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Palacios-Jaraquemada JM, Basanta NA, Nieto-Calvache ÁJ. Advanced repair of recurrent and low-large hysterotomy defects using a myometrial glide flap. J Matern Fetal Neonatal Med 2024; 37:2365344. [PMID: 38945839 DOI: 10.1080/14767058.2024.2365344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 06/03/2024] [Indexed: 07/02/2024]
Abstract
BACKGROUND The resolution of factors linked to the recurrence of cesarean section defects can be accomplished through a comprehensive technique that effectively addresses the dehiscent area, eliminates associated intraluminal fibrosis, and establishes a vascularized anterior wall by creating a sliding myometrial flap. OBJECTIVE Propose a comprehensive surgical repair for recurrent and large low hysterotomy defects in women seeking pregnancy or recurrent spotting. STUDY DESIGN A retrospective cohort analysis included 54 patients aged 25-41 with recurrent large cesarean scar defects treated at Otamendi, CEMIC, and Valle de Lili hospitals. Comprehensive surgical repair was performed by suprapubic laparotomy, involving a wide opening of the vesicouterine space, removal of the dehiscent cesarean scar and all intrauterine abnormal fibrous tissues, using a glide myometrial flap, and intramyometrial injection of autologous platelet-rich plasma. Qualitative variables were determined, and descriptive statistics were employed to analyze the data in absolute frequencies or percentages. The data obtained were processed using the InfostatTM statistic program. RESULTS Following the repair, all women experienced normal menstrual cycles and demonstrated an adequate lower uterine segment thickness, with no evidence of healing defects. All patients experienced early ambulation and were discharged within 24 h. Uterine hemostasis was achieved at specific points, minimizing the use of electrocautery. The standard duration of the procedure was 60 min (skin-to-skin), and the average bleeding was 80-100 ml. No perioperative complications were recorded. A control T2-weighted MRI was performed six months after surgery. All patients displayed a clean, unobstructed endometrial cavity with a thick anterior wall (Median: 14.98 mm, IQR 13-17). Twelve patients became pregnant again, all delivered by cesarean between 36.1 and 38.0 weeks, with a mean of 37.17 weeks. The thickness of the uterine segment before cesarean ranged between 3 and 7 mm, with a mean of 3.91 mm. No cases of placenta previa, dehiscence, placenta accreta spectrum (PAS), or postpartum hemorrhage were reported. CONCLUSIONS The comprehensive repair of recurrent low-large defects offers a holistic solution for addressing recurrent hysterotomy defects. Innovative repair concepts effectively address the wound defect and associated fibrosis, ensuring an appropriate myometrial thickness through a gliding myometrial flap.
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Affiliation(s)
- José M Palacios-Jaraquemada
- OB-GYN Department, Otamendi Hospital, City of Buenos Aires, Argentina
- OB-GYN Department, CEMIC University Hospital, Buenos Aires, Argentina
- Anatomy Department, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - Nicolás A Basanta
- OB-GYN Department, Otamendi Hospital, City of Buenos Aires, Argentina
- Anatomy Department, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
- Fernández Hospital, City of Buenos Aires, Argentina
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Li Q, Zhang X, Jiang S, Pang W, Sun N. Hysteroscopic Management of Symptomatic Cesarean Scar Diverticulum in Patients Undergoing Frozen-Thawed Embryo Transfer: Impact on Clinical Pregnancy Rates and Pregnancy Complications. Reprod Sci 2024:10.1007/s43032-024-01642-4. [PMID: 38977643 DOI: 10.1007/s43032-024-01642-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 06/29/2024] [Indexed: 07/10/2024]
Abstract
This retrospective cohort study aimed to compare the clinical outcomes of patients with cesarean scar defect (CSD) undergoing frozen embryo transfer (FET) with or without hysteroscopic repair surgery. The study included 82 patients, with 48 patients in surgical group A (undergoing CSD repair) and 34 patients in surgical group B (undergoing hysteroscopic treatment for other uterine lesions). The results showed that patients in group A had a larger CSD volume and a different shape compared to group B. However, there was no significant difference in clinical pregnancy rates between the two groups. Additionally, there were no differences in miscarriage, live birth, or preterm birth rates, and no complications such as scar pregnancy or placental abnormalities were observed in either group. These findings suggest that hysteroscopic treatment of CSD in symptomatic patients undergoing FET does not increase the risk of pregnancy complications and can lead to comparable clinical pregnancy rates with asymptomatic patients. Further studies with larger sample sizes are needed to confirm these results and evaluate long-term reproductive outcomes following CSD repair.
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Affiliation(s)
- Qingxian Li
- Reproductive Medicine Center, Second Affiliated Hospital of Naval Medical University, No. 415 Fengyang Road, Shanghai, 200003, China
| | - Xin Zhang
- Reproductive Medicine Center, Second Affiliated Hospital of Naval Medical University, No. 415 Fengyang Road, Shanghai, 200003, China
| | - Song Jiang
- Department of Medical Imaging, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Wenjuan Pang
- Reproductive Medicine Center, Second Affiliated Hospital of Naval Medical University, No. 415 Fengyang Road, Shanghai, 200003, China
| | - Ningxia Sun
- Reproductive Medicine Center, Second Affiliated Hospital of Naval Medical University, No. 415 Fengyang Road, Shanghai, 200003, China.
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Zhou X, Gao Z, Chen H, Wang Y, Yin Y, Zhang J, Wang X. A Prediction Model for the Efficacy of Transvaginal Repair in Patients With Cesarean Scar Defect: An Evidence-Based Proposal for Patient Selection. J Minim Invasive Gynecol 2024; 31:213-220. [PMID: 38135001 DOI: 10.1016/j.jmig.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 11/24/2023] [Accepted: 12/15/2023] [Indexed: 12/24/2023]
Abstract
STUDY OBJECTIVE To establish a prediction model to help doctors determine which patients with cesarean scar defect are more suitable for transvaginal repair. DESIGN Retrospective analysis. SETTING Xinhua Hospital and Shanghai First Maternity & Infant Hospital between June 2014 and May 2021. PATIENTS 1015 women who underwent transvaginal repair of cesarean scar defect (CSD). INTERVENTIONS All enrolled patients underwent CSD repair performed by the same gynecologist and his team. And followed up a clinic visit at 6 months to record their menstruation and measure multiple parameters of the CSD by Magnetic Resonance Imaging. MAIN OUTCOMES AND MEASURES CSD patients are categorized as optimal healing group when the menstruation duration is no more than 7 days, meanwhile the thickness of residual myometrium is no less than 5.39 mm after vaginal repair. The final nomogram is constructed to predict surgical outcomes based on preoperative variables. RESULTS The key factors that determine optimal healing are the timing of cesarean section (elective or emergency), menstrual cycle, CSD length, width, depth, and the thickness of the lower uterine segment. With the prediction model, scores are given to each parameter according to the statistics. Total scores range from 0 to 25 points, with a cutoff point of 16.5. When a score is greater than 16.5, the transvaginal repair can achieve optimal healing. Uterine position (anteflexion or retroflexion) and preoperative thickness of residual myometrium are the key factors affecting postoperative thickness of residual myometrium. The width of the CSD and the thickness of the lower uterine segment are the key factors affecting abnormal uterine bleeding symptoms (p < 0.01). CONCLUSIONS For the first time, we established a prediction model system that may predict the repair effect of CSD and can potentially be useful in future clinical trials to determine which patients are more suitable for surgery or other treatment options.
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Affiliation(s)
- Xingchen Zhou
- Department of gynecology and obstetrics, (Drs. Zhou, Gao, Chen, Wang, Yin, and Wang)
| | - Zhenyan Gao
- Department of gynecology and obstetrics, (Drs. Zhou, Gao, Chen, Wang, Yin, and Wang)
| | - Huihui Chen
- Department of gynecology and obstetrics, (Drs. Zhou, Gao, Chen, Wang, Yin, and Wang)
| | - Yizhi Wang
- Department of gynecology and obstetrics, (Drs. Zhou, Gao, Chen, Wang, Yin, and Wang)
| | - Yujia Yin
- Department of gynecology and obstetrics, (Drs. Zhou, Gao, Chen, Wang, Yin, and Wang)
| | - Jun Zhang
- Ministry of Education-Shanghai Key Laboratory of Children's Environmental Health (Dr. Zhang), Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xipeng Wang
- Department of gynecology and obstetrics, (Drs. Zhou, Gao, Chen, Wang, Yin, and Wang).
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Fatehnejad M, Hadizadeh A, Tayebi A, Ayati A, Marjani N, Gheshlaghi P, Asgari Z, Hosseini R. Assessment of the clinical outcomes and complications of hysteroscopic and laparoscopic approaches in the treatment of symptomatic isthmocele: An observational study. Int J Gynaecol Obstet 2023; 163:965-971. [PMID: 37350282 DOI: 10.1002/ijgo.14926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 05/23/2023] [Accepted: 05/28/2023] [Indexed: 06/24/2023]
Abstract
OBJECTIVES To investigate the outcomes of patients undergoing laparoscopic or hysteroscopic approaches for isthmoplasty. METHODS A total of 99 isthmocele patients with an average age of 38.45 ± 4.72 years were included in the 2 years of this retrospective cohort study. Forty-five underwent laparoscopic and 54 underwent hysteroscopic isthmocele excision and myometrial repair. RESULTS Pain scores were significantly higher in the hysteroscopy group before the procedure, but there were no significant pain score differences after the surgery. In 1 year of follow up, dysmenorrhea and dyspareunia were higher among hysteroscopy patients. Furthermore, hysteroscopy significantly improved postmenstrual spotting after surgery better than laparoscopy, but in the follow up, there was no significant difference between the two groups in this regard (mean rank for hysteroscopy vs. laparoscopy: 32.30 vs. 37.48, U = 418, P = 0.29). CONCLUSION In patients with a history of infertility, ectopic pregnancy, lower gravidity, lower parity, and a lower number of cesarean sections, laparoscopic isthmoplasty is preferred over the hysteroscopic approach. Both methods have similar effects on midcycle vaginal bleeding, duration of postmenstrual spotting, and pain. However, a higher rate of dyspareunia and dysmenorrhea could be associated with hysteroscopy.
