Hysteroscopic treatment of the cesarean-induced isthmocele in restoring infertility. Curr Opin Obstet Gynecol. 2012;24:180-186. [PMID: 22395067 DOI: 10.1097/gco.0b013e3283521202]

Laparoscopic isthmocele treatment - single center experience

INTRODUCTION

A cesarean section is the most frequently performed surgery in modern obstetrics. In case of an incorrect wound healing process there is a risk of a persistent uterine wall defect. Nowadays, due to the high frequency of cesarean sections, obstetricians have to deal with the threat of uterine rupture due to pathological wound healing. It has been proven that isthmocele can cause abnormal uterine bleeding (AUB), pelvic pain (PP), and secondary infertility (SI), and can be a place of improper pregnancy placement.

AIM

This article presents our experience with isthmocele treatment. We describe our diagnostic process scheme, method of corrective surgery and main therapeutic outcomes.

MATERIAL AND METHODS

In this manuscript we present a single center's experience in isthmocele therapy. We have operated on 16 patients who suffered from abnormal uterine bleeding, pain disorders or secondary infertility possibly due to a cesarean scar defect.

RESULTS

The results obtained in our center are promising. In 9 of 11 (81.8%) women with abnormal bleeding we obtained complete resolution of symptoms. We had slightly worse results in the case of pelvic pain. In 4 (66.6%) of 6 patients the pain resolved completely. We have obtained 7 pregnancies in 11 (63.6%) patients operated on due to secondary infertility.

CONCLUSIONS

In our opinion, laparoscopic treatment seems to be currently one of the most effective methods in isthmocele therapy. Further investigation is necessary to determine the indications for surgery, suitable treatment strategies and appropriate care.

Laparoscopic repair of the uterine scar defect - successful treatment of secondary infertility: a case report and literature review

Background.

The aim of this paper is to present a clinical case of laparoscopic repair of a uterine scar defect, to assess the effectiveness of treatment reviewing the latest literature sources, and to provide recommendations of uterine scar defect management.

Materials and methods.

We report the case of a 33-year-old woman with an insufficient uterine scar and one-year history of secondary infertility. Following this, she underwent corrective laparoscopic repair, successfully got pregnant two months later and carried pregnancy to full term. We discuss the prevalence of caesarean scar defects, their clinical symptoms, diagnostic methods, various treatment techniques, and their outcomes.

Results and conclusion.

Caesarean scar defects, insufficient uterine scars, isthmocele or scar dehiscence following a caesarean section involve myometrial discontinuity at the site of a scar previous caesarean section. These anatomical defects associated with prolonged menstrual bleeding, chronic pelvic pain, dysmenorrhea, dyspareunia and secondary infertility. Laparoscopic repair of the uterine scar defect is an effective method of treatment of secondary infertility. Patients with a previous history of caesarean section who present complaints of secondary infertility, need a detailed evaluation of the uterine scar before planning future pregnancies

Defect width: the prognostic index for vaginal repair of cesarean section diverticula

PURPOSE

To evaluate the clinical parameter associated with cesarean section diverticula anatomic healing via vaginal repair management.

METHODS

Observational cohort study. From Jul 2014 to Dec 2015, 143 women with CSD underwent vaginal repair surgery in Shanghai First Maternity and Infant Hospital, and 137(95.80%) were diagnosed using both transvaginal ultrasound and MRI. A total of 124 patients (86.71%) who were followed-up for more than 6 months after surgery were enrolled in this study. Excision and suture of CSD was performed through the vaginal approach. The defect sizes of the width, length, depth and TRM before or after repair were evaluated.

