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Candiani M, Dolci C, Schimberni M, Bartiromo L, Villanacci R, Grisafi G, Tandoi I, Salvatore S, Ferrari SM. Reproductive outcomes after vaginal repair of isthmocele: A preliminary study and systematic review of the literature. Eur J Obstet Gynecol Reprod Biol 2024; 296:163-169. [PMID: 38447278 DOI: 10.1016/j.ejogrb.2024.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 02/06/2024] [Accepted: 02/11/2024] [Indexed: 03/08/2024]
Abstract
OBJECTIVE Although vaginal repair of isthmocele is an effective and safe surgical option, data on reproductive and obstetrical outcomes are lacking. The aim of this study is to evaluate reproductive outcomes of women undergone vaginal repair of isthmocele. We also systematically reviewed the existent literature to offer a general view of available data. STUDY DESIGN Retrospective analysis of a database prospectively collected between January 2018 and January 2022 at San Raffaele Hospital, Milan, Italy. We included secondary infertile women with ultrasound documented isthmocele who undergone vaginal repair. Post-surgical clinical, reproductive and obstetric outcomes were recorded. An advanced systematic search of the literature up to January 2023 was conducted. RESULTS 17 women were included. The mean age of the included patients was 37.2 ± 2.7 years. The median of previous caesarian sections was 1 (1-2). One intra-operative complication (5.9 %) was reported (bladder injury, repaired at the time of surgery). At follow up, bleeding was successfully treated in 8 women (8/10; 80 %). Pregnancy was obtained in 7 women (7/17; 41.2 %): the conception was spontaneous in 4 women (4/7; 57.1 %) and trough assisted reproductive technology in 3 patients (3/7; 42.9 %). The mean time from surgery to pregnancy was 10.8 (±6.7) months. One spontaneous abortion was reported (1/7; 14.3 %), while live birth was achieved in 6 pregnancies (6/7; 85.7 %). All deliveries were by caesarian section at a median gestational age of 37.5 (36-38.25) weeks. No obstetrical complications were reported. At the time of caesarean section, no defects on the lower segment were retrieved. Regarding the systematic research, among the 21 studies screened, only 4 articles were included in the review. Pregnancy rate was around 60-70 % with very few obstetrical complications (0.01 %) such as abnormal placentation or preterm birth. CONCLUSIONS Vaginal repair of isthmocele is a minimally invasive, safe and effective surgical approach in terms of postsurgical residual myometrium tichness. Systematic review to date has found low-quality evidences on the impact of vaginal surgery in the management of secondary infertility and obstetrics outcomes in women with isthmocele.
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Affiliation(s)
- Massimo Candiani
- Gynecology/Obstetrics Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Carolina Dolci
- Gynecology/Obstetrics Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy.
| | - Matteo Schimberni
- Gynecology/Obstetrics Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Ludovica Bartiromo
- Gynecology/Obstetrics Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Roberta Villanacci
- Gynecology/Obstetrics Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Giorgia Grisafi
- Gynecology/Obstetrics Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Iacopo Tandoi
- Gynecology/Obstetrics Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Stefano Salvatore
- Gynecology/Obstetrics Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Stefano Maria Ferrari
- Gynecology/Obstetrics Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
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Gezer Ş, Daryal AS, Aksoy L. Effects of endometrial versus non-endometrial suturing on isthmocele development; a randomized controlled trial. J Gynecol Obstet Hum Reprod 2024; 53:102758. [PMID: 38432626 DOI: 10.1016/j.jogoh.2024.102758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 02/24/2024] [Accepted: 02/27/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVE Incomplete healing after cesarean section (CS) can result in isthmocele formation. When suturing the uterus, fully folding the wound lips may embed the endometrial layer into the myometrium, leading to isthmocele development. Hence, this study aimed to compare the effects of endometrial and non-endometrial suturing on isthmocele development. MATERIAL AND METHODS This randomized controlled trial included 274 patients. Women who underwent primary CS were randomly allocated to one of the two study groups: endometrial suturing and non-endometrial suturing. The primary outcome was isthmocele rate at postpartum 6 months. Secondary outcomes were the volume of the isthmocele, thickness of the residual myometrium, menstrual irregularities (intermenstrual spotting), and the relationship between the isthmocele and uterine position. RESULTS A total of 159 patients (81 in the endometrial suturing group and 78 in the non-endometrial suturing group) were analyzed. The incidence of isthmocele was significantly lower in the non-endometrial suturing group than in the endometrial suturing group (12 [15.4%] vs. 24 [29.6%] patients; p = 0.032). Menstrual irregularities, such as intermenstrual spotting, were significantly higher in the endometrial suturing group than in the non-endometrial group (p = 0.019). CONCLUSION Uterine closure with non-endometrial suturing was associated with significantly lower isthmocele development and less intermenstrual spotting compared to that with endometrial suturing.
