Transvaginal management of cesarean scar section diverticulum: a novel surgical treatment

Prevalence, definition, and etiology of cesarean scar defect and treatment of cesarean scar disorder: A narrative review

Background

Cesarean scar defects (CSD) are caused by cesarean sections and cause various symptoms. Although there has been no previous consensus on the name of this condition for a long time, it has been named cesarean scar disorder (CSDi).

Methods

This review summarizes the definition, prevalence, and etiology of CSD, as well as the pathophysiology and treatment of CSDi. We focused on surgical therapy and examined the effects and procedures of laparoscopy, hysteroscopy, and transvaginal surgery.

Main findings

The definition of CSD was proposed as an anechoic lesion with a depth of at least 2 mm because of the varied prevalence, owing to the lack of consensus. CSD incidence depends on the number of times, procedure, and situation of cesarean sections. Histopathological findings in CSD are fibrosis and adenomyosis, and chronic inflammation in the uterine and pelvic cavities decreases fertility in women with CSDi. Although the surgical procedures are not standardized, laparoscopic, hysteroscopic, and transvaginal surgeries are effective.

Conclusion

The cause and pathology of CSDi are becoming clear. However, there is variability in the prevalence and treatment strategies. Therefore, it is necessary to conduct further studies using the same definitions.

Association between the occurrence of adenomyosis and the clinical outcomes of vaginal repair of cesarean section scar defects: an observational study

Background

To examine the correlation between the occurrence of adenomyosis and the outcome of vaginal repair of cesarean section scar defects (CSDs).

Methods

A total of 278 women with CSD were enrolled in this retrospective observational cohort study at the Shanghai First Maternity & Infant Hospital between January 2013 and August 2017. Patients were divided into two groups according to preoperative magnetic resonance imaging (MRI) findings: the adenomyosis group and the non-adenomyosis group. They all underwent vaginal excision and suturing of CSDs and were required to undergo examinations 3 and 6 months after surgery. Preoperative and postoperative clinical information was collected. Optimal healing was defined as a duration of menstruation of no more than 7 days and a thickness of the residual myometrium (TRM) of no less than 5.8 mm after vaginal repair.

Results

Before vaginal repair, for patients in the adenomyosis group, the mean duration of menstruation was longer and TRM was significantly thinner than those in patients in the non-adenomyosis group (p < 0.05). The TRM and duration of menstruation 3 and 6 months after surgery were significantly improved in both groups (p < 0.05). There were more patients with optimal healing in the non-adenomyosis group than in the adenomyosis group (44.7% vs. 30.0%; p < 0.05). Furthermore, 59.3% (32/54) of the women tried to conceive after vaginal repair. The pregnancy rates of women with and without adenomyosis were 66.7% (8/12) and 61.9% (26/42), respectively. The duration of menstruation decreased significantly from 13.4 ± 3.3 days before vaginal repair to 7.6 ± 2.3 days after vaginal repair in 25 patients (p < 0.001). The TRM increased significantly from 2.3 ± 0.8 mm before vaginal repair to 7.6 ± 2.9 mm after vaginal repair (p < 0.001).

Conclusions

Vaginal repair reduced postmenstrual spotting and may have improved fertility in patients with CSDs. Patients with adenomyosis are more likely to have suboptimal menstruation and suboptimal healing of CSDs. Adenomyosis might be an adverse factor in the repair of uterine incisions.

Novel laparoscopic surgery for the repair of cesarean scar defect without processing scar resection

BACKGROUND

Cesarean scar defect (CSD), especially CSD with residual myometrium less than 3 mm is reported to be the highest risk agent associated with uterine rupture for subsequent pregnancy. Currently, laparoscopic resection and suture was the mainstay therapy method for CSD with a residual myometrium less than 3 mm in women with a desire to conceive. Besides, the women have CSD related symptoms, especially postmenstrual bleeding, should be recommended for CSD treatment. This study is to investigate the efficiency of this novel laparoscopic surgery for the repair of cesarean scar defect (CSD) without scar resection for residual myometrium thickening.

