Pregnancy outcomes after hysteroscopic surgery in women with cesarean scar syndrome

Effectiveness of an articulating laparoscopic needle holder for cesarean scar defect repair

AIM

To evaluate the efficacy of an articulating laparoscopic needle holder in laparoscopic surgery for cesarean scar defect.

METHODS

We performed a retrospective case-control study at the Shiga University of Medical Science. Patients who underwent laparoscopic uterine scar repair were divided into an articulating laparoscopic needle holder (ArtiSential®) group and a rigid needle holder (conventional) group to compare the suture and total operative times. Uterine myometrial suturing involves a double-layer interrupted suture, including a modified Gambee suture for the first layer. We measured the residual myometrial thickness using magnetic resonance imaging preoperatively and at 3 months postoperatively.

RESULTS

Both groups comprised 10 patients each. The time per stitch for the first and second layers was significantly shorter in the ArtiSential group than in the conventional group (median 208 s vs. 403 s, p < 0.0001 and median 17 s vs. 29 s; p < 0.0001, respectively). The total operating time was significantly shorter in the ArtiSential group (mean 188 min vs. 240 min, p = 0.0015). The postoperative residual myometrial thickness (mean 9.1 mm in the ArtiSential group and 9.6 mm in the conventional group) was significantly higher than the preoperative residual myometrial thickness (mean 1.6 mm in the ArtiSential group and 1.6 mm in the conventional group) (p < 0.0001 in both groups).

CONCLUSIONS

An articulating needle holder is useful in laparoscopic surgery for cesarean scar defect, especially when a modified Gambee suture is required.

Effect of hysteroscopic surgery on IVF/ICSI pregnancy outcomes for different cesarean scar diverticulum severity: A retrospective cohort study

OBJECTIVE

To investigate associations between hysteroscopic surgery for patients with varying cesarean scar diverticulum (CSD) severity and in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) embryo transfer (ET) pregnancy outcomes, focusing also on the correlation between the CSD size with its severity, and pregnancy outcomes.

METHODS

A retrospective study was conducted on patients with CSD who underwent IVF/ICSI-ET at a university-based hospital between January 2017 and July 2023. Patients were categorized into four groups based on CSD severity and whether they received hysteroscopic surgery: a mild surgical group (Group A, n = 86), a mild non-surgical group (Group B, n = 30), a moderate-to-severe surgical group (Group C, n = 173), and a moderate-to-severe non-surgical group (Group D, n = 96). Baseline characteristics and pregnancy outcomes were compared among these groups. Correlation assessments were conducted to explore relationships between CSD size with its severity, and pregnancy outcomes.

RESULTS

Compared with Group D, Group C exhibited significantly increased rates of biochemical pregnancy (odds ratio [OR] 1.90; 95% confidence interval [CI] 1.03-3.51, P = 0.041), clinical pregnancy (OR 2.30; 95% CI1.18-4.45; P = 0.014), and live birth (OR 2.77; 95% CI 1.10-7.00, P = 0.031). However, no differences in pregnancy outcomes were observed between Groups A and B. Correlation analyses revealed significant positive associations between CSD severity and its depth, length, width, and volume.

CONCLUSIONS

Patients with moderate-to-severe CSD achieved favorable IVF/ICSI pregnancy outcomes following hysteroscopic surgery. The CSD size was significantly related to its severity.

Knowledge, attitude, and practice of atrial fibrillation in high altitude areas

Background

To investigate the knowledge, attitude, and practice (KAP) of atrial fibrillation (AF) among the general population in high-altitude areas.

Methodology

A web-based cross-sectional study was conducted among the general population in high-altitude areas.

Results

A total of 786 valid questionnaires were enrolled, with a mean age of 34.75 ± 14.16 years. The mean score of knowledge, attitude and practice were 8.22 ± 6.50 (possible range: 0-10), 28.90 ± 5.63 (possible range: 8-40), 34.34 ± 6.44 (possible range: 9-45), respectively. The multivariate analysis showed that knowledge scores (OR = 1.108, 95% CI = 1.075-1.142, p < 0.001), attitude scores (OR = 1.118, 95% CI = 1.081-1.156, p < 0.001), and never smoking (OR = 2.438, 95% CI = 1.426-4.167, p = 0.001) were independently associated with proactive practice. The structural equation modeling (SEM) showed direct effect of knowledge on practice (p = 0.014), and attitude on practice (p = 0.004), while no effect of knowledge on attitude (p = 0.190).