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Affiliation(s)
- Şener Gezer
- Kocaeli University School of Medicine, Department of Obstetrics and Gynecology, Turkey
| | - Ayşe Seda Daryal
- Kocaeli University School of Medicine, Department of Obstetrics and Gynecology, Turkey
| | - Lale Aksoy
- Department of Obstetrics and Gynecology, Geyve State Hospital, Geyve, Turkey
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Vitagliano A, Cicinelli E, Viganò P, Sorgente G, Nicolì P, Busnelli A, Dellino M, Damiani GR, Gerli S, Favilli A. Isthmocele, not cesarean section per se, reduces in vitro fertilization success: a systematic review and meta-analysis of over 10,000 embryo transfer cycles. Fertil Steril 2024; 121:299-313. [PMID: 37952914 DOI: 10.1016/j.fertnstert.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 10/14/2023] [Accepted: 11/06/2023] [Indexed: 11/14/2023]
Abstract
IMPORTANCE Previous reviews have shown that a history of cesarean section (CS) is associated with a worse in vitro fertilization (IVF) prognosis. To date, whether the decline in the IVF chances of success should be attributed to the CS procedure itself or to the presence of isthmocele remains to be clarified. OBJECTIVE To summarize the available evidence regarding the impact of isthmocele on IVF outcomes. DATA SOURCES Electronic databases and clinical registers were searched until May 30, 2023. STUDY SELECTION AND SYNTHESIS Observational studies were included if they assessed the effect of isthmocele on IVF outcomes. Comparators were women with isthmocele and women without isthmocele with a previous CS or vaginal delivery. Study quality was assessed using the modified Newcastle-Ottawa Scale. MAIN OUTCOMES The primary outcome was the live birth rate (LBR). The effect measures were expressed as adjusted odds ratios (aORs) and unadjusted odds ratios (uORs) with 95% confidence intervals (95% CIs). The body of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation working group methodology. RESULTS Eight studies (n = 10,873 patients) were included in the analysis. Women with isthmocele showed a lower LBR than both women with a previous CS without isthmocele (aOR, 0.62; 95% CI, 0.53-0.72) and those with a history of vaginal delivery (aOR, 0.55; 95% CI, 0.42-0.71). The LBRs in women with a previous CS without isthmocele and those with a history of vaginal delivery were similar (aOR, 0.74; 95% CI, 0.47-1.15). Subgroup analysis suggested a negative effect of the intracavitary fluid (ICF) in women with isthmocele on the LBR (uOR, 0.36; 95% CI, 0.18-0.75), whereas the LBRs in women without ICF and those without isthmocele were similar (uOR, 0.94; 95% CI, 0.61-1.45). CONCLUSION AND RELEVANCE We found moderate quality of evidence (Grading of Recommendations Assessment, Development and Evaluation grade 3/4) supporting a negative impact of isthmocele, but not of CS per se, on the LBR in women undergoing IVF. The adverse effect of isthmocele on IVF outcomes appears to be worsened by ICF accumulation before embryo transfer. CLINICAL TRIAL REGISTRATION NUMBER CRD42023418266.