METHOD

This retrospective clinical study enrolled 76 women diagnosed with CSD who had a residual myometrium thickness less than 3 mm and also had a desire to conceive, had undergone laparoscopic surgery for the repair of CSD in the time period March 2016 to March 2018. Two study cohorts were created among the 76 patients: 40 patients had undergone the novel laparoscopic repair of CSD without processing scar resection (Group A), whereas 36 patients had undergone the traditional laparoscopic resection and suture of CSD (Group B).

RESULTS

Residual myometrium thickening occurred among all the 76 patients and the average residual myometrium thickness was increased to almost 6 mm, presenting no between-group difference. In Group A, all the CSD-related postmenstrual bleeding was resolved or improved, but one patient in Group B has no obvious change to postmenstrual bleeding. After CSD repair, 20 patients got pregnant naturally in Group A, and there was no cesarean scar pregnancy and uterine rupture. While, there were 9 cases of natural pregnancy in Group B. No uterine rupture occurred among these 9 pregnant women of Group B, but 1 case of pregnancy was terminated due to cesarean scar pregnancy.

CONCLUSION

Laparoscopic repair without processing scar resection seems to be a feasible, safe and simple operative approach for CSD treatment, which can thicken residual myometrium and improve postmenstrual bleeding.

Analysis on clinical association of uterine scar diverticulum with subsequent infertility in patients underwent cesarean section

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.

Single-port laparoscopy-assisted vaginal repair of a cesarean scar defect: a single-center retrospective study

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Background:

The incidence of uterine cesarean scar defect (niche) is high, and some patients require surgery. Single-port laparoscopy can reduce post-operative pain, and provide better cosmetic effects. This study was performed to evaluate the safety and superiority of single-port laparoscopy-assisted vaginal repair of uterine cesarean scar defect (niche) in women after cesarean section.

Methods:

This study included 74 patients who were diagnosed with uterine cesarean niche at the Shanghai First Maternity and Infant Hospital from January 2013 to June 2015. Thirty-seven patients underwent single-port laparoscopy-assisted vaginal surgery as the case group, and the remaining patients underwent vaginal repair surgery as the control group. We collected data from the inpatient and follow-up medical records. The clinical characteristics of these two groups were compared. The odds ratios and 95% confidential intervals were calculated for each variable by univariate and multivariate analyses.

Results:

Patients who underwent single-port laparoscopy-assisted vaginal repair had a significantly longer operation time (2.3 [2.0–2.7] vs. 2.0 [1.6–2.3] h, P = 0.015), shorter gas passage time (1.2 [1.0–1.5] vs. 1.7 [1.0–2.0] days, P = 0.012), shorter hospital stay (3.1 [3.0–4.0] vs. 4.5 [4.0–6.0] days, P = 0.019), and fewer complications (0 vs. 4 cases). Univariate analysis showed that depth of the niche (P = 0.021) the mild adhesiolysis score (P = 0.035) and moderate adhesiolysis score (P = 0.013) were associated with the bladder injury. Multivariate analysis showed that the moderate adhesiolysis score (P = 0.029; 95% confidence interval, 1.318–3.526) was the strongest independent predictor of bladder injury.

Conclusion:

This study confirmed the safety and superiority of single-port laparoscopy-assisted vaginal repair of uterine cesarean scars.

Comparison of the Efficacy of Two Laparoscopic Surgical Procedures Combined with Hysteroscopic Incision in the Treatment of Cesarean Scar Diverticulum

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.

Cesarean scar defects: management of an iatrogenic pathology whose prevalence has dramatically increased