Conclusion

The general population in high-altitude regions had adequate knowledge, positive attitude, and proactive practice towards AF. The SEM was suitable for explaining general population' KAP regarding AF, revealing that knowledge directly and positively affected attitude and practice.

Comparison of clinical effectiveness and subsequent fertility between hysteroscopic resection and vaginal repair in patients with cesarean scar defect: a prospective observational study

OBJECTIVE

To evaluate the clinical effectiveness and pregnancy rate after hysteroscopic resection (HR) and/or vaginal repair (VR) in patients with cesarean scar defect (CSD).

METHODS

This prospective observational study enrolled 191 patients who received CSD surgery in the First affiliated hospital of Sun Yat-sen University between September 2019 to February 2022 (96 in HR and 95 in VR, respectively). Patient follow-up were performed three months after surgery in both groups by transvaginal ultrasound to confirm the presence of fluid in the niche, along with the resolution of prolonged menses at the same time. The primary outcome was the clinical effectiveness between HR and VR, identified by the resolution of prolonged menses.

RESULTS

The rates of niche-fluid disappearance (70.1% vs 60.2%, P = 0.176) and prolonged menses resolution (74.8% vs 80.0%, P = 0.341) were comparable for HR and VR. A subgroup analysis for niche size revealed that HR provides patients with small niche a more favorable rate of menstrual resolution compared to VR (size of niche ≤ 15 mm2, aOR = 3.423, 95% confidence interval [CI] 1.073-10.918), but patients with large niche experience a lower rate of resolution compared to VR (size of niche > 25 mm2, aOR = 0.286, 95% CI 0.087- 0.938). During follow-up, 41 patients who wanted to conceive became pregnant. Kaplan-Meier estimates of the cumulative probability of pregnancy at 12 months and 24 months were 47.1% (95% CI: 34.5%, 58.8%) and 63.8% (95% CI: 52.5%, 72.9%), respectively. The median pregnancy time was 22 months (95% CI: 14.2, 29.8) after VR and 12 months (95% CI: 8.3, 15.7, Gehan-Breslow-Wilcoxon P = 0.021) after HR. Among patients with subsequent infertility, 31.6% achieved pregnancy by unassisted mode and 29.8% by IVF/ICSI. Moreover, among patients with previously failed IVF/ICSI treatment, 60% (12/20) obtained pregnancy, including 71.4% (10/14) after HR and 33.3% (2/6) after VR.

CONCLUSIONS

Hysteroscopic resection is as effective as vaginal repair at relieving symptoms of CSD-associated prolonged menses. Hysteroscopic resection is the modality of choice with an improvement in prolonged menses for small niche, while vaginal might be considered for a large niche. Furthermore, surgical intervention could improve the clinical pregnancy rate of CSD patients. All of these provide evidence for the individualized management of CSD.

The definition, diagnosis, and symptoms of the uterine niche - A systematic review

Of all neonates, 21% are delivered by cesarean section (CS). A long-term maternal complication of an SC is a uterine niche. The aim of this review is to provide an overview of the current literature on imaging techniques and niche-related symptomatology. We performed systematic searches on imaging and niche symptoms. For both searches, 87 new studies were included. Niche evaluation by transvaginal sonography (TVS) or contrast sonohysterography (SHG) proved superior over hysteroscopy or magnetic resonance imaging. Studies that used SHG in a random population identified a niche prevalence of 42%-84%. Niche prevalence differed based on niche definition, symptomatology, and imaging technique. Most studies reported an association with gynecological symptoms, poor reproductive outcomes, obstetrical complications, and reduced quality of life. In conclusion, non-invasive TVS and SHG are the superior imaging modalities to diagnose a niche. Niches are prevalent and strongly associated with gynecological symptoms and poor reproductive outcomes.

A Trimming Technique: A Case Report of a Novel Surgical Approach for Cesarean Scar Dehiscence During Cesarean Section

Cesarean section can lead to residual myometrial thickness thinning and cesarean scar syndrome. We report a novel trimming technique for residual myometrial thickness recovery in women with cesarean scar syndrome. Case 1: A 33-year-old woman who developed cesarean scar syndrome (CSS) and abnormal uterine bleeding post-cesarean scar became pregnant following hysteroscopic treatment. The myometrium at previous scar was dehiscent; therefore, a transverse incision was made above the scar. Post-operative uterine recovery failed owing to lochia retention, and developed cesarean scar syndrome again. Case 2: A 29-year-old woman who developed cesarean scar syndrome post-cesarean section became pregnant spontaneously. The myometrium at the previous scar was dehiscent like case 1. Scar repair was performed using a trimming technique during cesarean section; there were no subsequent complications and she conceived again spontaneously. Performing this novel surgical procedure during cesarean section may contribute to residual myometrial thickness recovery in women with cesarean scar syndrome.

