal/ Yakut Medical Journal. 2008; 4: 37-40 (in Russian)].

7. Щукина Н.А., Буянова С.Н., Чечнева М.А., Земскова Н.Ю., Пучкова Н.В., Барто Р.А., Баринова И.В., Благина Е.И. Причины формирования несостоятельного рубца на матке после кесарева сечения, роль дисплазии соединительной ткани Российский вестник акушера-гинеколога. 2018; 18(5): 4-11. [Shchukina N.A., Buyanova S.N., Chechneva M.A., Zemskova N.Yu., Puchkova N.V., Barto R.A., Barinova I.V., Blagina E.I. Causes of a postcesarean incompetent uterine scar: a role of connective tissue dysplasia. Russian Bulletin of obstetrician-gynecologist. 2018; 18(5): 4-11. (in Russian)].

8. Ofili-Yebovi D., Ben-Nagi J., Sawyer E., Yazbek J., Lee C., Gonzalez J., Jurkovic D. Deficient lower-segment Cesarean section scars: prevalence and risk factors. Ultrasound Obstet. Gynecol. 2008; 31(1): 72-7.

9. Osser O.V., Jokubkiene L., Valentin L. High prevalence of defects in Cesarean section scars at transvaginal ultrasound examination Ultrasound Obstet. Gynecol. 2009; 34(1): 90-7.

10. Краснопольская К.В., Поров А.А., Чечнева М.А., Федоров А.А., Ершова И.Ю. Прегравидарная метропластика по поводу несостоятельного рубца на матке после кесарева сечения: влияние на естественную фертильность и результаты ЭКО. Проблемы репродукции. 2015; 21(3): 56-62. [Krasnopol’skaya K.V., Popov A.A., Chechneva M.A., Fedorov A.A., Ershova I.Yu. Preconceptional methroplastic operation in patients with uterine scar incompetence after Caesarean section: the influence on natural fertility and IVF o utcomes. Problems of Reproduction. 2015; 21(3): 56-62. (in Russian)].

11. Попов А.А., Федоров А.А., Вроцкая В.С., Мананникова Т.Н., Тюрина С.С., Коваль А.А., Чечнева М.А., Логутова Л.С. Эндоскопические методы диагностики и хирургической коррекции несостоятельного рубца на матке после кесарева сечения. Акушерство и гинекология Санкт-Петербурга. 2017; 1: 54-7. [Popov A.A., Fedorov A.A., Vrotskaya V.S., Manannikova T.N., Tyurina S.S., Koval A.A., Chechneva M.A., Logutova L.S. Endoscopic diagnosis and surgical correction of the insolvent uterine scar after cesarean section. Obstetrics and gynaecology of Saint-Petersburg. 2017; 1: 54-7. (in Russian)].

12. Jordans I.P.M., de Leeuw R.A., Stegwee S.I., Amso N.N., Barri-Soldevila P.N., van den Bosch T. et al. Sonographic examination of uterine niche in non-pregnant women: a modified Delphi procedure. Ultrasound Obstet. Gynecol. 2019; 53(1): 107-15.

13. Bij de Vaate A.J, Brolmann H.A., van der Voet L.F., van der Slikke J.W., Veersema S., Huirne J.A. Ultrasound evaluation of the Cesarean scar: relation between a niche and postmenstrual spotting. Ultrasound Obstet. Gynecol. 2011; 37(1): 93-9.

14. Bij de Vaate A.J., van der Voet L.F., Naji O., Witmer M., Veersema S., Brolmann H.A. et al. Prevalence, potential risk factors for development and symptoms related to the presence of uterine niches following Cesarean section: systematic review. Ultrasound Obstet. Gynecol. 2014; 43(4): 372-82.

15. van der Voet L.F., Bij de Vaate A.M., Veersema S., Brolmann H.A., Huirne J.A. Long-term complications of caesarean section. The niche in the scar: a prospective cohort study on niche prevalence and its relation to abnormal uterine bleeding. BJOG. 2014; 121: 236-44. 1471-0528.12542.

16. Fabres C., Aviles G., De La Jara C., Escalona J., Munoz J.F., Mackenna A. et al. The cesarean delivery scar pouch: clinical implications and diagnostic correlation between transvaginal sonography and hysteroscopy. J. Ultrasound Med. 2003; 22(7): 695-700. jum.2003.22.7.695.

17. Thurmond A.S., Harvey W.J., Smith S.A. Cesarean section scar as a cause of abnormal vaginal bleeding: diagnosis by sonohysterography. J. Ultrasound Med. 1999; 18(1): 13-6.