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Affiliation(s)
- Amerigo Vitagliano
- 1(st) Unit of Obstetrics and Gynecology, Department of Interdisciplinary Medicine (DIM), University of Bari, Bari, Italy
| | - Ettore Cicinelli
- 1(st) Unit of Obstetrics and Gynecology, Department of Interdisciplinary Medicine (DIM), University of Bari, Bari, Italy
| | - Paola Viganò
- Infertility Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Giuseppe Sorgente
- 1(st) Unit of Obstetrics and Gynecology, Department of Interdisciplinary Medicine (DIM), University of Bari, Bari, Italy
| | - Pierpaolo Nicolì
- 1(st) Unit of Obstetrics and Gynecology, Department of Interdisciplinary Medicine (DIM), University of Bari, Bari, Italy
| | - Andrea Busnelli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy; IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy
| | - Miriam Dellino
- 1(st) Unit of Obstetrics and Gynecology, Department of Interdisciplinary Medicine (DIM), University of Bari, Bari, Italy
| | - Gianluca Raffaello Damiani
- 1(st) Unit of Obstetrics and Gynecology, Department of Interdisciplinary Medicine (DIM), University of Bari, Bari, Italy
| | - Sandro Gerli
- Section of Obstetrics and Gynecology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Alessandro Favilli
- Section of Obstetrics and Gynecology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy.
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David MS, Vintejoux E, Kucharczak F, Brouillet S, Rougier N, Huberlant S. Impact of Caesarean section on pregnancy outcomes in ART after transfer of one or more frozen blastocysts. J Gynecol Obstet Hum Reprod 2024; 53:102692. [PMID: 37979690 DOI: 10.1016/j.jogoh.2023.102692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 10/03/2023] [Accepted: 11/15/2023] [Indexed: 11/20/2023]
Abstract
INTRODUCTION The prevalence of Caesarean delivery is rising steadily worldwide, and it is important to identify its future impact on fertility. A number of articles have been published on this subject, but the impact of Caesarean section on reproductive outcomes is still under debate, and none of these articles focus exclusively on frozen blastocysts. OBJECTIVE The aim of this study was to evaluate the impact of a previous Caesarean delivery compared with a previous vaginal delivery on the chances of a live birth following the transfer of one or more frozen embryos at the blastocyst stage. METHODS This was a retrospective, bicentric study at the University Hospitals of Nîmes and Montpellier, conducted between January 1st, 2016 and February 1st, 2021. Three hundred and ninety women with a history of childbirth and a transfer of one or more frozen embryos at blastocyst stage were included in the analysis. The primary outcome was the number of live births. Secondary outcomes were: the rate of positive HCG, miscarriage, ectopic pregnancy and clinical pregnancy, as well as the live birth rate according to the presence or absence of an isthmocele. RESULTS Of the 390 patients included, 118 had a previous Caesarean delivery and 272 a vaginal delivery. No statistically significant differences were found for the primary (p = 0.9) or secondary outcomes. A trend towards lower live birth rates was observed in patients with isthmoceles, but this did not reach significance (p>0.9). On the other hand, transfers were more often described as difficult in the Caesarean delivery group (p = 0.011). CONCLUSION Our study found no effect of previous Caesarean delivery on the chances of live birth after transferring one or more frozen blastocysts. However, further prospective studies are needed to confirm these results.
