Higher cesarean section rates and better ultrasound diagnostics have led to a more frequent diagnosis of isthmocele, a cesarean scar defect. Sometimes, endometriosis is found in the isthmocele, but simultaneous extrauterine endometriosis and endometriosis in the isthmocele have not yet been reported. Additionally, the surgical technique to repair the isthmocele is the subject of ongoing controversy. The aim of this study is to analyze a possible correlation between uterine scar (isthmocele) endometriosis and extrauterine endometriosis and to investigate the outcome of laparoscopic isthmocele resection in the rendezvous technique. In this single-center retrospective study, we included 83 women of reproductive age with symptomatic isthmocele undergoing laparoscopic isthmocele repair in rendezvous technique from 2004 to 2020 at the University of Bern. We collected data on patient and surgical characteristics as well as on postoperative outcomes (symptoms, further pregnancy, and pregnancy outcomes) retrospectively. We analyzed and compared these data for patients with and without endometriosis. Endometriosis was diagnosed during surgery in 22 out of 83 operated patients (26.5%). Diagnosis of isthmocele endometriosis (n = 9, 11%) was significantly higher in patients with extrauterine endometriosis (n = 6, p = 0.004). While the duration of surgery was significantly longer for patients with endometriosis (p = 0.006), the groups did not differ with regard to blood loss or complications. In addition, both groups showed similar indications for isthmocele repair (infertility, abnormal uterine bleeding, or dysmenorrhea). Surgery significantly improved abnormal uterine bleeding (χ² p < 0.001), dysmenorrhea (χ², p = 0.03), and infertility (χ², p < 0.001). Regardless of the presence of endometriosis, 25 of 40 (63%) infertile patients became pregnant after surgery. In one out of eight pregnancies, however, we observed scar complications during pregnancy such as uterine scar pregnancy (n = 3), uterine scar dehiscence (n = 3), and placenta previa (n = 1). Endometriosis is a non-negligible intraoperative finding in patients with symptomatic isthmocele. The laparoscopic approach in the rendezvous technique is safe and effective. Therefore, this method should be recommended, especially in women with secondary infertility, and preoperatively simultaneous endometriosis resection should be discussed with the patient. In follow-up, postoperative pregnancies have to be monitored with care.

Background: Uterine contractility, also known as uterine peristalsis (UP), is a critical determinant of fertility, affecting sperm transport and embryo implantation. Increased uterine peristaltic activity has been associated with reduced pregnancy rates. However, data are heterogeneous and uterine contractility has not been widely translated into clinical practice. Cine-MRI, although limited by cost and heterogeneity in data reporting, has emerged as a promising tool to assess uterine dynamics and increase our knowledge of UP in physiological and pathological conditions. Objective: This systematic review and meta-analysis aimed to describe patterns of UP in physiological and pathological uterine conditions, including endometriosis and fibroids, using cine-MRI. Methods: A systematic literature search of the Medline, Embase, Cochrane and CENTRAL databases and Google Scholar was conducted up to May 2024, including studies evaluating UP by cine-MRI. Clinical studies evaluating uterine contractility were included, excluding those affected by therapeutic interventions or unrelated pathologies. This meta-analysis pooled data from studies comparing uterine contractility in patients with endometriosis. Results: In the 13 included studies (365 women), uterine contractility varied significantly according to menstrual cycle phases and pathological conditions. This meta-analysis showed that women with endometriosis had higher uterine contractility in the luteal phase (0.74; 95% CI: 0.27–1.21) but not in the periovulatory phase (SMD 0.8; 95% CI: −3.78–5.37). Conclusions: Cine-MRI is a promising diagnostic tool for the analysis of UP. Endometriosis is associated with impaired UP, which may be a cause of the decreased implantation rate and infertility in endometriosis. However, further research is needed to consolidate the effect of UP on implantation and fertility and to develop standardised and cost-effective tools to assess uterine contractility and tailor infertility treatment.