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Affiliation(s)
- Mina Fatehnejad
- Department of Laparoscopic Surgery, Arash Women Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Hadizadeh
- Research Center for Advanced Technologies in Cardiovascular Medicine, Cardiovascular Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Amirhossein Tayebi
- Research Center for Advanced Technologies in Cardiovascular Medicine, Cardiovascular Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Aryan Ayati
- Research Center for Advanced Technologies in Cardiovascular Medicine, Cardiovascular Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Narjes Marjani
- Department of Laparoscopic Surgery, Arash Women Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Parand Gheshlaghi
- Department of Laparoscopic Surgery, Arash Women Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Zahra Asgari
- Department of Laparoscopic Surgery, Arash Women Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Reihaneh Hosseini
- Department of Laparoscopic Surgery, Arash Women Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Al-Ghotani B, Martini N, Alabdallah E, Alawad I, Hussien K. A large post-caesarean Niche (Isthmocele) with amenorrhea, a symptom that was not reported in the medical literature: A rare case report. Int J Surg Case Rep 2023; 109:108528. [PMID: 37499350 PMCID: PMC10413087 DOI: 10.1016/j.ijscr.2023.108528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 07/02/2023] [Accepted: 07/14/2023] [Indexed: 07/29/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Isthmocele is identified as an iatrogenic defect in the myometrium of the anterior uterine wall at the site of a previous cesarean scar due to defective tissue healing. Patients may have varied symptoms including abnormal uterine bleeding (AUB) and pelvic pain. Herein, we report a rare case of a large isthmocele that manifested with secondary amenorrhea; which was not reported in the medical literature previously. CASE PRESENTATION A 30-year-old Syrian woman, G5P5, came to our clinic with a complaint of secondary amenorrhea that began two years ago. She was treated symptomatically with progesterone with no response. She has had five cesarean sections. Ultrasonography findings suggested a large uterine niche. Trans-Abdominal niche repair was the obtained technique, depending on the drainage of the isthmocele, excising the fibrotic tissue from the edges and re-approximating them. On follow-up, menstruation returned to normal. CLINICAL DISCUSSION Isthmocele can be, radiologically, defined as a hypoechoic or anechoic, triangular area at the scar site. Its pathophysiology is still unknown. Although, an isthmocele can be diagnosed using a variety of imaging techniques like ultrasonography (US), magnetic resonance imaging (MRI), sonohysterography, and hysteroscopy; transvaginal ultrasound (TVUS) is the first method described for assessing it. The goal of isthmocele treatment is to alleviate symptoms. CONCLUSION We recommend that health awareness campaigns alert people to the need to see a specialist doctor in the context of a serious complaint. For the uterine niche, many risk factors can be avoided to reduce its probability.
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Affiliation(s)
- Basel Al-Ghotani
- Damascus University, Faculty of Medicine, Damascus, Syrian Arab Republic; Stemosis for Scientific Research, Damascus, Syrian Arab Republic.
| | - Nafiza Martini
- Damascus University, Faculty of Medicine, Damascus, Syrian Arab Republic; Stemosis for Scientific Research, Damascus, Syrian Arab Republic
| | - Ebaa Alabdallah
- Damascus University, Faculty of Medicine, Damascus, Syrian Arab Republic; Stemosis for Scientific Research, Damascus, Syrian Arab Republic
| | - Ieman Alawad
- Stemosis for Scientific Research, Damascus, Syrian Arab Republic; Alassad Medical Complex, Hama, Syrian Arab Republic
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He C, Xia W, Yan L, Wang Y, Tian Y, Mol BW, Zhang J, Huirne J. Fertility outcomes after hysteroscopic niche resection compared with expectant management in women with a niche in the uterine cesarean scar. Eur J Obstet Gynecol Reprod Biol 2023; 284:136-142. [PMID: 36989689 DOI: 10.1016/j.ejogrb.2023.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 03/01/2023] [Accepted: 03/10/2023] [Indexed: 03/14/2023]
Abstract
OBJECTIVE To determine whether hysteroscopic niche resection (HNR) and expectant management are suitable in women with fertility desire and a niche with a residual myometrium thickness (RMT) ≥ 2.5 mm. STUDY DESIGN This retrospective cohort study was conducted at International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China between September 2016 and December 2021. We reported the fertility outcomes between women (with fertility desire and a niche with RMT ≥ 2.5 mm) who received HNR or expectant management. RESULTS We studied 166 women, of whom 72 accepted HNR and 94 accepted expectant management. The HNR group included more symptomatic women, in terms of postmenstrual spotting or infertility. No differences were found regarding niche measures before treatment. The live birth rate was comparable in both groups (HNR versus expectant management as 55.5% versus 45.7%, risk ratio = 1.48, 95% Cl 0.80-2.75, p = 0.21). The pregnancy rate was higher in HNR group than that in expectant management group (n = 72.2% versus n = 56.4%, risk ratio = 2.01, 95% CI 1.04-3.88, p = 0.04). In a subgroup of women with infertility before entry in the study, HNR resulted in a significant higher live birth rate (p = 0.04) and pregnancy rate (p = 0.01). CONCLUSION In women with infertility with a symptomatic niche with RMT ≥ 2.5 mm, HNR may be superior to expectant management. This retrospective cohort biased selection against a randomized study, our results still need to be validated in the future with larger clinical multicenter randomized controlled trials.
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Affiliation(s)
- Chuqing He
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China; Shanghai Key Laboratory Embryo Original Diseases, Shanghai, China
| | - Wei Xia
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China; Shanghai Key Laboratory Embryo Original Diseases, Shanghai, China
| | - Li Yan
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China; Shanghai Key Laboratory Embryo Original Diseases, Shanghai, China
| | - Yang Wang
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China; Shanghai Key Laboratory Embryo Original Diseases, Shanghai, China
| | - Yuan Tian
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China; Shanghai Key Laboratory Embryo Original Diseases, Shanghai, China
| | - Ben W Mol
- Department of Obstetrics and Gynecology, Monash University, 246 Clayton Road, Clayton 3168, Victoria, Australia; Aberdeen Centre for Women's Health Research, University of Aberdeen, Aberdeen, UK
| | - Jian Zhang
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China; Shanghai Key Laboratory Embryo Original Diseases, Shanghai, China.
| | - Jaf Huirne
- Department of Obstetrics and Gynecology, Amsterdam Reproduction and Development Research Institute, Amsterdam University Medical Centre, Location AMC and VUmc, Amsterdam, The Netherlands
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Huang CC, Chiu SC, Pan CM, Huang CC, Chang CYY, Chao SC, Cho DY, Lin WC. New Efficient Method for Hysteroscopic Isthmoplasty: Four Simple Steps Lead to a Significant Improvement in Bleeding Status. J Clin Med 2022; 11:jcm11216541. [PMID: 36362769 PMCID: PMC9655228 DOI: 10.3390/jcm11216541] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 10/31/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022] Open
Abstract
We demonstrate an effective reduction in postmenstrual spotting after our novel hysteroscopic isthmoplasty. This study included 66 patients with isthmocele-related postmenstrual spotting confirmed by sonography and diagnostic hysteroscopy between 2000 and 2017. Our new interventions included the following four steps: (1) make a resection gradient of the distal edge of the isthmocele from the ape of the isthmocele down to the cervical outer orifice; (2) resect the distal and proximal niches of the isthmocele; (3) electrocauterize the distal and proximal sides (not only the niche bottom) of the small cave on the scar side of the isthmocele; (4) manage the isthmocele until it is largely connected to the cavity. In our results, all patients underwent extensive hysteroscopic repair of newly hysteroscopic isthmoplasty without any intra- or postoperative complications. After final hysteroscopic repair modification, prolonged menstrual spotting was significantly decreased in 98.2% (53/54) of the patients, and the total number of bleeding days per menstrual cycle significantly decreased from a mean of 15.38 ± 3.3 days to 6.4 ± 1.9 days postoperatively (p < 0.001). Our four-step hysteroscopic technique successfully resolved prolonged menstrual spotting in over 90% of the patients, exceeding the resolution rates of 60−85% achieved with other hysteroscopic techniques used to treat symptomatic isthmocele. No patients experience recurrence after long-term follow up. Four simple steps led to a significant improvement in bleeding status.
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Affiliation(s)
- Chien-Chu Huang
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung 40402, Taiwan
- Department of Obstetrics and Gynecology, China Medical University Hospital, Taichung 404327, Taiwan
| | - Shao-Chih Chiu
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung 40402, Taiwan
- Translational Cell Therapy Center, China Medical University Hospital, Taichung 404327, Taiwan
| | - Chih-Ming Pan
- Translational Cell Therapy Center, China Medical University Hospital, Taichung 404327, Taiwan
| | - Chun-Chung Huang
- Institute of Oral Sciences, Chung Shan Medical University, Taichung 40201, Taiwan
| | - Cherry Yin-Yi Chang
- Department of Obstetrics and Gynecology, China Medical University Hospital, Taichung 404327, Taiwan
- School of Medicine, China Medical University, Taichung 40402, Taiwan
| | - Shih-Chi Chao
- Institute of Oral Sciences, Chung Shan Medical University, Taichung 40201, Taiwan
- Department of Medical Research and Education, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan 265501, Taiwan
| | - Der-Yang Cho
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung 40402, Taiwan
- Translational Cell Therapy Center, China Medical University Hospital, Taichung 404327, Taiwan
- Correspondence: (D.-Y.C.); (W.-C.L.)
| | - Wu-Chou Lin
- Department of Obstetrics and Gynecology, China Medical University Hospital, Taichung 404327, Taiwan
- School of Chinese Medicine, China Medical University, Taichung 40402, Taiwan
- Correspondence: (D.-Y.C.); (W.-C.L.)
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Li W, Lin T, Xie Y, Xu L, Chen Y, Zhu Y, Dong X, Cheng P, Duan C. The effects of hysteroscopy and laparoscopy for scar diverticulum resection and suture on blood loss, operation time and antibiotic time. J OBSTET GYNAECOL 2022; 42:3309-3314. [PMID: 36200382 DOI: 10.1080/01443615.2022.2122708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
To evaluate the effect of hysteroscopy and suture on uterine scar diverticulum (CSD) after caesarean section and its influence on blood loss, operation time and antibiotic time. Eighty-nine patients with CSD were divided into observation group (n = 41 cases) and control group (n = 48 cases). Control group received laparoscopic scar diverticulum resection and suture, while the observation group received hysteroscopic resection of scar diverticulum. The operation time of the observation group was longer, while the bleeding volume and antibiotic administration time were significantly lower. The surgical treatment efficiency of the observation group (97.56%) was significantly higher. After treatment, the observation group's diverticulum repair indexes (width, depth and lower uterine muscular layer thickness) were better than those of the control group (p<.05). Hysteroscopic resection of scar diverticulum in CSD reduces intraoperative blood loss and the risk of complications, shortens time of antibiotic administration, and promotes diverticulum repair.Impact StatementWhat is already known on this subject? Uterine scar diverticulum (CSD) after caesarean section, also called postoperative uterine incision defect (PCSD), is due to poor healing of the uterine incision after caesarean section.What do the results of this study add? Hysteroscopic resection of scar diverticulum in CSD has a significant clinical effect, which can effectively reduce intraoperative blood loss and the risk of complications, shorten the time of antibiotic administration, and promote diverticulum repair.What are the implications of these findings for clinical practice and/or further research? Clinical effect of hysteroscopic resection of scar diverticulum in CSD is significant.