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Affiliation(s)
- Marie-Sophie David
- Department of reproductive medicine, Obstetrics and Gynecology, CHU Arnaud de Villeneuve, 371 avenue du Doyen Gaston Giraud, Montpellier, France; Department of Obstetrics and Gynecology, CHU Nîmes, University of Montpellier, Nîmes, France
| | - Emmanuelle Vintejoux
- Department of reproductive medicine, Obstetrics and Gynecology, CHU Arnaud de Villeneuve, 371 avenue du Doyen Gaston Giraud, Montpellier, France
| | - Florentin Kucharczak
- Department of Biostatistics, Epidemiology, Public Health and Innovation in Methodology (BESPIM), CHU Nîmes, University of Montpellier, Nîmes, France
| | - Sophie Brouillet
- Laboratory of Medically Assisted Reproduction, CHU Arnaud de Villeneuve, 371 avenue du Doyen Gaston Giraud, Montpellier, France
| | - Nathalie Rougier
- Laboratory of Medically Assisted Reproduction, CHU Nîmes, University of Montpellier, Nîmes, France
| | - Stéphanie Huberlant
- Department of Obstetrics and Gynecology, CHU Nîmes, University of Montpellier, Nîmes, France; University of Nîmes-Montpellier, France.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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] [What about the content of this article? (0)] [Affiliation(s)] [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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Gozzi P, Hees KA, Berg C, David M, Wernecke KD, Hellmeyer L, Schlembach D. Frequency and associated symptoms of isthmoceles in women 6 months after caesarean section: a prospective cohort study. Arch Gynecol Obstet 2023; 307:841-8. [PMID: 36350429 DOI: 10.1007/s00404-022-06822-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 10/10/2022] [Indexed: 11/11/2022]
Abstract
PURPOSE The purpose of this study was to determine the frequency of detection of isthmoceles by ultrasound 6 months after caesarean section (CS) and which symptoms associated with isthmocele formation occur after CS. Subsequently, it was determined how often the ultrasound finding "isthmocele" coincided with the presence of complaints. METHODS A prospective multicentre cohort study was conducted with 546 patients from four obstetric centres in Berlin, who gave birth by primary or secondary CS from October 2019 to June 2020. 461 participants were questioned on symptoms 3 months after CS; 329 participants were included in the final follow-up 6 months after CS. The presence of isthmoceles was determined by transvaginal sonography (TVS) 6 months after CS, while symptoms were identified by questionnaire. RESULTS Of the 329 women, 146 (44.4%) displayed an isthmocele in the TVS. There was no statistically significant difference in the manifestation of symptoms between the two groups of women with and without isthmocele; however, when expressed on a scale from 1 to 10 the intensity of both scar pain and lower abdominal pain was significantly higher in the set of women that had shown to have developed an isthmocele (p = 0.014 and p = 0.031, respectively). CONCLUSION The prevalence of isthmoceles 6 months after CS was 44.4%. Additionally, scar pain and lower abdominal pain were more pronounced when an isthmocele was also observed in the TVS. TRIAL REGISTRATION Trial registration number DRKS00024977. Date of registration 17.06.2021, retrospectively registered.
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Mohamed Siraj SH, Tan KH, Wright AM. Conservative surgical approach towards placenta accreta spectrum disorders for uterine preservation. BMC Pregnancy Childbirth 2023; 23:28. [PMID: 36641463 PMCID: PMC9840328 DOI: 10.1186/s12884-023-05370-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 01/11/2023] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVE We previously described a technique for repair of the myometrial defect at repeat Caesarean section which increases residual myometrial thickness thereby potentially reducing future niche-related complications. Here we describe how this technique can be modified for use for placenta accreta spectrum disorders, in line with emerging evidence that this is more a disorder of myometrial deficiency than morbid adherence. DESIGN The surgical performance of peripartum hysterectomy was compared with that of the modified technique in all women having repeat Caesarean delivery for placenta accreta spectrum disorder in a tertiary unit in Singapore between December 2019 and October 2021. METHODS Modification of the original technique involved the systematic delivery of the placenta starting from its most posterior attachment after uterine exteriorization. This is followed by the identification, mobilization, and apposition of the boundaries of myometrial defects as described previously. RESULTS Ten women had Caesarean hysterectomy and ten had Caesarean section using the modified approach. Age and gestational age at delivery were similar for the two groups. Women in the modified technique group had had fewer prior Caesarean sections and had a lower body mass index. Operating time, estimated blood loss and need for transfusion were all lower in the myometrial repair group but without statistical significance. There were no visceral injuries in the repair group but there was one bladder injury in the hysterectomy group. CONCLUSION The modified approach provides an effective alternative to peripartum hysterectomy with favourable surgical profile and allows uterine conservation with restoration of myometrial thickness.