Around 20% of pregnant women undergo cesarean section (CS), and in most regions of the world CS rates continue to grow. There is still no clear definition of what is considered a normal physiologic aspect of a CS scar and what is abnormal. Cesarean scar defects (CSDs) should be suspected in women presenting with spotting, dysmenorrhea, pelvic pain, or infertility and a history of CS. CSDs can be visualized with the use of hysterosalpingography, transvaginal sonography, saline infusion sonohysterography, hysteroscopy, and magnetic resonance imaging. It is reasonable to consider hormone therapy for CSDs as a symptomatic treatment in women who no longer wish to conceive and have no contraindications. In case of failure of or contraindications to medical treatment, surgery should be contemplated according to the severity of symptoms, including infertility, the desire or otherwise to preserve the uterus, the size of the CSD, and residual myometrium thickness (RMT) measurement. Hysteroscopy is considered to be more of a resection than a repair, so women who desire pregnancy should be excluded from this technique if the RMT is <3 mm, in which case repair is essential and can be achieved by only laparoscopic or vaginal approach. Women with CSDs need to be given complete information, including available literature, before any treatment decision is made. Because prevention is better than cure, risk factors should be identified early to ensure appropriate management.

Hysteroscopic treatment of cesarean scar defect

OBJECTIVE

To investigate the effect of hysteroscopic surgery on the outcomes of obstetrics and gynecology among patients with cesarean section diverticulum.

METHODS

Ninety-nine infertile patients with cesarean section diverticulum received hysteroscopic treatment and were retrospectively analyzed. Patients were followed for 1 year.

RESULTS

The study included ninety-nine symptomatic patients with cesarean section diverticulum. After surgery, the menstrual periods of patients were improved from 11.15 ± 4.44 to 7.69 ± 2.85 days. Forty-seven (47/99) women became pregnant after surgery. The number of patients who became pregnant with an anteflexion uterus after hysteroscopic surgery is 32 (32/57), and the number of women who became pregnant with a retroflexion uterus is 15 (15/42).

CONCLUSION

Hysteroscopic surgery could improve the PCSD-associated prolonged menstrual bleeding, and satisfactory obstetrical outcomes could be achieved by the surgery treatment in women with cesarean defect.

Non-Invasive Isthmocele Treatment: A New Therapeutic Option During Assisted Reproductive Technology Cycles?

Background

The objective of the study was to evaluate a new medical treatment strategy for infertile patients with isthmocele.

Methods

This was a retrospective evaluation of the records of infertile patients with symptomatic isthmocele who received non-invasive isthmocele treatment (NIIT) before in vitro fertilization (IVF) treatment cycles. Isthmocele volumes were measured before and after NIIT. The IVF results and isthmocele-related complaints were also analyzed. The patients were treated with a depot gonadotropin-releasing hormone agonist for 3 months before frozen-thawed embryo transfer cycles.

Results

The mean isthmocele volume was 471.06 ± 182.81 mm³ (range: 289.43 - 765.4 mm³) in fresh cycles, but was reduced to 47.94 ± 29.48 mm³ (range: 18.70 - 105.6 mm³) in frozen-thawed cycles (P < 0.05). Intrauterine fluid was observed in two patients during fresh cycles, but was absent after NIIT during frozen-thawed cycles. There was no brown bloody discharge on the tip of the embryo transfer catheter in any case after NIIT. Two patients became pregnant and underwent term cesarean delivery (25%).

Conclusions

NIIT can serve as an alternative pretreatment option for patients with isthmocele during IVF cycles.

Endoscopic Treatment of Previous Cesarean Scar Defect in Women with Postmenstrual Bleeding: A Retrospective Cohort Study

OBJECTIVE

To compare the incidence of postmenstrual bleeding after hysteroscopic resection versus laparoscopic repair of previous cesarean scar defect (PCSD).

MATERIALS AND METHODS

Retrospective analysis of computerized patient records. For the diagnosis of PCSD, patients underwent transvaginal ultrasound first without and then with saline-assisted sonohysterography. Hysteroscopic PCSD resection was performed under sonographic guidance, while laparoscopic repair was guided by hysteroscopy for the confirmation of scar margins.