18. Wang C.B., Chiu W.W., Lee C.Y., Sun Y.L., Lin Y.H., Tseng C.J. Cesarean scar defect: correlation between Cesarean section number, defect size, clinical symptoms and uterine position. Ultrasound Obstet. Gynecol. 2009; 34(1): 85-9.

19. Erickson S.S., Van Voorhis B.J. Intermenstrual bleeding secondary to cesarean scar diverticuli: report of three cases. Obstet. Gynecol. 1999; 93(5, Pt. 2): 802-5.

20. Van H.A., Temmerman M., Dhont M. Cesarean scar dehiscence and irregular uterine bleeding. Obstet. Gynecol. 2003; 102(5, Pt. 2): 1137-9.

21. Vissers J., Sluckin T.C., Repelaervan Driel-Delprat C.C., Schats R., de Groot C.J.M., Lambalk C.B. et al. Reduced pregnancy and live birth rates after in vitro fertilization in women with previous Caesarean section: a retrospective cohort study. Hum. Reprod. 2020; 35(3): 595-604. humrep/dez295.

22. Naji O., Wynants L., Smith A., Abdallah Y., Saso S., Stalder C., Van Huffel S. et al. Does the presence of a Caesarean section scar affect implantation site and early pregnancy outcome in women attending an early pregnancy assessment unit? Hum. Reprod. 2013; 28(6): 1489-96. det110.

23. Fitzpatrick K.E., Kurinczuk J.J., Alfirevic Z., Spark P., Brocklehurst P., Knight M. Uterine rupture by intended mode of delivery in the UK: A National CaseControl Study. PLoS Med. 2012; 9(3): e1001184. journal.pmed.1001184.

24. Guise J.M., McDonagh M.S., Osterweil P., Nygren P., Chan B.K.S., Helfand M. Systematic review of the incidence and consequences of uterine rupture in women with previous caesarean section. BMJ. 2004; 329(7456): 19-25.

25. Savukyne E., Bykovaite-Stankeviciene R., Machtejeviene E., Nadisauskiene R., Maciuleviciene R. Symptomatic uterine rupture: a fifteen year review. Medicina (Kaunas). 2020; 56(11): 574.

26. Spong C.Y., Landon M.B., Gilbert S., Rouse D.J., Leveno K.J., Varner M.W. et al. Risk of uterine rupture and adverse perinatal outcome at term after cesarean delivery. Obstet. Gynecol. 2007; 110(4): 801-7. 01.AOG.0000284622.71222.b2.

27. Mourad W.S., Bersano D.J., Greenspan P.B., Harper D.M. Spontaneous rupture of unscarred uterus in a primigravida with proper prelabour rupture of membranes. BMJ Case Rep. 2015; 2015: bcr2014207321. bcr-2014-207321.

28. Smith G.C.S., Pell J.P., Pasupathy D., Dobbie R. Factors predisposing to perinatal death related to uterine rupture during attempted vaginal birth after caesarean section: Retrospective cohort study. BMJ. 2004; 329(7462): 375.

29. Kayani S.I., Alfirevic Z. Uterine rupture after induction of labour in women with previous cesarean section. BJOG. 2005; 112(4): 451-5.

30. Fabres C., Aviles G., De La Jara C., Escalona J., Munoz J.F., Mackenna A. et al. The cesarean delivery scar pouch: clinical implications and diagnostic correlation between transvaginal sonography and hysteroscopy. J. Ultrasound Med. 2003; 22(7): 695-700.

31. Clark E.A., Silver R.M. Long-term maternal morbidity associated with repeat cesarean delivery. Am. J. Obstet. Gynecol. 2011; 205 (6, Suppl.): S2-10.

32. Roberge S., Boutin A., Chaillet N. Systematic review of cesarean scar assessment in the nonpregnant state: Imaging techniques and uterine scar defect. Am. J. Perinatol. 2012; 29(6): 465-71. s-0032-1304829.

33. Kaplanoglu M., Bulbul M. Effect of multiple repeat Caesarean sections on maternal morbidity: data from Southeast Turkey. Med. Sci. Monit. 2015; 21: 1447-53.

34. Osser V.O., Lil V. Clinical importance of appearance of cesarean hysterotomy scar at transvaginal ultrasonography in nonpregnant women. Obstet. Gynecol. 2011; 117(3): 525-32.

35. Li C., Tang S., Gao X., Lin W., Han D., Zhai J. et al. Efficacy of combined laparoscopic and hysteroscopic repair of post-sesarean section uerine diverticulum: a retrospective analysis. Biomed. Res. Int. 2016; 2016: 1765624.