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Affiliation(s)
- Shahul Hameed Mohamed Siraj
- grid.414963.d0000 0000 8958 3388Department of Minimally invasive Surgery Unit, Division of Obstetrics and Gynaecology, KK Women’s and Children’s Hospital, 100 Bukit Timah Road, Singapore, 229899 Singapore
| | - Kok Hian Tan
- grid.414963.d0000 0000 8958 3388Department of Maternal Fetal Medicine, Division of Obstetrics and Gynaecology, KK Women’s and Children’s Hospital, 100 Bukit Timah Road, Singapore, 229899 Singapore ,grid.428397.30000 0004 0385 0924OBGYN Academic Clinical Programme, DUKE-NUS Medical School, 8 College Road, Singapore, 169857 Singapore
| | - Ann M Wright
- grid.414963.d0000 0000 8958 3388Department of Maternal Fetal Medicine, Division of Obstetrics and Gynaecology, KK Women’s and Children’s Hospital, 100 Bukit Timah Road, Singapore, 229899 Singapore
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Murji A, Sanders AP, Monteiro I, Haiderbhai S, Matelski J, Walsh C, Abbott JA, Munro MG, Maheux-Lacroix S. Cesarean scar defects and abnormal uterine bleeding: a systematic review and meta-analysis. Fertil Steril 2022; 118:758-766. [PMID: 35985862 DOI: 10.1016/j.fertnstert.2022.06.031] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 06/26/2022] [Accepted: 06/28/2022] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To synthesize the published literature to better understand the association between cesarean scar defects (CSDs) and abnormal uterine bleeding (AUB). In particular, we aimed to evaluate the risk and pattern(s) of CSD-associated AUB in addition to exploring the relationship between defect morphology with bleeding symptoms. DESIGN Systematic review and meta-analysis. SETTING Not applicable. PATIENTS Patients with CSD and reports of uterine bleeding as an outcome were identified in 60 studies from database searches. INTERVENTIONS Studies that investigated CSD (as defined by investigators) and reported uterine bleeding, menstrual bleeding, or AUB as an outcome were included. MAIN OUTCOME MEASURES The prevalence and risk of AUB (intermenstrual, postmenstrual, and unscheduled bleeding) in patients with confirmed CSD. RESULTS Nine studies reported on the prevalence of AUB in patients with a confirmed CSD. Patients with CSD were more likely to experience AUB, compared with those without CSD (relative risk, 3.47; 95% confidence interval [CI], 2.02-5.97; 6 studies, 1,385 patients; I2 = 67%). In a population of patients with at least 1 cesarean delivery, the prevalence of AUB in those with CSD was 25.5% (95% CI, 14.7-40.5; 6 studies, 667 patients, I2 = 93%). However, symptom prevalence was much higher in patients presenting for imaging for a gynecologic indication where the prevalence of AUB in the presence of a CSD was 76.4% (95% CI, 67.8-83.3; 5 studies, 505 patients; I2 = 71%). The mean menstrual duration in symptomatic patients with CSD was 13.4 days (95% CI, 12.6-14.2; 19 studies, 2,095 patients; I2 = 96%), and the mean duration of early-cycle intermenstrual bleeding was 6.8 days (95% CI, 5.7-7.8 days; 9 studies, 759 patients; I2 = 93%). The most common descriptor of CSD-associated AUB was "brown discharge". Patients with larger CSD experienced more bleeding symptoms. CONCLUSION There is a strong and consistent association between patients with CSD and AUB. These patients experience a unique bleeding pattern, namely prolonged menstruation and early-cycle intermenstrual bleeding. These data should provide impetus for including CSD as a distinct entity in AUB classification systems. High heterogeneity in our results calls for standardization of nomenclature and outcome reporting for this condition.
