Outcomes of Laparoscopic Treatment in Women with Cesarean Scar Syndrome

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.

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

Supplemental Digital Content is available in the text

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.

Optimal Isthmocele Management: Hysteroscopic, Laparoscopic, or Combination

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.

Association between deficient cesarean delivery scar and cesarean scar syndrome

INTRODUCTION

The aim of our study was to compare long-term morbidity after elective and emergency cesarean delivery (CD).

METHODS

A prospective cohort study was conducted in 200 women delivered by CD. Ultrasound examinations were performed transvaginally at 6 weeks and 18 months after CD. Clinical data were collected at the time of CD and after 18 months.

RESULTS

In the group of 200 women, 29% underwent emergency and 71% elective CD. Then, 6 weeks and 18 months after CD, a severe scar defect was present in 7% and 5%, respectively (P = .4). After 18 months of CD, 17% (34/200) of women had evidence of adhesions of the vesicouterine pouch. Severe CD scar defects were significant predictors for adhesion formation in vesicouterine pouch (OR 3.14, 95% CI, 1.54-4.74), pelvic pain (OR 1.68, 95% CI, 0.22-3.14), dysmenorrhea (OR 2.12, 95% CI, 0.74-3.50), and dyspareunia (OR 1.38, 95% CI, 0.09-2.67). Uterine scar defects detected at 6 weeks after elective CD were detectable at 18 months in only 40% of cases, whereas uterine scar defects after emergency CD were still detectable in 87% of cases.

CONCLUSION

Uterine scar defects are more frequent at 18 weeks after emergency CD, than after elective CD (40% vs 87%). Women with severe scar defects have higher risk of adhesion formation, dysmenorrhea, dyspareunia, and chronic pelvic pain.

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.

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.

Effects of Cesarean Section and Vaginal Delivery on Abdominal Muscles and Fasciae

Background and objectives: Possible disorders after delivery may interfere with the quality of life. The aim of this study was to ascertain whether abdominal muscles and fasciae differ in women depending on whether they experienced transverse cesarean section (CS) or vaginal delivery (VA) in comparison with healthy nulliparous (NU). Materials and methods: The thicknesses of abdominal muscles and fasciae were evaluated by ultrasound in 13 CS, 10 VA, and 13 NU women (we examined rectus abdominis (RA); external oblique (EO); internal oblique (IO); transversus abdominis (TrA); total abdominal muscles (TAM = EO + IO + TrA); inter-rectus distance (IRD); thickness of linea alba (TLA); rectus sheath (RS), which includes anterior fascia of RS and posterior fascia of RS (P-RS); loose connective tissue between sublayers of P-RS (LCT); abdominal perimuscular fasciae (APF), which includes anterior fascia of EO, fasciae between EO, IO, and TrA, and posterior fascia of TrA). Data on pain intensity, duration, and location were collected. Results: Compared with NU women, CS women had wider IRD (p = 0.004), thinner left RA (p = 0.020), thicker right RS (p = 0.035) and APF (left: p = 0.001; right: p = 0.001), and IO dissymmetry (p = 0.009). VA women had thinner RA (left: p = 0.008, right: p = 0.043) and left TAM (p = 0.024), mainly due to left IO (p = 0.027) and RA dissymmetry (p = 0.035). However, CS women had thicker LCT (left: p = 0.036, right: p < 0.001), APF (left: p = 0.014; right: p = 0.007), and right IO (p = 0.028) than VA women. There were significant correlations between pain duration and the affected fasciae/muscles in CS women. Conclusions: CS women showed significant alterations in both abdominal fasciae and muscle thicknesses, whereas VA women showed alterations mainly in muscles. Thinner RA and/or dissymmetric IO, wider IRD, and thicker LCT and APF after CS may cause muscle deficits and alteration of fascial gliding, which may induce scar, abdominal, low back, and/or pelvic pain.

Is it necessary to correct a caesarean scar defect before a subsequent pregnancy? A report of three cases

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.