36. Bakaviciute G., Spiliauskaite S., Meskauskiene A., Ramasauskaite D. Laparoscopic repair of the uterine scar defect - successful treatment of secondary infertility: a case report and literature review. Acta Med. Litu. 2016; 23(4): 227-31.

37. Donnez O., Donnez J., Orellana R., Dolmans M.M. Gynecological and obstetrical outcomes after laparoscopic repair of a cesarean scar defect in a series of women. Fertil. Steril. 2017; 107(1): 289-96. j.fertnstert.2016.09.033.

38. Макиян З.Н., Адамян Л.В., Карабач В.В., Чупрынин В.Д. Новый метод хирургического лечения несостоятельности рубца на матке после кесарева сечения с помощью внутриматочного манипулятора с желобом. Акушерство и гинекология. 2020; 2: 104-10. [Makiyan Z.N., Adamyan L.V., Karabach V.V., Chuprynin V.D. A new method for surgical treatment of uterine scar insuffisiency after a previous cesarean section using an intrauterine manipulator with a groove. Obstetrics and Gynecology. 2020; 2: 104-10. (in Russian)].

39. Donnez O., Jadoul P., Squifflet J., Donnez J. Laparoscopic repair of wide and deep uterine scar dehiscence after cesarean section. Fertil. Steril. 2008; 89(4): 974-80.

40. Ciebiera M., Jakiel G., Sbbuszewska-Jozwiak A. Laparoscopic correction of the uterine muscle loss in the scar after a Caesarean section delivery. Wideochir Inne Tech Maloinwazyjne. 2013; 8(4): 342-5. wiitm.2013.39514.

41. Федоров А.А., Попов А.А., Чечнева М.А., Логутова Л.С., Щукина Н.А., Вроцкая В.С., Коваль А.А., Тюрина С.С., Ефремова Е.С., Беспалова А.Г. Ниша в рубце на матке после кесарева сечения. Диагностика, хирургическая тактика и исходы. Российский вестник акушера-гинеколога. 2021; 21(2): 50-5. [Fedorov A.A., Popov A.A., Chechneva M.A., Logutova L.S., Schukina N.A., Vrotskaya V.S., Koval A.A., Tyurina S.S., Efremova E.S., Bespalova A.G. Niche in the uterine scar after cesarean section. Diagnostics, surgical tactics and outcomes. Russian Bulletin of ObstetricianGynecologist. 2021; 21(2): 50-5. (in Russian)]. rosakush20212102150.

42. Marotta M.L., Donnez J., Squifflet J., Jadoul P., Darii N., Donnez O. Laparoscopic repair of post cesarean section uterine scar defects diagnosed in nonpregnant women. J. Minim. Invasive Gynecol. 2013; 20(3): 386-91.

43. Vervoort A., Vissers J., Hehenkamp W, Brolmann H., Huirne J. The effect of laparoscopic resection of large niches in the uterine caesarean scar on symptoms, ultrasound findings and quality of life: a prospective cohort study. BJOG. 2018; 125(3): 317-25.

44. Mahmoud M.S., Nezhat F.R. Robotic-assisted laparoscopic repair of a cesarean section scar defect. J. Minim. Invasive Gynecol. 2015; 22(7): 1135-6.

45. Yalcinkaya T.M., Akar M.E., Kammire L.D., Johnston-MacAnanny E.B., Mertz H.L. Robotic-assisted laparoscopic repair of symptomatic cesarean scar defect: a report of two cases. J. Reprod. Med. 2011; 56(5-6): 265-70.

46. Guan Z., Liu J., Bardawil E., Guan X. Surgical management of cesarean scar defect: the hysteroscopic-assisted robotic single-site technique. J. Minim. Invasive Gynecol. 2020; 27(1): 24-5. j.jmig.2019.06.007.

47. Ye M., Zhang Q., Li Z., Gu C., Meng Y. Robotic CSP resection and hysterotomy repair. J. Minim. Invasive Gynecol. 2020; 28(5): 945-6.

48. La Rosa M.F., McCarthy S., Richter C., Azodi M. Robotic repair of uterine dehiscence. JSLS. 2013; 17(1): 156-60. 108680812X13517013317996.

49. Пономарева Ю.Н., Логинова Е.А., Семенцова Н.А. Робот-ассистированная коррекция несостоятельного рубца на матке после кесарева сечения. Акушерство и гинекология. 2021; 10: 143-52. [Ponomareva Yu.N., Loginova E.A., Sementsova N.A. Robot-assisted correction of incompetent uterine scar after cesarean section. Obstetrics and Gynecology. 2021; 10: 143-52 (in Russian)].