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Affiliation(s)
- Weifeng Li
- Department of Obstetrics and Gynecology, The First People's Hospital of Foshan, Foshan, China
| | - Tiecheng Lin
- Department of Obstetrics and Gynecology, The First People's Hospital of Foshan, Foshan, China
| | - Yong Xie
- Department of Obstetrics and Gynecology, The First People's Hospital of Foshan, Foshan, China
| | - Lijiang Xu
- Department of Obstetrics and Gynecology, The First People's Hospital of Foshan, Foshan, China
| | - Yangping Chen
- Department of Obstetrics and Gynecology, The First People's Hospital of Foshan, Foshan, China
| | - Yuyuan Zhu
- Department of Obstetrics and Gynecology, The First People's Hospital of Foshan, Foshan, China
| | - Xia Dong
- Department of Obstetrics and Gynecology, The First People's Hospital of Foshan, Foshan, China
| | - Pei Cheng
- Department of Obstetrics and Gynecology, The First People's Hospital of Foshan, Foshan, China
| | - Chunxiang Duan
- Department of Obstetrics and Gynecology, The First People's Hospital of Foshan, Foshan, China
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Antoine C, Meyer JA, Silverstein JS, Alexander J, Oh C, Timor-Tritsch IE. The Impact of Uterine Incision Closure Techniques on Post-cesarean Delivery Niche Formation and Size: Sonohysterographic Examination of Nonpregnant Women. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:1763-1771. [PMID: 34726789 DOI: 10.1002/jum.15859] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/24/2021] [Accepted: 09/19/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To compare the prevalence and size of residual niche in the nongravid uterus following Cesarean delivery (CD) with different hysterotomy closure techniques (HCTs). METHODS Saline infusion sonohysterogram (SIS) was performed in women after one prior CD, documenting the presence or absence of a postoperative niche and measuring its depth, width, length, and residual myometrial thickness. Women were grouped by HCT: Technique A (endometrium-free) and Technique B (routine non-endometrium-free). The primary outcome was the prevalence of a clinically significant niche, defined as a depth of >2 mm. HCT groups were compared using χ2 , T-test (ANOVA), and analyzed using logistic regression and two-sided test (P < .05). RESULTS Forty-five women had SIS performed, 25 and 20 via Technique A and B, respectively. Technique groups varied by average interval time from CD to SIS (13.6 versus 74.5 months, P = 0.006) but were otherwise similar. Twenty niches were diagnosed, 85% of which were clinically significant, including five following Technique A, nine following Technique B with double-layer closure, and three following Technique B with single-layer (P = .018). The average niche depth was 2.4 mm and 4.9 mm among the two-layer subgroups following Techniques A and B, respectively (P = .005). A clinically significant niche development was six times higher with Technique B when compared to Technique A (OR 6.0, 95% CI 1.6-22.6, P = .008); this significance persisted after controlling for SIS interval on multivariate analysis (OR 4.4, 95% CI 1.1-18.3, P = .04). The average niche depth was 5.7 ± 2.9 mm following Technique B with single-layer. CONCLUSION Hysterotomy closure techniques determine the prevalence of post-Cesarean delivery niche formation and size. Exclusion of the endometrium at uterine closure reduces the development of significant scar defects.
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Affiliation(s)
- Clarel Antoine
- Department of Obstetrics and Gynecology, NYU Grossman School of Medicine, New York, New York, USA
| | - Jessica A Meyer
- Department of Obstetrics and Gynecology, NYU Grossman School of Medicine, New York, New York, USA
| | - Jenna S Silverstein
- Department of Obstetrics and Gynecology, NYU Grossman School of Medicine, New York, New York, USA
| | | | - Cheongeun Oh
- Biostatistics, Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA
| | - Ilan E Timor-Tritsch
- Department of Obstetrics and Gynecology, NYU Grossman School of Medicine, New York, New York, USA
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Mutlu AE. Assessment of in vitro fertilization outcomes after hysteroscopic isthmoplasty in recurrent implantation failure. J Obstet Gynaecol Res 2022; 48:1829-1835. [PMID: 35623894 DOI: 10.1111/jog.15317] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/28/2022] [Accepted: 05/18/2022] [Indexed: 11/29/2022]
Abstract
AIM The aim of this study was to assess the in vitro fertilization (IVF) treatments outcomes of women with recurrent implantation failure (RIF) after hysteroscopic isthmoplasty for isthmocele. METHODS This retrospective, observational study included 61 patients with RIF and isthmocele who presented to IVF Unit of Hüma Obstetrics and Gynecology Hospital between January, 2018 and December, 2020. Thirty-one patient who underwent hysteroscopic isthmoplasty-before IVF procedure-were included. Remaining 30 patients underwent IVF without hysteroscopic isthmoplasty were included as controls. The fertility outcome were compared between groups. RESULTS After 3 months, spontaneous pregnancy was achieved in 18.4% (7/38) of patients with isthmocele who underwent hysteroscopic isthmoplasty. In the isthmoplasty group, implantation rate, clinical pregnancy rate, biochemical pregnancy rate, and the miscarriage rate were 41.9% (13/31), 35.5% (11/31), 6.5% (2/31), and 9.7% (3/31), respectively. The live birth rate after in vitro fertilization was 25.8% (8/31) in the isthmoplasty group and 3.3% (1/30) in the control group (p < 0.05). There were no significant differences in the IVF outcomes such as the biochemical pregnancy rate and miscarriage rate between the isthmoplasty and control groups. CONCLUSION This study demonstrated that hysteroscopic isthmoplasty improves pregnancy and live birth rates for women with a history of RIF and isthmocele. Reproductive results of the IVF cycles after hysteroscopic correction of isthmocele were comparable to those of the patients without any uterine abnormalities and those with diagnosis of unexplained infertility.
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Affiliation(s)
- Ahmet Emin Mutlu
- Department of Obstetrics and Gynecology, Hüma Obstetrics and Gynecology Hospital, IVF Center, Kayseri, Turkey
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11
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Pirtea L, Balint O, Secoşan C, Grigoraş D, Pirtea P. Case Report: Laparoscopic Isthmocele Repair on an 8 Weeks Pregnant Uterus. Front Med (Lausanne) 2022; 9:831588. [PMID: 35252262 PMCID: PMC8891219 DOI: 10.3389/fmed.2022.831588] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 01/24/2022] [Indexed: 11/18/2022] Open
Abstract
An isthmocele, also known as a caesarean scar defect, is a long-term complication of caesarean sections with an increasing incidence. Although is often asymptomatic, it is a novel recognised cause of abnormal uterine bleeding, and it is a major risk factor for caesarean scar pregnancies or uterine ruptures in subsequent pregnancies. Currently there are no guidelines for the diagnosis and management of this condition. Several surgical techniques for the correction of isthmocele are proposed, including laparoscopic excision, vaginal repair, a combined laparoscopic-vaginal approach or more recently hysteroscopic resection. We present the case of a GII PI, 29 years old patient with a previous c-section who presented in our clinic with a positive pregnancy test for pregnancy confirmation. The ultrasound examination revealed an intrauterine evolutive 8 weeks pregnancy and a caesarean scar defect. After counselling the patient opted for pregnancy continuation and laparoscopic correction of the isthmocele. The surgery was performed under ultrasound guidance. The defect was resected, and the uterus was closed with a continuous two-layer suture. No intraoperative or postoperative complications were present. The pregnancy continued uneventfully A caesarean section was performed at term revealing a fully healed scar.
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Affiliation(s)
- Laurentiu Pirtea
- Department of Obstetrics-Gynecology, University of Medicine and Pharmacy Timişoara, Timişoara, Romania
| | - Oana Balint
- Department of Obstetrics-Gynecology, University of Medicine and Pharmacy Timişoara, Timişoara, Romania
- *Correspondence: Oana Balint
| | - Cristina Secoşan
- Department of Obstetrics-Gynecology, University of Medicine and Pharmacy Timişoara, Timişoara, Romania
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12
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Vrijdaghs V, Dewilde K, Froyman W, Van den Bosch T. Hysteroscopic management of caesarean scar defects. J OBSTET GYNAECOL 2022; 42:816-822. [PMID: 35014923 DOI: 10.1080/01443615.2021.2003310] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
A caesarean section may lead to a defect of the myometrium at the site of the uterine scar. The association with abnormal uterine bleeding or impaired fertility has been demonstrated. Hysteroscopic remodelling reportedly reduces the symptoms. To review the available literature reporting on hysteroscopic treatment of these defects in symptomatic women with abnormal uterine bleeding or impaired fertility. A systematic search of PubMed and Cochrane databases has been performed until January 2021, including 27 articles. Hysteroscopic remodelling relieved symptoms of abnormal uterine bleeding in 60-100% and 25-100% of women with impaired fertility conceived within the follow up period. No major complications were reported. Hysteroscopic remodelling seems a treatment option in the management of symptomatic caesarean scar defects. Long-term follow-up and larger studies are needed to evaluate the effect on abnormal uterine bleeding as well as on reproductive outcomes.