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Affiliation(s)
- Ally Murji
- Department of Obstetrics and Gynaecology, University of Toronto, Mount Sinai Hospital, Toronto, Ontario, Canada.
| | - Ari P Sanders
- Department of Obstetrics and Gynecology, University of Calgary, Peter Lougheed Centre, Calgary, Alberta, Canada
| | - Ilza Monteiro
- Department of Obstetrics and Gynecology, University of Campinas Faculty of Medical Sciences (UNICAMP), Campinas, SP, Brazil
| | - Shabbir Haiderbhai
- Department of Obstetrics and Gynaecology, University of Toronto, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - John Matelski
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Chris Walsh
- Department of Obstetrics and Gynaecology, University of Toronto, Mount Sinai Hospital, Toronto, Ontario, Canada; Sidney Liswood Library, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Jason A Abbott
- School of Women's and Children's Health University of New South Wales (UNSW), Sydney, Australia
| | - Malcolm G Munro
- Department of Obstetrics & Gynecology, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
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Gencer FK, Dincgez B, Yuksel S. Levonorgestrel-Releasing Intrauterine Device Use Can Be a Treatment Option in Symptomatic Patients with Isthmocele. Reprod Sci 2022; 29:2977-2982. [PMID: 35610461 DOI: 10.1007/s43032-022-00976-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 05/16/2022] [Indexed: 11/26/2022]
Abstract
Levonorgestrel-releasing intrauterine devices have been used for contraception and treatment of heavy menstrual bleeding. There is only limited data about the effect of this on isthmocele. Here, we aimed to evaluate the effect of levonorgestrel-releasing intrauterine devices in a larger study population with a longer follow-up as compared to the literature on symptomatic patients with isthmocele. A total of 29 patients with symptomatic isthmocele and inserted levonorgestrel-releasing device were included in this prospective study. All patients were included at January 2020 and followed for 18 months. Sociodemographic findings, laboratory parameters, premenstrual spotting, postmenstrual spotting, menorrhagia, dysmenorrhea, and pelvic pain related to isthmocele were recorded. In sonography, width, length, area of isthmocele, and residual myometrial thickness were determined. The frequency of symptoms during follow-up was compared between visits and also compared between groups according to residual myometrial thickness. Premenstrual spotting and pelvic pain were significantly reduced at 6th months (48.3 to 10.3%, p = 0.007 and 34.5 to 10.3%, p = 0.039, respectively) and no significant change was detected until the end of follow-up period. Postmenstrual spotting reduced at 6th months (96.6 to 34.5%, p < 0.001) and also significant change was detected between 6 and 12th months (34.5% vs 13.8%, p = 0.031). Menorrhagia and dysmenorrhea disappeared at 12th months. No association was found between residual myometrial thickness and the frequency of symptoms for each follow-up. Levonorgestrel-releasing intrauterine devices are useful and reliable therapeutic tools for symptomatic isthmocele patients who do not desire fertility, regardless of residual myometrial thickness.
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Affiliation(s)
- Fatma Ketenci Gencer
- Department of Obstetrics and Gynecology, Istanbul Gaziosmanpasa Training and Research Hospital, University of Health Sciences, Hizirefendi Street, Gaziosmanpasa, 34255, Istanbul, Turkey.
| | - Burcu Dincgez
- Department of Obstetrics and Gynecology, Bursa Yuksek Ihtisas Training and Research Hospital, University of Health Sciences, Bursa, Turkey
| | - Semra Yuksel
- Department of Obstetrics and Gynecology, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
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11
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Piriyev E, Schiermeier S, Römer T. Laparoscopic Isthmocele (Niche) Correction as prevention in patients with fertility desire. Ginekol Pol 2022; 93:954-961. [PMID: 35315009 DOI: 10.5603/gp.a2021.0250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 12/21/2021] [Accepted: 12/29/2021] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVES To report the technique of Laparoscopic Isthmocele (Niche) Correction and surgical outcomes. MATERIAL AND METHODS The retrospective study included only patients with current or potential fertility desire who had laparoscopic surgery for an isthmocele at the Academic Hospital Cologne Weyertal between the beginning of 2014 and the end of 2020. A total of 28 patients were included. Sonographic follow-up of myometrial thickness was performed in 67% cases. RESULTS In 18% cases myometrial thickness was 5-7 mm, in 11% cases > 7-10 mm and in 39% cases > 10 mm. In the group with postoperative myometrium of 5-7 mm, two patients had preoperative residual myometrium of 2 mm, one patient of 2.5 mm and in one patient residual myometrium was not measurable (< 1 mm). In 11 patients, the postoperative myometrium was either greater than 10 mm and/or no isthmoceles were detectable. There was an increase in mean preoperative myometrial thickness from 2 mm to a mean myometrial thickness of 8.7 mm (myometrial thickness increase to 335%). CONCLUSIONS In this study, laparoscopic correction of the isthmocele resulted in an increase in myometrial thickness from 2 mm to 8.7 mm (average values). This represents an increase in myometrial thickness of 335%. According to the literature review performed and based on our own results, we recommend prophylactic isthmoceles correction in patients with fertility desire by means of laparoscopic procedure. Laparotomy should be performed only in special cases. Surgical hysteroscopy is not suitable for this purpose, but sufficient studies are still lacking.