RESULTS

Records of 62 patients presenting with PCSD-related postmenstrual bleeding were included in analysis. Hysteroscopic surgery had significantly shorter operative time compared to the laparoscopic approach (Mean =30.9 vs 71.0 minutes; p < 0.001). Blood loss and hospital stay were significantly less (p < 0.001) in hysteroscopic resection (10.4 ± 4.6 ml and 2.1 ± 0.4 days) than in laparoscopic repair (36.6 ± 4 ml, and 4.6 ± 1 days). After surgical interventions, the postmenstrual bleeding was resolved or improved. The effectiveness rates of hysteroscopic resection and laparoscopic repair were 91.4% and 96.3%, respectively. Incidence of post-treatment postmenstrual bleeding was not significantly different between hysteroscopy and laparoscopy (OR= 1.29 [95% confidence interval 0.367, 4.86]; p = 0.662). Pretreatment postmenstrual bleeding was associated with time since cesarean section (B= -0.091 [-0.158, -0.023]; p = 0.01) and PCSD length (B = 0.502 [0.085, 0.919]; p = 0.019).

CONCLUSION

Both hysteroscopic resection and laparoscopic repair of PCSD yield comparable efficacy in reducing postmenstrual bleeding. However, hysteoroscopic resection of PCSD is associated with comparatively shorter operative time, less blood loss, and shorter hospital stay.

Treatment of C-section diverticula with hysteroscopic resection in women without childbearing intention: a retrospective cohort study

Background

Diverticulum, one of the long-term sequelae of cesarean section, can cause abnormal uterine bleeding, dysmenorrhea and chronic pelvic pain. Hysteroscopic resection of diverticula is thought to reduce abnormal uterine bleeding and chronic pelvic pain. In this study, we aim to describe the improvement after hysteroscopic resection of cesarean section diverticula (CSD) in women without childbearing intention, and to explore the variables associated with poor prognosis.

Methods

A retrospective cohort study of women aged 25–48 with CSD diagnosis by transvaginal ultrasonography (TVS) and hysteroscopy that were enrolled at Guangzhou Women and Children’s Medical Center between June 2017 and December 2018. A total of 124 women met the inclusion criteria and all patients had undergone hysteroscopic resection and accepted a follow-up interview at the 3rd and 6th months postoperatively to record symptom improvement.

Result

The mean of intraoperative blood loss and operative time of hysteroscopic resection were (12.94 ± 12.63) ml and (33.63 ± 6.87) min in 124 patients. Overall observed improvement rates of CSD symptom were 47.2 and 65.6% in the first 3 and 6 months, respectively. Multivariable logistic regression models revealed that timing of surgery < 14 days was a good prognostic factor associated with both 3-month improvement (OR, 16.59; 95% CI, 2.62–104.90; P = 0.003) and 6-month improvement (OR, 15.51; 95%CI, 1.63–148.00; P = 0.02); Patients with numbers of cesarean section (CS) ≥2 had a lower rate of improvement after 6 months of CSD repair surgery compared with patients who underwent one CS (OR, 8.29; 95%CI, 1.05–65.75; P = 0.04).

Conclusions

A hysteroscopic repair might be an appropriate method for CSD in women who no childbearing intentions. The timing of surgery and the number of CS seems to be factors influencing the postoperative improvement of CSD.

From hysteroscopy to laparoendoscopic surgery: what is the best surgical approach for symptomatic isthmocele? A systematic review and meta-analysis

PURPOSE

To investigate the effectiveness and risks of different surgical therapies for isthmocele in symptomatic women with abnormal uterine bleeding, infertility, or for the prevention of obstetric complications, considering safety and surgical complications.

METHODS

PubMed/MEDLINE, Scopus, Embase, Science Direct, and Cochrane Library were systematically searched (n° CRD4201912035) for original articles on the surgical treatment of isthmocele published between 1950 and 2018. Data synthesis was completed using MedCalc 16.4.3. The body of evidence was assessed using the GRADE methodology.

RESULTS

We retrieved 33 publications: 28 focused on a single surgical technique, and five comparing different techniques. Meta-analysis showed an improvement of symptoms in 85.00% (75.05-92.76%) of women after hysteroscopic correction, 92.77% (85.53-97.64%) after laparoscopic/robotic correction, and 82.52% (67.53-93.57%) after vaginal correction. Hysteroscopic surgery was associated with the lowest risk of complications (0.76%, 0.20-1.66%).