Definition and Criteria for Diagnosing Cesarean Scar Disorder

Importance

Approximately 60% of women develop a uterine niche after a cesarean delivery (CD). A niche is associated with various gynecological symptoms including abnormal uterine bleeding, pain, and infertility, but there is little consensus in the literature on the distinction between the sonographic finding of a niche and the constellation of associated symptoms.

Objective

To achieve consensus on defining the clinical condition that constitutes a symptomatic uterine niche and agree upon diagnostic criteria and uniform nomenclature for this condition.

Design, Setting, and Participants

A consensus based modified electronic Delphi (eDelphi) study, with a predefined Rate of Agreement (RoA) of 70% or higher. Experts were selected according to their expertise with niche-related consultations, publications, and participation in expert groups and received online questionnaires between November 2021 and May 2022.

Main Outcomes and Measures

Definition, nomenclature, symptoms, conditions to exclude, and diagnostic criteria of an illness caused by a symptomatic uterine niche.

Results

In total, 31 of the 60 invited experts (51.7%) participated, of whom the majority worked in university-affiliated hospitals (28 of 31 [90.3%]), specialized in benign gynecology (20 of 31 [64.5%]), and worked in Europe (24 of 31 [77.4%]). Three rounds were required to achieve consensus on all items. All participants underlined the relevance of a new term for a condition caused by a symptomatic niche and its differentiation from a sonographic finding only. Experts agreed to name this condition cesarean scar disorder, defined as a uterine niche in combination with at least 1 primary or 2 secondary symptoms (RoA, 77.8%). Defined primary symptoms were postmenstrual spotting, pain during uterine bleeding, technical issues with catheter insertion during embryo transfer, and secondary unexplained infertility combined with intrauterine fluid. Secondary symptoms were dyspareunia, abnormal vaginal discharge, chronic pelvic pain, avoiding sexual intercourse, odor associated with abnormal blood loss, secondary unexplained infertility, secondary infertility despite assisted reproductive technology, negative self-image, and discomfort during participation in leisure activities. Consensus was also achieved on certain criteria that should be met and conditions that should be excluded before making the diagnosis.

Conclusions and Relevance

In this modified Delphi study, a panel of 31 international niche experts reached consensus for the constellation of symptoms secondary to a uterine niche and named it cesarean scar disorder.

Fertility outcomes after hysteroscopic niche resection compared with expectant management in women with a niche in the uterine cesarean scar

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.

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.

Prediction of Scar Myometrium Thickness and Previous Cesarean Scar Defect Using the Three-Dimensional Vaginal Ultrasound

This research aimed to explore the related factors of scar myometrial thickness and scar diverticulum formation and then predict the occurrence of uterine diverticula. 140 patients with cesarean section were selected as the research objects. According to the three-dimensional (3D) vaginal ultrasound echo and the diagnostic criteria of uterine diverticulum, the research objects were divided into a diverticulum group and a control group, with 70 cases in each group. Data such as age, number of cesarean sections, endometrial thickness, uterine position, and diverticulum size was collected, and their relationship with uterine diverticulum was compared and analyzed. The results showed that there were significant differences in menstrual days, cesarean section times, and uterine position between the two groups (P < 0.05). The height (9.02 ± 2.97), width (14.02 ± 3.08), and depth (5.14 ± 1.23) of the posterior uterine diverticula in the scar diverticulum group were all greater than the anterior uterine height (6.69 ± 1.36), the width (10.69 ± 2.15), and the depth (3.86 ± 0.69), respectively. The residual myometrium thickness in posterior position of the uterus (2.98 ± 0.75) was < anterior position of uterus (3.43 ± 0.47), and the difference was statistically significant (P < 0.05). Multivariate analysis showed that the frequency of cesarean section (1 time, 2 times), uterine position, and abnormal menstruation were independent risk factors in the scar diverticulum group (P < 0.05). In conclusion, menstrual abnormalities, the number of cesarean sections (1 time or twice), and the position of the uterus are independent risk factors for the formation of uterine scar diverticula. The deeper the diverticula, the more likely to have menstrual abnormalities, the more prone to diverticulum in patients with posterior uterus, and the deeper the diverticula in patients with 2 dissections.