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Affiliation(s)
- V Vrijdaghs
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - K Dewilde
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - W Froyman
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - T Van den Bosch
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
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13
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Nguyen AD, Nguyen HTT, Duong GTT, Phan TTH, Do DT, Tran DA, Nguyen TK, Nguyen TB, Ville Y. Improvement of symptoms after hysteroscopic isthmoplasty in women with abnormal uterine bleeding and expected pregnancy: A prospective study. J Gynecol Obstet Hum Reprod 2022; 51:102326. [DOI: 10.1016/j.jogoh.2022.102326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 01/11/2022] [Accepted: 01/24/2022] [Indexed: 10/19/2022]
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14
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Rupa R, Kushvaha S, Venkatesh K. Uterine Isthmocele-A Frequently Overlooked Complication of Cesarean Sections. Indian J Radiol Imaging 2021; 31:601-604. [PMID: 34790304 PMCID: PMC8590568 DOI: 10.1055/s-0041-1736393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Uterine isthmocele or uterine niche is a late complication of cesarean deliveries and causes chronic pelvic pain, menorrhagia or postmenstrual spotting, and infertility. As the number of cesarean sections are constantly increasing, it is important to be aware of this entity so as to make an early diagnosis. This would enable the clinicians to manage these patients efficiently. We present three patients of uterine isthmocele who were evaluated and managed at our institution.
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Affiliation(s)
- R Rupa
- Division of Women's Imaging, Department of Diagnostic and Interventional Radiology, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India
| | - Suchana Kushvaha
- Division of Women's Imaging, Department of Diagnostic and Interventional Radiology, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India
| | - K Venkatesh
- Division of Women's Imaging, Department of Diagnostic and Interventional Radiology, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India
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15
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Zhang Q, Lei L, Zhang A, Zou L, Xu D. Comparative effectiveness of laparoscopic versus hysteroscopic approach in patients with previous cesarean scar defect: a retrospective cohort study. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1529. [PMID: 34790735 PMCID: PMC8576701 DOI: 10.21037/atm-21-4339] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 09/24/2021] [Indexed: 11/24/2022]
Abstract
Background The aim of this study was to evaluate the clinical effectiveness and obstetric outcomes of laparoscopic and hysteroscopic surgery in patients with previous cesarean scar defect (PCSD). Methods A retrospective cohort analysis was performed on women who underwent laparoscopic or hysteroscopic surgery for PCSD from 2016 to 2019 at the Third Xiangya Hospital of Central South University. Among these participants, 13 underwent laparoscopic surgery and 33 received hysteroscopic surgery. Results Significant differences were displayed in the operative times (156.9±42.3 vs. 40.7±38.9 min, P<0.05), intra-operative blood loss (80.0±61.0 vs. 17.9±51.2 mL, P<0.05), hospital stay (7.1±1.6 vs. 4.1±2.1 days, P<0.05), postoperative hospital stay (4.3±0.8 vs. 1.5±1.1 days, P<0.05), and hospitalization expenses (22,240.3±249.9 vs. 9,547.1±4,747.2 yuan, P<0.05) between the laparoscopic surgery and hysteroscopic group. No significant difference was observed in the incidence of clinical efficacy between the laparoscopic and hysteroscopic surgery group. A total of 2 of the 4 patients in the laparoscopic surgery group, and 9 of 11 patients in the hysteroscopic surgery group delivered successfully. All 2 participants in the laparoscopic surgery group and 2 participants in the hysteroscopic surgery group were diagnosed with placenta previa. No uterine rupture was reported in our study. Conclusions Both laparoscopic and hysteroscopic surgery are safe and effective treatments for PCSD patients, and hysteroscopic surgery is more efficient for PCSD patients.
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Affiliation(s)
- Qi Zhang
- Department of Obstetrics and Gynecology, Third Xiangya Hospital, Central South University, Changsha, China
| | - Lei Lei
- Department of Obstetrics and Gynecology, Third Xiangya Hospital, Central South University, Changsha, China.,Medical Center of Hysteroscopy, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Aiqian Zhang
- Department of Obstetrics and Gynecology, Third Xiangya Hospital, Central South University, Changsha, China
| | - Lingxiao Zou
- Department of Obstetrics and Gynecology, Third Xiangya Hospital, Central South University, Changsha, China
| | - Dabao Xu
- Department of Obstetrics and Gynecology, Third Xiangya Hospital, Central South University, Changsha, China
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16
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Bi B, Gao S, Ruan F, Shi Y, Jiang Y, Liu S, Lv W. Analysis on clinical association of uterine scar diverticulum with subsequent infertility in patients underwent cesarean section. Medicine (Baltimore) 2021; 100:e27531. [PMID: 34731147 PMCID: PMC8519233 DOI: 10.1097/md.0000000000027531] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 09/28/2021] [Indexed: 01/05/2023] Open
Abstract
To evaluate the relationship between uterine cesarean scar diverticulum (CSD) and subsequent infertility in patients who underwent cesarean section, and determine the effects of pelvic fluid-releasing inflammations on infertility.A retrospective analysis was designed among patients with CSD who were admitted to our hospital from January 1, 2018 to December 31, 2019. A total of 60 patients with CSD and uterine fibroids or benign ovarian tumors who underwent cesarean section were included, and divided into the CSD group and control group. Baseline characteristics of all patients were collected, and the pelvic adhesion scores and the percents of tubal patency were evaluated. Furthermore, the postoperative clinical outcomes were followed up. The levels of inflammatory factors in pelvic fluid were tested using Elisa kits.Preoperative data indicated that the size of the uterine scar diverticulum was (1.68 ± 0.52) cm, the pelvic adhesion scores were higher in CSD group than control group (4.67 ± 0.90 vs 0.47 ± 0.90, P < .05), and 21 of 30 patients with unobstructed fallopian tubes. The levels of tumor necrosis factor-α, interleukin-1β, and interleukin-6 in patients with CSD were obviously higher than control group (P < .05). After the follow-up, the data displayed that no CSD was found in all patients, the time of menstrual period in patients with CSD was shortened to 7.80 ± 1.27 days, and the myometrial thickness at uterine scar was significantly increased (P < .05). Additionally, the pregnancy rate was increased, and 12 of 30 patients were repregnant. Correlation analysis showed that the levels of inflammatory factors (tumor necrosis factor-α, interleukin-1β, interleukin-6), the size of uterine scar diverticulum, and the myometrial thickness at uterine scar were significantly correlated with subsequent infertility (r = 0.307, 0.083, 0.147, 0.405, 0.291, P < .05).Uterine scar diverticulum repair could improve menstrual prolongation, increased the thickness of myometrium and repregnant rate. Subsequent infertility was positively correlated with uterine scar diverticulum and the levels of inflammatory factors.
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17
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Dai L, Wang H, Xing X, Peng Y, Wang Q, Li Q, Luo D, Gao H, Jiang G. An analysis of curative effect of combined transvaginal and hysteroscopic electrocauterization of partial endometrium to treat previous cesarean scar diverticulum. Minerva Surg 2021; 77:139-146. [PMID: 34342398 DOI: 10.23736/s2724-5691.21.08999-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND To explore the curative effect of the combined transvaginal and hysteroscopic electrocauterization of partial endometrium to treat previous cesarean scar diverticulum. METHODS The retrospective study method is adopted. 28 cases of cesarean scar diverticulum patients were selected as research objects and divided into two groups: one is combined hysteroscopic and transvaginal surgery group (n=15) and the other is hysteroscopic electrocauterization group (n=13). The curative effects of the two groups are observed and compared, including clinical treatment indicators (operation duration, intraoperative blood loss, fever, length of hospital stay (LOS), etc.), and follow-up visits are carried out to check the differences of diverticulum repair and menostaxis improvement one to six months after surgery. RESULTS The average operation duration, length of stay, and hospitalization expenses for the hysteroscopic electrocauterization group are respectively (28.84 ± 12.61) min, (2.93 ± 1.04) d, and (7916.57 ± 1948.45) yuan, all significantly lower than the combined hysteroscopic and transvaginal surgery group, those are respectively 73.93 ± 15.46 min, 5.93 ± 1.22 d, and 10,130.10 ± 1,037.75 yuan. The differences are statistically significant (P < 0.05). The follow-up visits in six months after operation find that the effective rate of menstrual period (menostaxis) improvement of the combined hysteroscopic and transvaginal surgery group is 93.3% (14 / 15), and that of scar diverticulum repair is 73.3% (11/15), which are notably higher than the hysteroscopic electrocauterization group, those are respectively 46.2% (6/13) and 23.1% (3/13). The differences are also statistically significant (P < 0.05). CONCLUSIONS The repairing effect of the combined transvaginal and hysteroscopic electrocauterization of partial endometrium to treat previous cesarean scar diverticulum [previous cesarean scar defect (PCSD)] is obvious. As it can fully remove previous cesarean scars and the surrounding ectopic intimae and reduce the recurrence rate, it is worthy of clinical promotion and application.
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Affiliation(s)
- Li Dai
- Department of Gynecology and Obstetrics, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Hui Wang
- Department of Gynecology and Obstetrics, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Xiaoxiao Xing
- Department of Medical imaging, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Yan Peng
- Department of Pathology, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Qing Wang
- Department of Gynecology and Obstetrics, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Qin Li
- Department of Gynecology and Obstetrics, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Dan Luo
- Department of Gynecology and Obstetrics, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Hongyan Gao
- Department of Gynecology and Obstetrics, The Third Affiliated Hospital of Soochow University, Changzhou, China -
| | - Guohua Jiang
- Department of Gynecology and Obstetrics, The Third Affiliated Hospital of Soochow University, Changzhou, China
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18
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Wu Y, Sun LF, Si YN, Luan XL, Gao YM. Clinical efficacy analysis of different therapeutic methods in patients with cesarean scar pregnancy. Taiwan J Obstet Gynecol 2021; 60:498-502. [PMID: 33966735 DOI: 10.1016/j.tjog.2021.03.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2020] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE The purpose of this study was to analyze the clinical efficacy of five therapeutic strategies in patients with CSP. MATERIALS AND METHODS A total of 135 CSP patients were included and divided into five groups based on the treatment they received, including transvaginal resection (Group A), laparoscopic resection (Group B), uterine arterial embolization (UAE) combined with hysteroscopic curettage (Group C), UAE combined with uterine curettage (Group D), and hysteroscopic curettage (Group E). To investigate the clinical efficacy of these strategies, intraoperative bleeding, serum β-hCG levels and recovery time, menstruation recovery time, hormone levels at 1 month after treatment. RESULTS Patients in group A had the lowest postoperative serum β-hCG levels, and the shortest recovery times of both serum β-hCG and menstruation, followed by patients in group B. Group C and D had small amount of blood loss. The hospital stays and costs were low in group E. In addition, the sex hormone levels showed no significant difference among the five groups. CONCLUSION Our results indicated that resection surgery and UAE have good curative effects, but high hospital costs in CSP treatment. The selection of an optimal treatment regimen for CSP should be carried out based on specific conditions of the patients.