RESULTS

The mean preoperative duration of menstruation was 14.47 ± 3.30 days and the thickness of the remaining muscular layer was 2.65 ± 1.13 mm before surgery. The study revealed that the healing effects of CSD repair stabilized 3 months after surgery. At the median follow-up time (11.28 months), CSD disappeared after surgery in 64.52% of patients (80/124), and 60.0% of patients (48/80) reached ≤7 days of menstruation. Meanwhile, for 35.48% of patients (44/124), CSD persisted at the median follow-up after surgery, and 31.82% (14/44) of these patients reached ≤7 days of menstruation(P < 0.05). TRM at a median follow-up time after vaginal repair >7.88 mm, 92.11% (70/76) of CSD disappeared. Moreover, when preoperative CSD width ≤18.85 mm indicates that only 18.75% (12/64) of patients will present with CSD after vaginal repair, as determined by MRI (95% CI 0.515-0.737).

CONCLUSION

The defect width of the preoperative CSD was the prognostic index of CSD anatomical repair effect. When the preoperative CSD width >18.85 mm, we should pay more attention to the edge of the defect during vaginal repairing.

Gynecological and obstetrical outcomes after laparoscopic repair of a cesarean scar defect in a series of 38 women

OBJECTIVE

To evaluate gynecological and obstetrical outcomes, as well as remaining myometrial thickness, after laparoscopic repair of a cesarean scar.

DESIGN

Observational study and prospective evaluation of the remaining myometrium before and after repair.

SETTING

Academic department in a university hospital.

PATIENT(S)

A series of 38 symptomatic women with cesarean scar defects and remaining myometrial thickness of less than 3 mm, according to magnetic resonance imaging.

INTERVENTION(S)

Laparoscopic repair of the defect.

MAIN OUTCOMES MEASURE(S)

Increase in myometrial thickness at the site of cesarean section, gynecological and obstetrical outcomes, and histological analysis of the defect after excision.

RESULT(S)

The mean thickness of the myometrium increased significantly from 1.43 ± 0.7 mm before surgery to 9.62 ± 1.8 mm after surgery. All but three patients were free of symptoms. Among the 18 women with infertility, eight (44%) became pregnant and delivered healthy babies by cesarean section at 38-39 weeks of gestation. Histological analysis, performed in all 38 cases, revealed the presence of endometriosis in eight women (21.1%). Muscle fiber density was significantly lower compared with adjacent myometrium.

CONCLUSION(S)

In symptomatic women with residual myometrial thickness of less than 3 mm who wish to conceive, laparoscopic repair could be considered an appropriate approach.

Vaginal Repair of Cesarean Section Scar Diverticula that Resulted in Improved Postoperative Menstruation

STUDY OBJECTIVE

Owing to the increase in cesarean sections (C-sections) worldwide, long-term complications such as postmenstrual spotting, chronic pelvic pain, and C-section scar ectopic pregnancies have created a new medical era of gynecologic disease. A new type of vaginal repair is evaluated to repair C-section diverticulum (CSD) and rebuild the muscular layer to improve symptoms of abnormal uterine bleeding and decrease the risk of uterine rupture.

DESIGN

Retrospective cohort study (Canadian Task Force classification II-2).

SETTING

University hospital.

PATIENTS

A total of 121 patients with CSD diagnoses by transvaginal ultrasound (TVU) presented with postmenstrual spotting between June 2012 and March 2015. All patients had undergone at least 1 C-section delivery and had no history of postmenstrual spotting before undergoing C-section.

INTERVENTION

Vaginal excision and suture of CSD.

MEASUREMENT AND MAIN RESULTS

The mean duration of menstruation was 14.87 ± 3.46 days preoperatively and decreased to 8.22 ± 2.73 days at 1 month after surgery, 8.89 ± 2.67 days at 3 months after surgery, and 9.02 ± 2.47 days at 6 months after surgery (p < .01). The length, width, depth, and thickness of the remaining muscular layer (TRM) at 1 month, 3 months, and 6 months assessed by TVU also improved significantly after surgery (p < .05). However, postoperative menstruation and imaging data did not differ markedly between 3 months and 6 months, suggesting that follow-up at 3 months represents an adequate endpoint for evaluating the effectiveness of surgery. At 6 months, 80.3% of patients (94 of 117) reached ≤10 days of menstruation. Further study revealed that a TRM at 6 months of ≥8.5 mm measured by TVU (relative risk [RR], 6.418; 95% confidence interval [CI], 1.478-28.443) and an interval between CS and vaginal repair of ≤2.5 years (RR, 12.0; 95% CI, 1.541- 93.454) were good prognostic factors associated with surgery.