CONCLUSIONS

We found adequate evidence supporting the use of surgery for the treatment of symptomatic isthmocele, as it was found to improve the bleeding symptoms in more than 80% of patients. Differently, we found a lack of evidence regarding the role of surgery with the purpose of improving fertility or reducing the risk of obstetric complications in women with asymptomatic isthmocele. The hysteroscopic correction of isthmocele may be the safest and most effective strategy in those patients with adequate residual myometrial thickness overlying the isthmocele. Laparoscopic and vaginal surgeries may be the preferred options for patients with a thinner residual myometrium over the defect (< 2.5 mm) and when hysteroscopic treatment is inconclusive.

Clinical outcomes of hysteroscopy-assisted transvaginal repair of cesarean scar defect

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.

Association of Menstrual Extension and Surgery Effectiveness with Ultrasound Parameters of Cesarean Section Scar Diverticulum in Patients Undergoing Transvaginal Uterine Diverticulum Repair

The association of residual myometrium thickness (RMT) and scar defect depth (D) with menstrual abnormalities and the effectiveness of vaginal repair remain to be determined in patients with cesarean section scar diverticulum (CSD). To assess the value of ultrasound to predict vaginal repair effectiveness. This was a retrospective study of patients with CSD treated with vaginal repair between 01/2014 and 02/2016 at Shanghai First Maternity and Infant Hospital (Tongji University). Transvaginal ultrasound was performed before and 3 months after surgical repair. RMT, D, scar defect length (L), and scar defect width (W) were measured. Width (W), D, and L increased along the duration of menstrual period (P < 0.05). When the menstrual extension time was ≥15 days, RMT/D and RMT/(RMT + D) were smaller than in patients with period <15 days (P < 0.05). L was the most positively correlated ultrasonic parameter with menstrual prolongation (r = 0.492). RMT/D and RMT/(RMT + D) were negatively correlated with prolonged menstruation (r = ‐0.304 and -0.305, respectively). RMT/D and RMT/(RMT + D) were associated with the disappearance of CSD after vaginal repair (P < 0.05). The cutoff value of RMT/(RMT + D) was 0.496, with sensitivity of 53.0% and specificity of 61.4%. L of CSD is closely correlated with menstrual extension but has no relationship with the effectiveness of surgery. RMT/(RMT + D) is correlated with menstrual extension time ≥15 days and the effectiveness of vaginal repair.

Niche-related outcomes after caesarean section and quality of life: a focus group study and review of literature

Background

A niche in the uterus, present in 60% of women after caesarean section (CS), is associated with several gynaecological symptoms and possibly with subfertility. Studies that focus on quality of life (QoL) in relation to a niche are lacking.

Purpose

To identify niche-related outcomes that influence QoL and to compare patient-reported outcomes with outcomes studied in the literature.

Methods

Two focus group discussions (FGDs, N = 8 and 5) were conducted in Amsterdam UMC—location VUmc. Participants were Dutch patients with a large niche, with (planned) surgical treatment for their symptoms. Niche-related symptoms and impact on functioning or participation were fixed topics. The transcripts of the FGDs were coded into outcomes, themes and domains of QoL according to the WHOQOL model. Additionally, participants created a top five important outcomes. Next, we performed a systematic review (SR) on niche-related outcomes and compared the FGDs with niche-related outcomes from the SR.

Results

In four domains (physical health, psychological domain, social relationships and environment), fifteen themes were reported in the FGDs. Abnormal uterine bleeding (AUB), subfertility, sexual activity, abdominal pain and self-esteem were themes prioritised by participants. In the literature, gynaecological symptoms and reproductive outcomes were predominantly studied. Sexuality and self-esteem were prioritised in the FGDs but hardly or never studied in the literature.

Conclusion

We found a broad range of niche-related outcomes influencing QoL. Apart from symptoms evaluated in the literature such as AUB, abdominal pain and subfertility, clinicians and researchers should be more aware of sexual activity and self-esteem in this population.

Electronic supplementary material

The online version of this article (10.1007/s11136-019-02376-6) contains supplementary material, which is available to authorized users.