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Affiliation(s)
- Yan Wu
- Department of Obstetrics and Gynecology, The Affiliated Qingdao Hiser Hospital of Qingdao University (Qingdao Hospital of Traditional Chinese Medicine), Qingdao, 266033, Shandong, China
| | - Lei-Fang Sun
- Department of Obstetrics and Gynecology, The Affiliated Qingdao Hiser Hospital of Qingdao University (Qingdao Hospital of Traditional Chinese Medicine), Qingdao, 266033, Shandong, China
| | - Ya-Nan Si
- Department of Obstetrics and Gynecology, The Affiliated Qingdao Hiser Hospital of Qingdao University (Qingdao Hospital of Traditional Chinese Medicine), Qingdao, 266033, Shandong, China
| | - Xiao-Li Luan
- Department of Obstetrics and Gynecology, The Affiliated Qingdao Hiser Hospital of Qingdao University (Qingdao Hospital of Traditional Chinese Medicine), Qingdao, 266033, Shandong, China
| | - Yong-Mei Gao
- Department of Obstetrics and Gynecology, The Affiliated Qingdao Hiser Hospital of Qingdao University (Qingdao Hospital of Traditional Chinese Medicine), Qingdao, 266033, Shandong, China.
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Du Q, Zhao W. Exploring the value of cesarean section diverticulum area to predict the safety of hysteroscopic management for cesarean scar pregnancy patients. Int J Gynaecol Obstet 2021; 156:488-493. [PMID: 33754364 DOI: 10.1002/ijgo.13682] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/14/2021] [Accepted: 03/19/2021] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To study indicators predicting the safety of hysteroscopic management for cesarean scar pregnancy (CSP) patients. METHODS This was a retrospective study, starting from June 1, 2020. The study included 141 CSP patients who underwent hysteroscopic surgery and met the requirements of gestational age ≤12 weeks, stable vital signs, and preoperative magnetic resonance imaging. Patients were divided into control group and testing group according to surgical outcomes. Preoperative indicators were compared between the two groups, including a novel indicator, cesarean section diverticulum (CSD) area. RESULTS Univariate analysis identified five statistically significant (P < 0.05) factors associated with hysteroscopy failure including a large CSD area. Multifactor logistic regression analysis showed that the only statistically significant indicator of all five factors was the CSD area. The area under the receiver operating characteristics curve of CSD area was 0.848. Next, we determined three cut-off values for CSD area that can be used to predict the outcome of surgery: 138, 189, and 300 mm2 . CONCLUSION For the first time, we found that CSD area could predict the safety of hysteroscopic management for CSP patients and might be helpful for clinical decision making. The findings need to be verified by further research.
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Affiliation(s)
- Qinghua Du
- Department of Obstetrics and Gynecology, Chaoyang Central Hospital, Chaoyang, Liaoning Province, China
| | - Wancheng Zhao
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
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20
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Jia H, Zhao X, Qin L, Cai X. Imaging Method for Osteosarcoma Diagnosis and Clinical Staging Information Optimization. JOURNAL OF MEDICAL IMAGING AND HEALTH INFORMATICS 2021. [DOI: 10.1166/jmihi.2021.3421] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
In order to better assist clinicians in the diagnosis and treatment of osteosarcoma, and our understanding of the advantages and disadvantages of different examination techniques of DR, CT and MRI, this article collects the pathological diagnosis of the PACS Medical system of Liaocheng
People’s Hospital 2015 to 2018. 130 patients with osteosarcoma and imaging examination data, retrospectively analyzed the diagnostic and clinical staging information contained in DR, CT and MRI examination data of osteosarcoma patients, and detected the diagnosis and clinical staging
information of osteosarcoma by comparing various examination methods ability to obtain the optimal imaging examination method that can provide complete diagnosis and clinical staging information of osteosarcoma, and is recommended as a routine clinical examination program. Finally, we conclude
that: DR, CT, and MRI examinations have no significant differences in the detection capacity of osteosarcoma bone destruction, periosteal response, and periosteal triangle; MRI has less ability to detect tumor bone than DR and CT; DR has soft tissue. The ability to detect masses is inferior
to CT and MRI. Among the single DR, CT or MRI examinations, CT examinations have the best comprehensive detection ability for all imaging diagnostic signs of osteosarcoma. MR examination has the best comprehensive display of clinical staging information such as infiltration range and infiltration
boundary of osteosarcoma. Combined DR, CT, and MRI examinations are optimized imaging procedures that provide complete osteosarcoma diagnosis and clinical staging information.
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Affiliation(s)
- Huijuan Jia
- Computerized Tomography Room, Liaocheng People’s Hospital, Shandong Liaocheng, 252000, China
| | - Xiuqin Zhao
- Magnetic Resonance Imaging Room, Liaocheng People’s Hospital, Shandong Liaocheng, 252000, China
| | - Lei Qin
- Department of Nuclear Medicine, Liaocheng People’s Hospital, Shandong Liaocheng, 252000, China
| | - Xiansheng Cai
- Department of Nuclear Medicine, Liaocheng People’s Hospital, Shandong Liaocheng, 252000, China
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21
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Xie S, Dong W, Liu Y, Gao H. Comparative Study of Ultrasound Signs of Scar Pregnancy in Patients with Cesarean Section and Their Clinical Outcomes. JOURNAL OF MEDICAL IMAGING AND HEALTH INFORMATICS 2021. [DOI: 10.1166/jmihi.2021.3325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Caesarean scar pregnancy is the implantation of fertilized eggs in the scar of the previous cesarean section in the lower uterus. It is a serious long-term complication after cesarean section. Ultrasound examination, as the first choice to evaluate cesarean scar pregnancy plays an important
role in its diagnosis, treatment and follow-up. This study first tried to propose new ultrasound diagnostic indicators to distinguish cesarean scar pregnancy from non-scar pregnancy of the lower uterine cavity; Logistic regression analysis was used to screen for risk factors related to scar
pregnancy bleeding, with a view to providing clinical ultrasound indicators to predict bleeding risk; Secondly, the use of contrast-enhanced ultrasound and three-dimensional ultrasound to observe the scar diverticulum of cesarean section more than six months after the different surgical treatments
of scar pregnancy, and to evaluate whether surgical scar repair can improve the scar diverticulum. Finally, using ultrasound to predict the position of the embryonic placenta, the new type of scar pregnancy in cesarean section is divided into three types: anterior wall placenta, anterior wall
posterior placenta and posterior wall placental. The three types of CSP have significant differences in the thickness of the muscular layer in the scar of the lower part of the anterior wall of the uterus, the blood flow in the scar of the lower part of the anterior wall of the uterus, the
number of days of hospitalization, the treatment method, and the treatment effect, which indicate that the new type is used for the diagnosis of CSP. Treatment and prognosis evaluation have high clinical value, can be used to guide clinical work, and provide a new idea for clinical diagnosis
and treatment.
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Affiliation(s)
- Shasha Xie
- Affliated Xingtai People’s Hospital of Heibei Medical University, Hebeixingtai, 054000, China
| | - Wei Dong
- Affliated Xingtai People’s Hospital of Heibei Medical University, Hebeixingtai, 054000, China
| | - Yeting Liu
- The First Affliated Hospital, Xingtai Medical College, Hebeixingtai, 054000, China
| | - Haixiao Gao
- The Third Hospital of Xingtai City, Hebeixingtai, 054000, China
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22
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Post-caesarean Niche (Isthmocele) in Uterine Scar: An Update. J Obstet Gynaecol India 2021; 70:440-446. [PMID: 33417629 DOI: 10.1007/s13224-020-01370-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 08/01/2020] [Indexed: 10/23/2022] Open
Abstract
Uterine niche is one of the emerging complications of caesarean section. With rising caesarean rates, the caesarean-related iatrogenic complications are also on the rise. These include placenta accreta, scar ectopic pregnancy and uterine niche which is a newer entity being described in the recent literature. Uterine niche, also described as uterine isthmocele, caesarean scar defect and diverticulum, is an iatrogenic defect in the myometrium at the site of previous caesarean scar due to defective tissue healing. Patients may have varied symptoms including abnormal uterine bleeding, post-menstrual spotting and infertility, though many women may be asymptomatic and diagnosed incidentally. Diagnosis is made radiologically by transvaginal sonography, saline instillation sonohysterography or magnetic resonance imaging. Occurrence of niche may be prevented by using correct surgical technique during caesarean. Patients may be managed medically; however, subfertility and persistent symptoms may require surgical correction either by hysteroscopic resection or transabdominal or transvaginal repair. This mini-review comprehensively covers the potential risk factors, clinical presentation, diagnosis and management of this increasingly encountered condition due to rising caesarean rates.
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Deng K, Liu W, Chen Y, Lin S, Huang X, Wu C, Wang H, Wang J, Chen L, Liu X, Zheng Y. Obstetric and Gynecologic Outcomes after the Transvaginal Repair of Cesarean Scar Defect in a Series of 183 Women. J Minim Invasive Gynecol 2020; 28:1051-1059. [PMID: 33326862 DOI: 10.1016/j.jmig.2020.12.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 12/02/2020] [Accepted: 12/07/2020] [Indexed: 01/23/2023]
Abstract
STUDY OBJECTIVE To analyze retrospectively the effect of hysteroscopy combined with transvaginal repair on the cesarean section diverticulum (CSD) and explore the clinical significance of this procedure. DESIGN Retrospective study. SETTING University-affiliated hospital and a gynecology hospital. PATIENTS A total of 183 patients with scar diverticulum after cesarean section were recruited from the Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan and Shenzhen In Vitro Fertilization Gynecological Hospital. INTERVENTIONS In this study, we reported a surgical method for repairing uterine scar through uterine therapy and explored its clinical efficacy and pregnancy outcome. MEASUREMENTS AND MAIN RESULTS The time of operation, volume of bleeding, and duration of hospitalization were recorded. The size of the scar diverticulum and the remaining myometrium were examined by B-mode ultrasonography before and after the operation. The length of the menstrual cycle and pelvic pain were recorded during follow-up to check the recovery of patients after surgery. The pregnancy of patients with pregnancy needs was recorded to check the pregnancy outcome. All 183 patients successfully completed the repair of the transvaginal uterus scar diverticulum with the help of a hysteroscopy examination. The mean (± standard deviation) operation time was 58.61 ± 18.56 minutes. The mean blood loss was 36.97 ± 22.32 mL. The mean hospital stay was 6.08 ± 1.89 days. In 57.14% of patients, the CSD completely disappeared, whereas the volume of CSD shrank by at least 50% in 88.95% of patients. The mean menstrual period of patients after surgery was 7.72 ± 2.68 days, which was significantly shorter than that recorded preoperatively (13.45 ± 3.69 days) (t = 19.62, p = .00). The pelvic pain disappeared in 81.08% of the patients. The mean postoperative thickness of the remaining muscular layer was 5.30 ± 1.27-mm, which was significantly higher than the preoperative value of 2.25 ± 0.92-mm (t = 28.21, p = .00). The mean postoperative thickness of the remaining muscular layer of patients with improved menstrual cycle was 5.40 ± 1.27-mm, which was significantly higher than the thickness of 4.88 ± 1.11-mm in patients without improved menstrual cycle (t = 2.31, p = .025). A total of 124 patients attempted to become pregnant, 83 of whom were successful. The pregnancy rate was as high as 66.95%, which included 2 scar pregnancies, 4 ectopic pregnancies, and 87 intrauterine pregnancies. No uterine rupture occurred. CONCLUSION The transvaginal repair of the uterine diverticulum improved the symptoms and probability of a successful pregnancy effectively. This process is a surgical procedure to increase the thickness of the residual uterine muscle wall effectively.