CONCLUSION

Vaginal repair of CSD improved the symptoms of postmenstrual spotting and anatomically corrected the scars. An interval between C-section and a surgery of ≤2.5 years was optimal for vaginal repair, and a TRM at 6 months of ≥8.5 mm represented the standard healing of CSD.

Efficacy of Combined Laparoscopic and Hysteroscopic Repair of Post-Cesarean Section Uterine Diverticulum: A Retrospective Analysis

Background. Diverticulum, one of the long-term sequelae of cesarean section, can cause abnormal uterine bleeding and increase the risk of uterine scar rupture. In this study, we aimed to evaluate the efficacy of combined laparoscopic and hysteroscopic repair, a newly occurring method, treating post-cesarean section uterine scar diverticulum. Methods. Data relating to 40 patients with post-cesarean section uterine diverticulum who underwent combined laparoscopic and hysteroscopic repair were retrospectively analyzed. Preoperative clinical manifestations, size of uterine defects, thickness of the lower uterine segment (LUS), and duration of menstruation were compared with follow-up findings at 1, 3, and 6 months after surgery. Results. The average preoperative length and width of uterine diverticula and thickness of the lower uterine segment were recorded and analyzed. The average durations of menstruations at 1, 3, and 6 months after surgery were significantly shorter than the preoperative one (p < 0.05), respectively. At 6 months after surgery, the overall success improvement rate of surgery was 90% (36/40). Three patients (3/40 = 7.5%) developed partial improvement, and 1/40 (2.5%) was lost to follow-up. Conclusions. Our findings showed that combined treatment with laparoscopy and hysteroscopy was an effective method for the repair of post-cesarean section uterine diverticulum.

Conservative Management of a Scar Abscess formed in a Cesarean-induced Isthmocele

Background

Abscesses located in the cesarean-section (CS) induced isthmoceles are rarely encountered and are usually treated surgically, mostly by hysterectomy.

Case description

We here report the case of a 40-year-old primiparous woman presenting a symptomatic abscess in the isthmocele 10 years after a CS. She was treated by antibiotics and was closely monitored by clinical evaluation, ultrasonography, and pelvic magnetic resonance imaging. This treatment led to complete resolution of symptoms and a disappearance of the abscess at imagery.

Conclusion

Our report shows that a conservative medical management of isthmocele abscesses can be an effective approach in women wishing to preserve their uterus.

Successful treatment of atypical cesarean scar defect using endoscopic surgery

Background

Cesarean scar syndrome results from a postoperative defect of the uterine isthmus, also known as an isthmocele. Patients present with gynecological symptoms, such as abnormal genital bleeding or infertility, after cesarean delivery. Although the cesarean rate is increasing worldwide, this syndrome is not widely known.

Case presentation

A 43-year-old G2P1 Japanese woman with atypical cesarean scar syndrome had a 3-year history of secondary infertility and postmenstrual brown discharge. Laparoscopic and hysteroscopic exploration revealed a cesarean scar defect connected to a small cavity in the myometrium: this was not an endometrial cavity or a uterine diverticulum. After endoscopic excision of the cavity, the brown discharge resolved, and the patient achieved ongoing pregnancy on her third attempt at intrauterine insemination.

Conclusion

Consensus is still lacking regarding the diagnosis and treatment of cesarean scar defect. However, the gynecologists should be aware that cesarean scar syndrome can have scar defects forming cavities of unusual shapes and features. Surgical correction of these defects will often improve postmenstrual bleeding and subfertility in these cases.