Endometriosis and Isthmocele: Common or Rare?

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

Comparison of Diagnostic Efficacy among Transvaginal Sonography, Transabdominal Sonography, and 3.0 T Magnetic Resonance Imaging in Early Cesarean Scar Pregnancy

Objective

To compare the diagnostic efficacy among transvaginal sonography (TVS), transabdominal sonography (TAS), and 3.0 T magnetic resonance imaging (MRI) in early cesarean scar pregnancy (CSP).

Methods

The clinical data of 65 patients initially diagnosed with CSP in our hospital from November 2019 to November 2020 were selected for the retrospective analysis, and all patients received TVS, TAS, and 3.0 T MRI. Taking the pathological findings as the “gold standard”, the diagnostic efficacy of different diagnostic modalities in early CSP was compared.

Results

In terms of the AUC value, the result was 3.0 T MRI > TVS > TAS, and among the three diagnosis methods, 3.0 T MRI had the highest diagnostic specificity, and TVS and 3.0 T MRI had the highest sensitivity; other than intragestational hemorrhage, the detection rates of other signs of disease by TVS and TAS were significantly higher than 3.0 T MRI (P < 0.05).

Conclusion

3.0 T MRI has better diagnostic efficacy in early CSP than TVS and TAS, while TVS and TAS work better in diagnosing uterine bleeding, plumule, yolk sac, and fetal heartbeat than 3.0 T MRI. The results are more beneficial to the guidance on selecting treatment modalities.

Histopathological evaluation of cesarean scar defect in women with cesarean scar syndrome

Purpose

To explore the histopathological findings of cesarean scar defect (CSD) and the immunological component in women with cesarean scar syndrome (CSS).

Methods

This retrospective study was conducted in a university hospital and a public hospital. A total of 63 patients with secondary infertility due to CSS who underwent laparoscopic resection of the CSD lesion were enrolled (CSS group), and 21 patients who underwent hysterectomy with a history of cesarean section were enrolled as control (non-CSS group). We compared the differences in histopathological findings of CSD lesions by hematoxylin and eosin staining and immunohistochemistry for CD3, CD20, CD56, CD68, CD138, myeloperoxidase, and tryptase between the two groups.

Results

The frequency of presence of endometrium on the CSD surface was significantly lower (p = 0.0023) and that of adenomyosis was significantly higher (p = 0.0195) in the CSS group than in the non-CSS group. The number of CD3-, CD20-, CD68-, and tryptase-positive cells was significantly lower in the CSS group than in the non-CSS group; however, the number of CD138-positive cells was significantly higher in the CSS group (p = 0.0042).

Conclusions

This study suggested that the absence of endometrium, presence of adenomyosis, and chronic inflammation in CSD contributes to secondary infertility due to CSS.

[Cesarean scare niche: Definition, diagnosis, risk factors, prevention, symptoms, adverse effects, and treatments]

OBJECTIVES

To review the definitions, diagnostic methods, risk factors, symptoms, and treatments for caesarean scar niche.

METHODS

Review of the literature, critical reflection, and pragmatic advice.

RESULTS

There is no consensus on the definition of caesarean scar niche. Some suggest an indentation≥2mm of the myometrium of the caesarean scar, but this is present in more than half of women with caesarean history and takes no account of woman's symptoms. The most popular diagnostic method is ultrasound±hysterosonography. Risks factors for niche are multiple Caesareans, Cesarean during labor with too low incision, and retroverted uterus. Symptoms include abnormal gynaecologic bleeding and pelvic pain, and their presence establish the "Caesarean scar syndrome". The risks of pregnancy with niche is poorly studied, but pregnancy is not contraindicated, even if the niche is untreated. The treatment of caesarean scar niche is mainly surgery and conservative. The former should be reserved for symptomatic patients, and those with secondary infertility and fertility treatment failure. Patients with residual myometrium thickness≥2.5mm may benefit from first-line hysteroscopic treatment, whereas a laparoscopic or vaginal approach could be offered in other cases.

CONCLUSIONS

A pragmatic definition of caesarean scar niche as a disease including symptoms is the necessary prerequisite for the management of women. The treatment is mainly surgical, or conservative depending on the desire for subsequent pregnancy.