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Affiliation(s)
- Kaixian Deng
- Department of Gynecology, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan (Drs. Deng, Chen, Lin, Huang, X. Liu, Zheng); Department of Gynecology, Shunde Hospital, Southern Medical University (The First People's Hospital of Shunde) (Dr. Deng), Foshan
| | - Wujiang Liu
- Department of Gynecology, Shenzhen In Vitro Fertilization Gynecological Hospital (Drs. W. Liu, Wu, H. Wang, J. Wang, and Chen), Shenzhen, Guangdong, China
| | - Yonglian Chen
- Department of Gynecology, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan (Drs. Deng, Chen, Lin, Huang, X. Liu, Zheng)
| | - Shaoying Lin
- Department of Gynecology, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan (Drs. Deng, Chen, Lin, Huang, X. Liu, Zheng)
| | - Xiaomin Huang
- Department of Gynecology, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan (Drs. Deng, Chen, Lin, Huang, X. Liu, Zheng)
| | - Congbo Wu
- Department of Gynecology, Shenzhen In Vitro Fertilization Gynecological Hospital (Drs. W. Liu, Wu, H. Wang, J. Wang, and Chen), Shenzhen, Guangdong, China
| | - Hualing Wang
- Department of Gynecology, Shenzhen In Vitro Fertilization Gynecological Hospital (Drs. W. Liu, Wu, H. Wang, J. Wang, and Chen), Shenzhen, Guangdong, China
| | - Jiao Wang
- Department of Gynecology, Shenzhen In Vitro Fertilization Gynecological Hospital (Drs. W. Liu, Wu, H. Wang, J. Wang, and Chen), Shenzhen, Guangdong, China
| | - Lingyou Chen
- Department of Gynecology, Shenzhen In Vitro Fertilization Gynecological Hospital (Drs. W. Liu, Wu, H. Wang, J. Wang, and Chen), Shenzhen, Guangdong, China
| | - Xiaochun Liu
- Department of Gynecology, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan (Drs. Deng, Chen, Lin, Huang, X. Liu, Zheng)
| | - Yuhua Zheng
- Department of Gynecology, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan (Drs. Deng, Chen, Lin, Huang, X. Liu, Zheng).
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Tsuji S, Takahashi A, Higuchi A, Yamanaka A, Amano T, Kimura F, Seko-Nitta A, Murakami T. Pregnancy outcomes after hysteroscopic surgery in women with cesarean scar syndrome. PLoS One 2020; 15:e0243421. [PMID: 33270754 PMCID: PMC7714235 DOI: 10.1371/journal.pone.0243421] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 11/03/2020] [Indexed: 11/18/2022] Open
Abstract
Cesarean scar defect often causes postmenstrual abnormal uterine bleeding, dysmenorrhea, chronic pelvic pain, and infertility, which are collectively known as cesarean scar syndrome (CSS). Several studies have reported that hysteroscopic surgery can restore fertility in women with CSS. The study aimed to identify factors that influence subsequent pregnancy following hysteroscopic surgery. Therefore, we studied 38 women with secondary infertility due to CSS who underwent hysteroscopic surgery at Shiga University of Medical Hospital between July 2014 and July 2019. Our hysteroscopic procedure included inferior edge resection and superficial cauterization of the cesarean scar defect under laparoscopic guidance. Patients were followed up for 3 to 40 months after surgery. Surgery was successful in all cases and no complications were observed. Twenty-seven patients (71%) became pregnant (pregnant group), while 11 (29%) did not (non-pregnant group). Baseline characteristics of age, body mass index, gravidity, parity, previous cesarean section, presence of endometriosis, retroflex uterus, and preoperative residual myometrial thickness were not significantly different between the groups. However, the median residual myometrium thickness was significantly higher after surgery than before surgery in the pregnant group (1.9 [1.1-3.6] vs 4.9 [3.4-6.6] mm, P<0.0001), whereas this difference was not significant in the non-pregnant group. Of those who became pregnant, 85% conceived within 2 years of surgery. Although three pregnancies resulted in abortion and one is ongoing at the time of writing, 23 pregnancies resulted in healthy babies at 35-38 gestational weeks by scheduled cesarean sections with no obstetrical complications due to hysteroscopic surgery. The average birth weight was 3,076 g. Our findings support that hysteroscopic surgery is a safe and effective treatment for secondary infertility due to CSS. The thickness of the residual myometrium may be a key factor that influences subsequent pregnancy in women with CSS.
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Affiliation(s)
- Shunichiro Tsuji
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu City, Shiga, Japan
- * E-mail:
| | - Akimasa Takahashi
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu City, Shiga, Japan
| | - Asuka Higuchi
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu City, Shiga, Japan
| | - Akiyoshi Yamanaka
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu City, Shiga, Japan
| | - Tsukuru Amano
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu City, Shiga, Japan
| | - Fuminori Kimura
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu City, Shiga, Japan
| | - Ayumi Seko-Nitta
- Department of Radiology, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu City, Shiga, Japan
| | - Takashi Murakami
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu City, Shiga, Japan
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Zeller A, Villette C, Fernandez H, Capmas P. Is Hysteroscopy a Good Option to Manage Severe Cesarean Scar Defect? J Minim Invasive Gynecol 2020; 28:1397-1402. [PMID: 33197611 DOI: 10.1016/j.jmig.2020.11.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 10/28/2020] [Accepted: 11/10/2020] [Indexed: 11/15/2022]
Abstract
STUDY OBJECTIVE To compare the outcomes of hysteroscopic management in women with a severe or nonsevere symptomatic cesarean scar defect (residual myometrium ≤3-mm vs >3-mm, respectively). DESIGN Retrospective cohort study. SETTING Gynecology department of a teaching hospital. PATIENTS Seventy-one women with an operative hysteroscopy for a symptomatic defect (49 with severe defects and 22 with nonsevere ones). INTERVENTIONS Operative hysteroscopy for cesarean scar defect in women with a severe defect (residual myometrium ≤3-mm) and with nonsevere defect (residual myometrium >3-mm). MEASUREMENTS The main objective was to compare success rates between the 2 groups. The secondary objectives were the comparisons of (1) the number of women who required more than 1 procedure, (2) the rate of complications, (3) the number of subsequent pregnancies, and (4) the evolution of residual myometrium thickness between the groups. MAIN RESULTS The success rates were not significantly different between the groups (73.5% in the severe group and 63.6% in the nonsevere group [p = .40]). The number of women requiring more than 1 procedure was also similar, as were the rate of complications and the mean increase of myometrium thickness. The rate of subsequent pregnancies in women who were infertile was significantly higher in women with a severe defect (p = .04). CONCLUSION The hysteroscopic approach seems to be a good way to manage cesarean scar defects even when the residual myometrium is thin. A prospective study is, however, necessary to confirm these findings.
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Affiliation(s)
- Amélie Zeller
- Department of Gynecology and Obstetrics, AP-HP, GHU-Sud, Hospital Bicêtre (Drs. Zeller, Villette, Fernandez, and Capmas); Faculty of Medicine, University Paris-Sud Saclay (Drs. Fernandez and Capmas), Le Kremlin-Bicêtre; INSERM, centre de research in Epidemiology and Population Health, U1018 (Drs. Fernandez and Capmas), Villejuif, France
| | - Claire Villette
- Department of Gynecology and Obstetrics, AP-HP, GHU-Sud, Hospital Bicêtre (Drs. Zeller, Villette, Fernandez, and Capmas); Faculty of Medicine, University Paris-Sud Saclay (Drs. Fernandez and Capmas), Le Kremlin-Bicêtre; INSERM, centre de research in Epidemiology and Population Health, U1018 (Drs. Fernandez and Capmas), Villejuif, France
| | - Hervé Fernandez
- Department of Gynecology and Obstetrics, AP-HP, GHU-Sud, Hospital Bicêtre (Drs. Zeller, Villette, Fernandez, and Capmas); Faculty of Medicine, University Paris-Sud Saclay (Drs. Fernandez and Capmas), Le Kremlin-Bicêtre; INSERM, centre de research in Epidemiology and Population Health, U1018 (Drs. Fernandez and Capmas), Villejuif, France
| | - Perrine Capmas
- Department of Gynecology and Obstetrics, AP-HP, GHU-Sud, Hospital Bicêtre (Drs. Zeller, Villette, Fernandez, and Capmas); Faculty of Medicine, University Paris-Sud Saclay (Drs. Fernandez and Capmas), Le Kremlin-Bicêtre; INSERM, centre de research in Epidemiology and Population Health, U1018 (Drs. Fernandez and Capmas), Villejuif, France.