50. Wang H.F., Chen H.H., Ting W.H., Lu H.F., Lin H.H., Hsiao S.M. Robotic or laparoscopic treatment of cesarean scar defects or cesarean scar pregnancies with a uterine sound guidance. Taiwan. J. Obstet. Gynecol. 2021; 60(5): 821-6.

51. Van der Voet L.F., Vervoort A.J., Veersema S., BijdeVaate A.J., Brolmann H.A., Huirne J.A. Minimally invasive therapy for gynaecological symptomms related to a niche in the caesarean scar: a systematic review. BJOG. 2014; 121(2): 145-56.

52. Vervoort A., Voet L.F., Hehenkamp W., Thurkow A.L., Kesteren P., Quartero H. et al. Hysteroscopic resection of a uterine caesarean scar defect (niche) in women with postmenstrual spotting: a randomised controlled trial. BJOG. 2018; 125(3): 326-34. 1471-0528.14733.

53. Фархат К.Н., Адамян Л.В. Аномалии развития матки и влагалища в сочетании с эндометриозом: тактика ведения и хирургическая коррекция. Акушерство и гинекология. 2016; 5: 96-102. [Farkhat K.N., Adamyan L.V. Uterine and vaginal malformations concurrent with endometriosis: Management tactics and surgical correction. Obstetrics and Gynecology. 2016; 5: 96-102. (in Russian)]. aig.2016.5.96-102.

54. Vissers J., Hehenkamp W., Lambalk C.B., Huirne J.A. Post-Caesarean section niche-related impaired fertility: hypothetical mechanisms Hum. Reprod. 2020; 35(7): 1484-94.

55. Gardeil F., Daly S., Turner M.J. Uterine rupture in pregnancy reviewed. Eur. J. Obstet. Gynecol. Reprod. Biol. 1994; 56(2): 107-10.

56. Vitale S.G., Ludwin A., Vilos G.A., Torok P, Tesarik J., Vitagliano A. et al. From hysteroscopy to laparoendoscopic surgery: what is the best surgical approach for symptomatic isthmocele? A systematic review and meta-analysis. Arch. Gynecol. Obstet. 2020; 301(1): 33-52. s00404-020-05438-0.

Received 28.01.2022

Accepted 24.02.2022

About the Authors

Ekaterina A. Loginova, PhD, Researcher at the Laboratory of Gynecology, Department of Pelvic Oncology, A.S. Loginov Moscow Clinical Scientific and Practical Center, Moscow Healthcare Department, +7(495)304-30-35, +7(985)182-28-58,,, 111123, Russia, Moscow, Entuziastov Highway, 86.
Julia N. Ponomareva, Dr. Med. Sci., Head of the Department of Operative Gynecology and Robotic Surgery, Academician V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology, Ministry of Health of Russia,,, 117997, Moscow, Russia, Ac. Oparina str., 4.
Irina Yu. Davydova, Dr. Med. Sci., Leading Researcher, Department of Pelvic Floor Oncology, A.S. Loginov Moscow Clinical Scientific and Practical Center,
Moscow Healthcare Department, +7(495)304-30-35,, 111123, Russia, Moscow, Entuziastov Highway, 86.
Larisa B. Ivanova, PhD, Head of the Laboratory of Gynecology, Pelvic Oncology Department, A.S. Loginov Moscow Clinical Scientific and Practical Center,
Moscow Healthcare Department, +7(495)304-30-35,, 111123, Russia, Moscow, Entuziastov Highway, 86.
Ramiz K. Valiev, PhD, Head of the Department of Pelvic Floor Oncology, A.S. Loginov Moscow Clinical Scientific and Practical Center, Moscow Healthcare Department, +7(495)304-30-35,, 111123, Russia, Moscow, Entuziastov Highway, 86.
Corresponding author: Ekaterina A. Loginova,

Authors’ contributions: Loginova E.A., Davydova I.Yu., Ivanova L.B. - concept and design of the article, material collection and processing, text writing and design; Ponomareva Yu.N., Loginova E.A., Ivanova L.B. - material collection; Davydova I.Yu., Valiev R.K., Ivanova L.B. - editing.
Conflicts of interest: The authors declare that there are no conflicts of interest.
Funding: The investigation has not been sponsored.
Patient Consent for Publication: The patient provided informed consent for the publication of her data and associated images.
For citation: Loginova E.A., Ponomareva Yu.N., Davydova I.Yu., Ivanova L.B., Valiev R.K. Robot-assisted metroplasty.
Akusherstvo i Ginekologiya/Obstetrics and Gynecology. 2022; 3: 129-137 (in Russian)

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