Gynecological and postpartum ultrasonography of cesarean uterine scar defects: a pictorial essay

There is an increasing incidence of cesarean scar defect. This article will discuss and show different and variable sonographic presentations of scar niches and uterine postpartum ultrasonography with vaginal birth after cesarean section that can be confusing and many should be unaware of. This brief review aims to help practitioners to avoid confusion and be aware and acquainted with the different sonographic findings encountered in practice related to cesarean scar. It can lead to uterine rupture I labour, dehiscence in pregnancy and placenta accreta in the future pregnancy, but this is not evidence-based and not even a contraindication for pregnancy. It is neither an indication of repair for the presenting patient nor an indication to screen these patients for such complications. It is treated if associated with infertility or bleeding and not in asymptomatic ones.

Isthmocele: an overview of diagnosis and treatment

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.

Comparison of transvaginal repair versus laparoscopic repair of lower-segment cesarean scar defects

OBJECTIVE

To evaluate transvaginal repair versus laparoscopic repair of cesarean scar defects (CSDs).

METHODS

A retrospective cohort study was conducted among 67 symptomatic women with CSDs who attended a tertiary hospital in Beijing, China, between July 1, 2013, and March 31, 2017. The participants underwent either transvaginal repair (n=31) or laparoscopic repair (n=36). Medical costs, perioperative outcomes, and surgical outcomes were compared.

RESULTS

No statistically significant between-group differences were found at baseline. The mean thickness of the residual myometrium increased from 1.71 ± 0.67 mm before surgery to 4.41 ± 2.09 mm after surgery in the transvaginal repair group (P<0.001), and from 1.81 ± 0.93 to 4.68 ± 1.96 mm in the laparoscopic repair group (P<0.001). The duration of menses after surgery was less than 10 days in both the transvaginal repair group (n=30, 96.3%) and the laparoscopic repair group (n=30, 83.9%; P=0.113). Operative time and medical costs were both lower in the transvaginal repair group than in the laparoscopic repair group (P<0.001). Conception rates for the two groups were similar among women who desired fertility.

CONCLUSION

Transvaginal repair of CSD was associated with reduced operative times and medical costs when compared with laparoscopic repair.

Mini-invasive transvaginal repair of isthmocele: a video case report

OBJECTIVES

To describe our technique for transvaginal treatment of isthmocele.

DESIGN

Surgical video article. Local Institutional Review Board approval for the video reproduction was obtained.

SETTING

A scientific institute.

PATIENT(S)

A 26-year-old patient complaining of abnormal uterine bleeding and pelvic pain was referred to our gynecological clinic for secondary infertility. At transvaginal ultrasound examination, a cesarean scar defect of 22 × 11 mm was identified, with a residual myometrial thickness over the defect of 2 mm.

INTERVENTION(S)

Isthmocele excision and myometrial repair was performed transvaginal, under regional anesthesia. Before surgery, a hysteroscopy was performed to identify the dehiscence of the cesarean scar on the anterior wall of the uterus and to confirm the presence of the isthmocele and its distance from the external os. Then an incision was made at the anterior cervicovaginal junction and the bladder was dissected away until the anterior peritoneal reflection was identified. Hysteroscopic guidance by transillumination was used to identify the exact position and the limits of the isthmocele. The fibrotic tissue was then removed, and the myometrial defect was closed with interrupted sutures by using 2-0 Vicryl, engulfing the myometrial fibers that would tend to slide laterally. The vaginal mucosa was then sutured with interrupted Vicryl 2-0 sutures. At the end of the procedure, a hysteroscopy was performed to visualize the correction of the defect and to prove the continuity of the cervical canal with the uterine cavity.

MAIN OUTCOME MEASURES(S)

Repair of isthmocele and relief of symptoms.

RESULT(S)

The postoperative course was uneventful, and the patient was discharged the day after surgery. At 1-month follow-up pelvic ultrasound showed complete anatomic repair of the uterine defect. The patient was asymptomatic with no more postmenstrual bleeding. She is satisfied with the treatment and is still trying for pregnancy.