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Optimal Isthmocele Management: Hysteroscopic, Laparoscopic, or Combination. J Minim Invasive Gynecol 2020; 28:565-574. [PMID: 33152531 DOI: 10.1016/j.jmig.2020.10.026] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 10/26/2020] [Accepted: 10/30/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To conduct a systematic review of the literature on the hysteroscopic and laparoscopic repair of isthmocele. DATA SOURCES A thorough search of the PubMed/Medline, Embase, and Cochrane databases was performed. (PROSPERO registration number CRD42020190668). METHODS OF STUDY SELECTION Studies from the last 20 years that addressed isthmocele repair were collected. Both authors screened for study eligibility and extracted data. All prospective and retrospective studies of more than 10 women were included. TABULATION, INTEGRATION, AND RESULTS The initial search identified 666 articles (Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow chart) (see Supplemental Fig.). We excluded duplicates, case reports, reviews, video articles, and technique articles. We also excluded studies describing only laparotomy or vaginal repair as these were not in the scope of this review. A total of 31 articles met the inclusion criteria, 21 for hysteroscopic resection and 13 for laparoscopic or combined repair (4 articles tested both modalities and appear in both Tables 1 and 2).For abnormal uterine bleeding, hysteroscopic remodeling relived symptoms in 60% to 100% of cases and laparoscopy in 78% to 94%. Secondary infertility was not evaluated in all studies. After hysteroscopic and laparoscopic treatment, 46% to 100% and 37.5% to 90% of those who wished to conceive became pregnant, after the procedure, respectively. Pain and dysmenorrhea seem to be uncommon. All studies that tested improvement of pain had fewer than 10 women. However, between 66% and 100% of women who complain of pain or dysmenorrhea will note a marked improvement to full resolution. CONCLUSION Patients with an isthmocele or cesarean scar defect are usually asymptomatic. For symptomatic women, a repair is a valid option. For those with residual myometrial thickness >2 to 3 mm, hysteroscopic remodeling is the modality of choice with an improvement in abnormal uterine bleeding, secondary infertility, and pain. Women with a residual myometrial thickness <2- to 3-mm laparoscopic repair with simultaneous hysteroscopic guidance show similar results. Because available data are limited, no cutoff for the correct choice between hysteroscopy and laparoscopy can be concluded. We recommend 2.5 mm as the cutoff value based on common practice and expert opinion, although no significance between hysteroscopic and laparoscopic treatment was shown.
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Peng C, Huang Y, Lu Y, Zhou Y. Comparison of the Efficacy of Two Laparoscopic Surgical Procedures Combined with Hysteroscopic Incision in the Treatment of Cesarean Scar Diverticulum. J INVEST SURG 2020; 35:225-230. [PMID: 33059509 DOI: 10.1080/08941939.2020.1830319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To investigate the efficacy of two different surgical procedures in combined hysteroscopic and laparoscopic surgery-the "folding suture method" and the "muscle flap filling suture method"-in the treatment of cesarean scar diverticulum (CSD). METHODS The clinical data of 24 patients with CSD who underwent surgery in the Peking University First Hospital from August 2016 to December 2018 were retrospectively analyzed. RESULTS There was no difference in age, vaginal bleeding time, thickness of the lower uterine segment, operative time and intraoperative bleeding between the two groups. At three months after the operation, the patients of the folding suture and muscle flap groups had an average menstrual period of 6.9 ± 1.8 days and 7.5 ± 3.0 days, respectively, which was 5.8 ± 4.2 days and 4.4 ± 3.8 days, respectively, shorter than that before the operation, as well as a lower segment thickness of the uterus of 6.7 ± 1.8 mm and 6.3 ± 1.7 mm, respectively. Among the patients in the folding suture and muscle flap groups, 8 and 6 cases were cured, and 3 and 6 cases were improved, respectively, resulting in an effective rate of 100%. There was no significant difference in any indicator between the two groups. CONCLUSION As two new surgical methods that preserve uterine integrity, the laparoscopic "muscle flap filling suture method" and "folding suture method" combined with hysteroscopic incision are safe and effective treatments for repairing CSD.
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Affiliation(s)
- Chao Peng
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
| | - Yan Huang
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
| | - Ye Lu
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
| | - Yingfang Zhou
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
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Zhang Y, Jia Y, Wang X, Sun Q. Feasibility analysis of different surgical methods for uterine cesarean section scar diverticulum. J Obstet Gynaecol Res 2020; 46:1758-1765. [PMID: 32567071 DOI: 10.1111/jog.14351] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 05/02/2020] [Accepted: 05/23/2020] [Indexed: 11/29/2022]
Abstract
AIM This study analyses the effects of surgical indicators and clinical efficacy of different surgical methods for uterine cesarean section scar diverticulum. METHODS This retrospective cohort study included 65 patients who underwent surgery and postoperative follow-up at Gansu Provincial Maternity and Child-care Hospital from 1 January 2013 to 31 February 2019. RESULTS All participants were treated surgically. Among them, patients in Group A underwent combined laparoscopic and hysteroscopic surgery (n = 45), Group B underwent transvaginal surgery (n = 11), Group C underwent laparotomy (n = 9). The primary outcomes were surgical indicators. The secondary outcomes were clinical efficacy. Bleeding, operation time and hospitalization expenses were significantly different among the three groups (P < 0.05). There was no difference in the hospital stay among the three groups P = 0.22). The menstrual period before and after surgery was significantly different among the groups (P < 0.05). The recurrence outcome was no significantly different (P = 0.16), but the pregnancy outcome was not (P = 0.78). CONCLUSION The three surgical methods are effective for treating cesarean section scar diverticulum with favorable effects. Laparoscopic combined with hysteroscopic surgery is minimally invasive with less bleeding compared with the other two techniques and it is easier for patients to accept. It is the most widely used surgical method.
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Affiliation(s)
- Yanhua Zhang
- Department of Gynecology, Gansu Provincial Maternity and Child-Care Hospital, Lanzhou, China
| | - Yanfeng Jia
- Department of Gynecology, Gansu Provincial Maternity and Child-Care Hospital, Lanzhou, China
| | - Xiaoli Wang
- Department of Gynecology, Gansu Provincial Maternity and Child-Care Hospital, Lanzhou, China
| | - Qian Sun
- Department of Gynecology, Gansu Provincial Maternity and Child-Care Hospital, Lanzhou, China
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Wang Y, Li J, Wang H, Wang X. Vaginal repaired cesarean section diverticulum is beneficial in women with two prior cesarean sections. BMC WOMENS HEALTH 2020; 20:81. [PMID: 32326910 PMCID: PMC7181476 DOI: 10.1186/s12905-020-00940-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 04/06/2020] [Indexed: 11/10/2022]
Abstract
Background The aim of this study was to evaluate the effect of vaginal repair in patients with cesarean section diverticulum (CSD) who had one or two previous cesarean sections (CSs). Methods From January 2012 to December 2014, 248 women with CSD underwent vaginal repair surgery in Shanghai First Maternity and Infant Hospital. These included 193 women with one previous cesarean section and 55 women with two previous cesarean sections. Excision and suture of CSD was performed through a vaginal approach. The duration of menstruation, the length, width and depth of the CSD and thickness of the remaining muscular layer (TRM) were evaluated before and after surgery by transvaginal three-dimensional (3D) color Doppler ultrasound. Results A total of 221 (89.11%) women were followed-up for more than 3 months, and 168 (67.74%) women were followed-up for more than 6 months. There were significant differences in the average duration of menstruation (7.77 ± 2.05 and 8.02 ± 2.06 days VS 13.99 ± 3.71 days), the average size of CSD (5.54*9.19*5.60 and 5.75*9.04*6.18 mm VS 7.99*12.43*6.62 mm) and the TRM (7.61 ± 2.52 and 7.60 ± 3.00 mm VS 2.51 ± 1.02 mm) after surgery compared with those figures before surgery. The results of this study reveal that vaginal repair could shorten the duration of menstruation and improve anatomical defects (P < 0.05). Moreover, there was no significant difference in the effect of clinical repair between women with one or two previous cesarean sections (P > 0.05). Conclusion In CSD patients, the clinical effectiveness of vaginal repair was equivalent between women with one or two previous cesarean sections.
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Affiliation(s)
- Yizhi Wang
- Departments of Gynecology and Obstetrics, Xin Hua Hospital Affiliated with Shanghai JiaoTong University School of Medicine, 1665 Kong Jiang Road, Shanghai, 200092, China
| | - Jiarui Li
- Departments of Gynecology and Obstetrics, Xin Hua Hospital Affiliated with Shanghai JiaoTong University School of Medicine, 1665 Kong Jiang Road, Shanghai, 200092, China
| | - Husheng Wang
- Departments of Gynecology and Obstetrics, Xin Hua Hospital Affiliated with Shanghai JiaoTong University School of Medicine, 1665 Kong Jiang Road, Shanghai, 200092, China.
| | - Xipeng Wang
- Departments of Gynecology and Obstetrics, Xin Hua Hospital Affiliated with Shanghai JiaoTong University School of Medicine, 1665 Kong Jiang Road, Shanghai, 200092, China.
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Zhou D, Wu F, Zhang Q, Cui Y, Huang S, Lv Q. Clinical outcomes of hysteroscopy-assisted transvaginal repair of cesarean scar defect. J Obstet Gynaecol Res 2020; 46:279-285. [PMID: 31960535 DOI: 10.1111/jog.14161] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 11/10/2019] [Indexed: 12/01/2022]
Abstract
AIM This study was conducted to evaluate comparative clinical outcomes of hysteroscopy-assisted transvaginal repair in the treatment of cesarean scar defect (CSD) in patients desirous of conceiving again. METHODS We retrospectively enrolled 63 patients with CSD who were treated at Beijing Hospital between January 2014 and January 2016. Patients were divided into the hysteroscopic electrocauterization group (electrocauterization group, n = 28) and hysteroscopy-assisted transvaginal repair group (transvaginal group, n = 35). Perioperative parameters including operation time, intraoperative blood loss, time to passage of flatus, hospitalization duration, duration of postoperative vaginal bleeding, pre- and postoperative myometrial thickness, rate of full-term births and surgical complications were compared between the two groups. RESULTS At the 6-month follow-up, myometrial thickness was significantly greater in the transvaginal group (9.8 ± 1.0 mm) compared to the electrocauterization group (3.3 ± 0.7 mm, P < 0.05). One patient in the transvaginal group required intraoperative conversion to laparotomy because of surgical complications. The transvaginal group had a significantly higher rate of full-term live birth compared to the electrocauterization group (92% vs 46%, P < 0.05). There were no significant between-group differences in the other pre-, intra-, and postoperative parameters. The maximum postoperative diameter of the CSD in the transvaginal and electrocauterization groups was 1.6 ± 0.8 and 17 ± 2.0 mm, respectively. CONCLUSION Compared to hysteroscopic electrocauterization, hysteroscopy-assisted transvaginal repair of CSD was associated with better clinical outcomes and higher rate of full-term live births.