Background: In recent decades, there has been a notable rise in the prevalence of caesarean sections, which has been accompanied by a concomitant increase in the incidence of long-term complications, including the occurrence of isthmocele. This anatomical alteration has been associated with symptoms such as abnormal uterine bleeding (AUB), chronic pelvic pain, and secondary infertility. On the other hand, chronic endometritis (CE), characterised by the infiltration of plasma cells into the endometrium, is also associated with infertility and repeated implantation failures. Given the coincidence of symptoms between these two conditions, the question arises as to whether there is an association between isthmocele and CE. Objective: This systematic review and meta-analysis aim to examine the association between isthmocele and CE and to assess its potential clinical implications. Methods: A systematic literature search was conducted in Medline, Embase, and Cochrane CENTRAL up to February 2025. The inclusion criteria were studies involving histopathological findings in isthmocele. The results of the meta-analysis incorporated observational studies and trials to evaluate the prevalence of CE in women with isthmocele, as well as the odds ratios (OR) for CE in isthmocele compared to women without isthmocele, and for CE in isthmocele with AUB compared to women without AUB. Results: A total of seven studies were included in the systematic review, comprising 976 women in the systematic review and 876 women in the meta-analysis. The pooled prevalence of CE in women with an isthmocele was 40% (95% CI: 24–58%). Here, the risk of CE was threefold higher in the presence of an isthmocele as compared to its absence (OR = 3.01; 95% CI: 1.02–9.03). Furthermore, the risk of CE was further increased in women with AUB and isthmocele compared to those without AUB (OR = 6.33, 95% CI: 1.94–20.67). Conclusions: CE and isthmocele are both under-diagnosed and poorly understood conditions. The high prevalence of CE in isthmocele indicates a substantial clinical burden. Specifically, women with AUB and isthmocele exhibit a six-fold higher risk of developing CE. These results underscore the importance of recognising isthmocele as a significant risk factor for CE, particularly in women presenting with isthmocele-associated AUB. Further research is warranted to elucidate the underlying mechanisms and to develop targeted interventions for the prevention and management of CE in this population.

Background: The presence of ectopic endometrial glands within the uterine myometrium in patients with adenomyosis has been associated with adverse fertility outcomes. UP (Uterine Peristalsis), a movement of contractions at the junctional zone of the non-pregnant uterus, can be impacted by an altered architecture of uterine layers. Abnormal contractility patterns could impact both uterotubal sperm transport as well as embryo implantation. Because of this potential influence on clinical symptoms and reproduction in patients with adenomyosis, studies have been analyzing the feasibility of diagnostic techniques in assessing uterine peristalsis. Objective: This systematic review and meta-analysis aimed to detect an alteration in patterns of UP in patients with adenomyosis. Methods: A systematic literature search of Medline, Embase, Cochrane, CENTRAL databases and Google Scholar was conducted up to June 2025, including studies evaluating UP and adenomyosis. Clinical studies evaluating uterine contractility were included, excluding those potentially affected by therapeutic interventions. The meta-analysis pooled data from studies to compare uterine contractility direction between patients with adenomyosis and control groups. Results: In seven included studies (442 women), uterine contractility varied significantly in association with menstrual cycle phases and pathological conditions. The meta-analysis revealed two statistically significant findings: women with adenomyosis showed significantly reduced uterine contraction frequency (SMD −1.81, 95% CI: −3.04 to −0.58, p = 0.0039) and fewer antegrade contractions (OR 0.35, 95% CI: 0.13–0.96, p = 0.0423) compared to controls. Other contractility patterns showed non-significant trends with substantial heterogeneity. Conclusions: Our findings show a significant difference in uterine contraction patterns in patients with adenomyosis compared to controls, namely a decrease in frequency and an increased number of retrograde uterine contractions in the adenomyosis group. The remarkable heterogeneity of the results highlighted the need for larger study cohorts in the future, especially to address the main diagnostic possibilities and treatments in order to improve reproductive outcomes.

Minimally invasive hysterectomy is the preferred surgical approach for benign gynecologic conditions. The DEXTER® Robotic Surgery System was developed to address the limitations of conventional robotic systems, offering a mobile, modular, and accessible alternative adaptable to various surgical environments. This prospective, multicenter, single-arm study evaluated the clinical performance and early postoperative safety of the robotic-assisted hysterectomy with adnexal surgery for benign indications with DEXTER. The primary endpoints were short-term safety, assessed by the occurrence of Clavien–Dindo grade ≥ III adverse events up to 42 days postoperatively, and procedural success without conversion to laparoscopy or open surgery. Fifty-two patients were enrolled across four European centers—one university hospital and three community hospitals. All procedures were successfully completed without intraoperative complications or conversions. The mean total skin-to-skin operative time was 121.9 ± 42.7 min, and the mean estimated blood loss was 87.8 ± 93.8 mL. The system also demonstrated efficient setup with a mean docking time of 3.8 ± 1.3 min, as well as the feasibility of a three-trocar technique for minimal scarring and potential for outpatient application in select cases. The mean time to discharge was 2.0 ± 0.9 days. One major Clavien–Dindo IIIb complication occurred. No device-related adverse events were reported. These results confirm the safety and performance of DEXTER in robotic-assisted hysterectomy and support its role in expanding access to robotic-assisted surgery in diverse clinical settings. Trial registration : ClinicalTrials.gov NCT06473675.