CONCLUSION(S)

Symptomatic isthmocele can be treated surgically via a hysteroscopic, laparoscopic, or vaginal approach, depending on the clinical findings and the skill set and comfort level of the surgeon. Unfortunately, there is no consensus about the ideal surgical approach. The hysteroscopic approach has been demonstrated to be effective for the treatment of abnormal uterine bleeding; however, it does not strengthen the uterine wall and it has a risk of bladder injury. The laparoscopic approach provides good anatomic results, but it requires general anesthesia and may be associated with bladder injury. The transvaginal approach appears to be a feasible, effective, and safe modality to repair the uterine defect and to restore the original thickness of the myometrium. It is a minimally invasive, scarless, and low-cost procedure. It ensures quick recovery and a relatively pain-free postoperative course with early return to normal function.

Isthmocele: From Risk Factors to Management

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.

Cornual uterine diverticulum following a failed pregnancy

The discovery of a uterine diverticulum is a rare event. Diverticula can lead to outcomes including pelvic pain, ectopic pregnancy, and diverticula rupture and should be considered in cases of uterine cystic masses. We report a case of a 32-year-old G3P0030 with a complicated pregnancy and surgical history who presented to us following an abnormal laparoscopy for severe pelvic pain four years after salpingectomy for a tubal pregnancy. This laparoscopy reported a cornual uterine cystic structure. Saline infusion sonohysterography was performed with fluid filling a uterine cornual cystic mass. On hysteroscopy, no outpouching was identified. With chromopertubation on laparoscopy, methylene blue filled the diverticulum. The diverticulum was laparoscopically removed. Pathology examination was consistent with a diverticulum containing a placental implantation site and necrotic chorionic villi.

Hysteroscopy combined with laparoscopy in treatment of patients with post-cesarean section uterine diverticulum

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.

Treatment for Uterine Isthmocele, A Pouchlike Defect at the Site of a Cesarean Section Scar

An isthmocele appears as a fluid pouchlike defect in the anterior uterine wall at the site of a prior cesarean section and ranges in prevalence from 19% to 84%, a direct relation to the increase in cesarean sections performed worldwide. Many definitions have been suggested for the dehiscence resulting from cesarean sections, and we propose standardization with a single term for all cases-isthmocele. Patients are not always symptomatic, but symptoms typically include intermittent abnormal bleeding, pain, and infertility. Pregnancy complications that result from an isthmocele include ectopic pregnancy, low implantation, and uterine rupture. Magnetic resonance imaging and transvaginal ultrasound are the gold standard imaging techniques for diagnosis. Surgical treatment of an isthmocele is still a controversial issue but should be offered to symptomatic women or the asymptomatic patient who desires future pregnancy. When surgery is the treatment choice, laparoscopy guided by hysteroscopy, hysteroscopy alone, or vaginal repair are the best options depending on the isthmocele's characteristics and surgeon expertise.

Hysteroscopy in the treatment of uterine cesarean section scar diverticulum: A systematic review

The aim of this paper is to review and to analyze the results of previous studies dealing with hysteroscopic treatment of postcesarean scar defects. A systematic review of publications indexed in MEDLINE/PubMed database identified a total of 11 studies dealing with resectoscopic treatment of postcesarean scar defect. The review was conducted in line with the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines and the PRISMA statement. In only few studies, patients were qualified for hysteroscopic surgery based on the measurement of the defect depth and thickness of residual myometrium above the pouch. Two principal techniques were used for the hysteroscopic treatment: resection of one edge of the scar diverticulum, and resection of the inferior and superior edges of the defect. Additionally, most authors performed electrocauterization of the niche bottom. Resectoscopic treatment turned out to be highly effective in the case of women with AUB. No complications of the hysteroscopic procedure have been reported. Methodological value of the reviewed studies was relatively low due to non-unified selection/verification criteria and incomplete, non-systematic postoperative assessment. In conclusion, hysteroscopic treatment seems to be a promising option in the management of postcesarean scar defects, but still further research is needed on the problem in question.