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Affiliation(s)
- Dan Zhou
- Department of Gynecology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, P.R. China
| | - Fengli Wu
- Department of Gynecology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, P.R. China
| | - Qiao Zhang
- Department of Gynecology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, P.R. China
| | - Ying Cui
- Department of Gynecology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, P.R. China
| | - Shuai Huang
- Department of Gynecology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, P.R. China
| | - Qiubo Lv
- Department of Gynecology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, P.R. China
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Deffieux X, S V, E S, A C. Successful Management of an Extremely Large Uterine Scar Defect. Surg Case Rep 2019. [DOI: 10.31487/j.scr.2019.04.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Cesarean section is one of the most common surgical procedures in young women. Cesarean scar defects may occur postoperatively and may cause symptoms such as chronic pain, postmenstrual bleeding as well as secondary infertility.
Case presentation: We report the case of a 35-year-old woman who was referred to our center for the management of a large cesarean scar defect. She had history of two cesarean sections and presented with abnormal uterine bleeding, chronic pain and dyspareunia. Hysteroscopic examination showed the presence of a little isthmocele on the anterior uterine wall. Hysteroscopic resection with electrocoagulation was performed. The patient remained symptomatic and, unfortunately, five years later, magnetic resonance imaging (MRI) revealed a large anterior isthmocele (50x80 mm). A complete repair of the large defect was achieved by laparotomy.Postoperative MRI as well as hysteroscopic examination showed no signs of residual isthmocele.
Conclusion: There are three main surgical options for isthmocele repair: vaginal approach, hysteroscopic resection or laparoscopic resection and repair of the uterine wall. While there is no clear consensus about general management of isthmocele, there are very few cases the medical literature of large isthmoceles, such as the one we describe. This case is interesting since no case of worsening of isthmocele following hysteroscopic treatment has been described so far.
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Kremer TG, Ghiorzi IB, Dibi RP. Isthmocele: an overview of diagnosis and treatment. ACTA ACUST UNITED AC 2019; 65:714-721. [PMID: 31166450 DOI: 10.1590/1806-9282.65.5.714] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 12/31/2018] [Indexed: 11/21/2022]
Abstract
An isthmocele, a cesarean scar defect or uterine niche, is any indentation representing myometrial discontinuity or a triangular anechoic defect in the anterior uterine wall, with the base communicating to the uterine cavity, at the site of a previous cesarean section scar. It can be classified as a small or large defect, depending on the wall thickness of the myometrial deficiency. Although usually asymptomatic, its primary symptom is abnormal or postmenstrual bleeding, and chronic pelvic pain may also occur. Infertility, placenta accrete or praevia, scar dehiscence, uterine rupture, and cesarean scar ectopic pregnancy may also appear as complications of this condition. The risk factors of isthmocele proven to date include retroflexed uterus and multiple cesarean sections. Nevertheless, factors such as a lower position of cesarean section, incomplete closure of the hysterotomy, early adhesions of the uterine wall and a genetic predisposition may also contribute to the development of a niche. As there are no definitive criteria for diagnosing an isthmocele, several imaging methods can be used to assess the integrity of the uterine wall and thus diagnose an isthmocele. However, transvaginal ultrasound and saline infusion sonohysterography emerge as specific, sensitive and cost-effective methods to diagnose isthmocele. The treatment includes clinical or surgical management, depending on the size of the defect, the presence of symptoms, the presence of secondary infertility and plans of childbearing. Surgical management includes minimally invasive approaches with sparing techniques such as hysteroscopic, laparoscopic or transvaginal procedures according to the defect size.
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Affiliation(s)
- Thaysa Guglieri Kremer
- Department of Medicine at the Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brasil
| | - Isadora Bueloni Ghiorzi
- Department of Medicine at the Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre, RS, Brasil
| | - Raquel Papandreus Dibi
- Department of Gynecology and Obstetrics at the Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre, RS, Brasil
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Szkodziak P, Stępniak A, Czuczwar P, Szkodziak F, Paszkowski T, Woźniak S. Is it necessary to correct a caesarean scar defect before a subsequent pregnancy? A report of three cases. J Int Med Res 2019; 47:2248-2255. [PMID: 30880523 PMCID: PMC6567761 DOI: 10.1177/0300060519835068] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Rates of caesarean section have increased over recent years and so too have associated complications, one of which is a caesarean scar defect (CSD). The defect may cause gynaecological symptoms, such as menometrorrhagia, infertility, chronic abdominal/pelvic pain or it may be asymptomatic. The presence of CSD may lead to obstetrical sequalae such as preterm delivery, uterine rupture, caesarean scar pregnancy or abnormal placenta implantation. Three cases of CSD are described here. In one case, surgical correction of the CSD was performed before a subsequent pregnancy with an uncomplicated obstetric outcome. In the other two cases, surgical correction of the CSD was not performed and the pregnancies were complicated by caesarean scar dehiscence and caesarean scar pregnancy. We suggest that women with a CSD may benefit from surgical correction of the defect before becoming pregnant to reduce the likelihood of serious complications.
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Affiliation(s)
- Piotr Szkodziak
- 3rd Department of Gynaecology, Medical University of Lublin, Lublin, Poland
| | - Anna Stępniak
- 3rd Department of Gynaecology, Medical University of Lublin, Lublin, Poland
| | - Piotr Czuczwar
- 3rd Department of Gynaecology, Medical University of Lublin, Lublin, Poland
| | - Filip Szkodziak
- 3rd Department of Gynaecology, Medical University of Lublin, Lublin, Poland
| | - Tomasz Paszkowski
- 3rd Department of Gynaecology, Medical University of Lublin, Lublin, Poland
| | - Sławomir Woźniak
- 3rd Department of Gynaecology, Medical University of Lublin, Lublin, Poland
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Iannone P, Nencini G, Bonaccorsi G, Martinello R, Pontrelli G, Scioscia M, Nappi L, Greco P, Scutiero G. Isthmocele: From Risk Factors to Management. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2019; 41:44-52. [PMID: 30646424 PMCID: PMC10416161 DOI: 10.1055/s-0038-1676109] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 10/10/2018] [Indexed: 10/27/2022] Open
Abstract
OBJECTIVE The aim of the present study was to perform a comprehensive review of the literature to provide a complete and clear picture of isthmocele-a hypoechoic area within the myometrium at the site of the uterine scar of a previous cesarean section-by exploring in depth every aspect of this condition. METHODS A comprehensive review of the literature was performed to identify the most relevant studies about this topic. RESULTS Every aspect of isthmocele has been studied and described: pathophysiology, clinical symptoms, classification, and diagnosis. Its treatment, both medical and surgical, has also been reported according to the actual literature data. CONCLUSION Cesarean section is the most common surgical procedure performed worldwide, and one of the consequences of this technique is isthmocele. A single and systematic classification of isthmocele is needed to improve its diagnosis and management. Further studies should be performed to better understand its pathogenesis.
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Affiliation(s)
- Piergiorgio Iannone
- Section of Obstetrics and Gynecology, Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliero-Universitaria S. Anna, Università di Ferrara, Cona, Ferrara, Italy
| | - Giulia Nencini
- Section of Obstetrics and Gynecology, Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliero-Universitaria S. Anna, Università di Ferrara, Cona, Ferrara, Italy
| | - Gloria Bonaccorsi
- Section of Obstetrics and Gynecology, Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliero-Universitaria S. Anna, Università di Ferrara, Cona, Ferrara, Italy
| | - Ruby Martinello
- Section of Obstetrics and Gynecology, Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliero-Universitaria S. Anna, Università di Ferrara, Cona, Ferrara, Italy
| | - Giovanni Pontrelli
- Section of Obstetrics and Gynaecology, Policlinico di Abano Terme, Abano Terme, Padova, Italy
| | - Marco Scioscia
- Section of Obstetrics and Gynaecology, Policlinico di Abano Terme, Abano Terme, Padova, Italy
| | - Luigi Nappi
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, Foggia, Italy
| | - Pantaleo Greco
- Section of Obstetrics and Gynecology, Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliero-Universitaria S. Anna, Università di Ferrara, Cona, Ferrara, Italy
| | - Gennaro Scutiero
- Section of Obstetrics and Gynecology, Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliero-Universitaria S. Anna, Università di Ferrara, Cona, Ferrara, Italy
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Hysteroscopy combined with laparoscopy in treatment of patients with post-cesarean section uterine diverticulum. Wideochir Inne Tech Maloinwazyjne 2018; 14:297-303. [PMID: 31118997 PMCID: PMC6528112 DOI: 10.5114/wiitm.2018.77775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 07/21/2018] [Indexed: 11/17/2022] Open
Abstract
Introduction Post-cesarean section uterine diverticulum (PCSUD) is a recess in the lower uterine segment of the cesarean section incision that protrudes to the serosa due to healing defects. With the abolition of the one-child policy, allowing couples to have two children in the past year in China, more and more couples plan to give birth to a second baby. However, with the significant increase in the cesarean section rate in the past two decades in China, the incidence of PCSUD also obviously increased. Aim To evaluate the clinical efficacy and safety of hysteroscopy combined with laparoscopy in treatment of patients with PCSUD. Material and methods Fifty-two cases of patients with post-cesarean section uterine diverticulum (PCSUD) who suffered from conservative treatment failure in the Beijing Obstetrics and Gynecology Hospital (affiliated to Beijing Capital Medical University) between January 2012 and June 2017 were retrospectively analyzed in this study. Patients with reproductive requirements were treated with hysteroscopy combined with laparoscopy surgery (experimental group, n = 31); those without reproductive requirements were treated with hysteroscopic surgery (control group, n = 21). The operation time, intraoperative blood loss, hospital stay period, clinical efficacy and recurrence rate of the two groups were compared. Results All the patients successfully completed the operation procedure in both experimental and control groups. The operation time, intraoperative blood loss and post-operative hospital stay in the experimental group were significantly higher than those of the control group (p < 0.05). There was no significant difference in clinical efficacy or recurrence between the two groups (p > 0.05). Six months after the operation, the uterus muscularis thickness was 4.2 ±1.9 mm and 9.8 ±6.2 mm for control and experimental groups respectively, which indicates that the muscularis thickness in the experimental group was significantly greater than that of the control group (p < 0.05). Conclusions Hysteroscopy combined with laparoscopy was safe with satisfactory results in treatment of patients with PCSUD.
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