Hysteroscopic treatment of symptomatic cesarean-induced isthmocele: a prospective study

An isthmocele, also known as a cesarean scar defect, is an emerging condition that typically affects women with a history of previous cesarean section, and its presence is a novel under-recognized cause of postmenstrual abnormal uterine bleeding and/or pelvic pain. The incidence of symptoms and their resolution after hysteroscopic surgery were evaluated prospectively in 120 consecutive isthmocele patients. Patients included only symptomatic premenopausal women. Transvaginal ultrasound and office hysteroscopy were used to diagnose isthmocele. Operative hysteroscopy was performed to correct the cesarean scar defect, and histologic findings were evaluated. Correction of an isthmocele via operative hysteroscopy was successful in all cases evaluated. Isthmoplasty resulted in the resolution of postmenstrual abnormal uterine bleeding and suprapubic pelvic pain in 80% of patients. In the remaining cases, 7% of patients had an improvement of symptoms, whereas 13% did not obtain any relief. Considering the recent diagnostic recognition of isthmoceles, we conclude that surgical treatment of this pathology by operative hysteroscopy may represent the best choice in symptomatic women because of its minimal invasiveness and beneficial therapeutic results.

Laparoscopic correction of the uterine muscle loss in the scar after a Caesarean section delivery

Caesarean section is the most frequently conducted surgery in modern obstetrics. It involves a significant risk of complications; also disorders in the area of the scar after hysterotomy may lead to menstrual disorders, pain and secondary infertility. In light of the presented facts the significance of a good uterus muscle correction method is high. We present a case of a 28-year-old patient after Caesarean section with further reproductive plans. In the ultrasonographic examination the residual thickness of the uterine wall was approx. 2.5–3 mm. The patient was operated on using laparoscopy and the fibrotic scar tissue was removed. During the follow-up examination in transvaginal ultrasonography the uterine muscularis was continuous on the whole surface. Laparoscopic treatment ensures the appropriate visibility which makes the risk of damage to the adjacent organs lower, and the time of convalescence is short. It provides repetitive good results from the anatomical and functional points of view.

[Uterine ishtmique transmural hernia: results of its repair on symptoms and fertility]

OBJECTIVE

To study the effect of the surgical repair (isthmorraphy) of the large scar dehiscence after cesarean on symptoms and fertility for women who desire pregnancy.

PATIENTS AND METHODS

In this retrospective study, 14 symptomatic patients, who desire a new pregnancy underwent a surgical repair by laparotomy, laparoscopic or vaginal technique. Five women experienced failure of Assistance Reproductive Technique (IVF or ICSI) for idiopathic secondary infertility. The dehiscent scars were evaluated by ultrasound, hysterography, hysteroscopy and magnetic resonance imaging.

OUTCOME

Symptoms improvement was found in 92% of case. Ten pregnancy (71%) was obtained after surgical repair, 6 spontaneous and 4 after Assistance Reproductive Technique. Among the 5 women initially followed in the reproductive unit, 4 became pregnant, 3 after IVF or ICSI and 1 spontaneous. No operative complication occurred. The subsequent pregnancy was unremarkable with no uterine rupture.

DISCUSSION

Large scar defect after cesarean can take shape of a complete absent of the anterior wall of the uterus. No incident has been proved in this condition. There is a lack of data concerning these isthmocele. The experience of hysteroscopic repair cannot be applied to these real large diverticule of the scar cesarean. The results of this study suggest a link between the isthmocele and reversible symptoms after surgery. The first results concerning the subsequent fertility after surgical repair seem interesting

CONCLUSION

When a large scare defect (isthmocele) is found in symptomatic woman (pelvic pain, bleeding uterine, infertility), a surgical repair can be proposed, especially for woman who desire a new pregnancy.