Laparoscopic isthmocele treatment - single center experience

INTRODUCTION

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

AIM

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Laparoscopic repair with hysteroscopy of cesarean scar diverticulum

AIM

The aim of this study was to investigate the clinical data of laparoscopic repair with hysteroscopy of cesarean scar diverticulum (CSD).

METHODS

We retrospectively evaluated 49 patients with CSD in our hospital who had undergone laparoscopic repair with hysteroscopy from January 2014 to June 2015. All patients had a history of cesarean section deliveries and prolonged postmenstrual spotting (duration 16.1 ± 3.4 days). The diagnosis of CSD was established by using 2-D transvaginal ultrasound.

RESULTS

All patients underwent the surgical repair successfully, without evident complications. The mean operation time was 90.4 ± 9.1 min, the mean volume of blood loss was 31.2 ± 14.3 mL, and the mean length of hospital stay was 4.1 ± 0.3 days. All patients were followed for 6 months after the operation; the mean duration of menstruation was 7.5 ± 2.5 days shorter on average than the pre-surgical menstrual days, and the difference was statistically significant (P = 0.001). According to the clinical symptoms assessment, 89.8% (44/49) of the surgeries were effective, while according to the anatomic assessment, 95.9% (47/49) were effective.

CONCLUSION

Laparoscopic repair with hysteroscopy of CSD was confirmed to be a safe, effective, and minimally invasive treatment, and should be widely used to treat patients with CSD.

Prospective evaluation of five methods used to treat cesarean scar defects

OBJECTIVE

To evaluate operative and nonoperative therapies for cesarean scar defects (CSDs).

METHODS

A prospective study was conducted among patients who underwent treatment of CSDs at a hospital in Shanghai, China, between April 1, 2010, and December 31, 2014. Treatment included laparoscopy (group 1), vaginal surgery (group 2), hysteroscopy (group 3), combined oral contraceptives (group 4), and the levonorgestrel intrauterine system (group 5).

RESULTS

Among 142 participants, 119 patients underwent surgical repair and 23 received nonsurgical (conservative) treatment. Operation time, blood loss, and length of hospital stay reported for patients in group 3 (n=19) were all lower than those reported for patients in group 1 (n=86) and group 2 (n=14; P<0.001 for all comparisons). Patients who underwent surgery and those in group 4 (n=18) experienced shortened menstrual periods after treatment (P<0.001 for all comparisons). For group 5 (n=5), the duration of menstruation was similar before and after therapy (P=0.89). All 32 women who desired fertility underwent laparoscopy; 12 (37.5%) became pregnant after this procedure.

CONCLUSION

All treatments for CSDs other than the levonorgestrel intrauterine system shortened menstrual periods. Laparoscopic surgery was effective for patients with fertility requirements.

Efficacy of transvaginal debridement and repair surgery for cesarean scar pregnancy: a cohort study compared with uterine artery embolism

OBJECTIVE

Compared with uterine artery embolism (UAE), we aimed to investigate the efficacy and safety of transvaginal debridement and repair surgery (TDRS) and analyze the association between postoperative recovery and individual related factors.

METHODS

A total of 128 patients diagnosed with cesarean scar pregnancy (CSP) from January 2006 to June 2014 were divided into 2 groups. Group A: 38 cases were treated with UAE. Group B: 90 cases were treated with TDRS, of whom 41 received preoperative chemotherapy.

RESULTS

The failure rate in Group A was 5.3% (2/38) and the 2 cases of secondary vaginal hemorrhage after UAE were cured by hysterectomy and TDRS respectively. All patients were successfully treated in Group B and the postoperative outcomes of the patients who received preoperative chemotherapy showed no statistically differences compared with those who didn't. The hospital stays, serumβ-hCG and menstruation recovery in Group B were significantly shorter than those in Group A (P<0.001). In Group B, there was no significant correlation between serumβ-hCG recovery, menstruation recovery and individual related factors including serumβ-hCG, gestational age and maximum diameter of gestational sac at diagnosis.

CONCLUSION

Compared with UAE, TDRS is safer, more effective and with a rapider recovery. As an alternative therapeutic option, its prognosis isn't associated with some individual related factors. Furthermore, preoperative chemotherapy is unnecessary.