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Affiliation(s)
- Elvin Piriyev
- University Witten Herdecke, Witten, Germany. .,Evangelisches Klinikum Köln Weyertal, Weyertal, Köln, Germany.
| | | | - Thomas Römer
- Evangelisches Klinikum Köln Weyertal, Weyertal, Köln, Germany
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Gupta T, Singal K, Gupta N, Kohli S, Kanyal M. Comparative Study of USG and MRI in Evaluation of Isthmocele. J Obstet Gynaecol India 2021; 71:292-296. [PMID: 34408349 DOI: 10.1007/s13224-021-01433-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 01/11/2021] [Indexed: 10/22/2022] Open
Abstract
Objective To study the presence of isthmocele in post-cesarean women using USG and MRI and its correlation with risk factors. Method This was a prospective observational study. A total of 90 patients were enrolled at the time of discharge of cesarean delivery and were advised to come for follow-up at 3-4 months for detection of isthmocele. A total of 82 patients reported for follow-up, and TVS and MRI Pelvis were done for visualization of isthmocele. If isthmocele was diagnosed, its correlation with risk factors was studied. Results On TVS isthmocele was present in 11 patients and on MRI in 16 patients. Detection rate was 77.07% in comparison with previous studies. Compared to MRI, sensitivity of USG was 68.75%; however, the specificity and positive predictive value for both were 100%. The negative predictive value for USG compared to MRI was 92.96%. Shape of the isthmocele was triangular in most women. Obesity, prior history of cesarean delivery, elective cesarean, gestational diabetes, preeclampsia and prolonged active labor were associated with development of isthmocele. Conclusion The study concluded that yield of diagnosis of isthmocele by MRI was better than TVS but not statistically significant. Further study with large sample size is needed to identify the best tool for diagnosis of isthmocele. Obesity, gestational diabetes, preeclampsia, prior history of cesarean, elective cesarean and prolonged active labor were associated with development of isthmocele.
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Affiliation(s)
- Taru Gupta
- Department of Obstetrics & Gynaecology, ESI PGIMSR Basaidarapur, New Delhi, India
| | - Khushbu Singal
- Department of Obstetrics & Gynaecology, ESI PGIMSR Basaidarapur, New Delhi, India
| | - Nupur Gupta
- Department of Obstetrics & Gynaecology, ESI PGIMSR Basaidarapur, New Delhi, India
| | - Supreeti Kohli
- Department of Radiology, ESI PGIMSR Basaidarapur, New Delhi, India
| | - Monica Kanyal
- Department of Obstetrics & Gynaecology, ESI PGIMSR Basaidarapur, New Delhi, India
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Alessandri F, Evangelisti G, Centurioni MG, Gustavino C, Ferrero S, Barra F. Fishbone double-layer barbed suture in cesarean section: a help in preventing long-term obstetric sequelae? Arch Gynecol Obstet 2021; 304:573-6. [PMID: 34146146 DOI: 10.1007/s00404-021-06121-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Due to the high number of cesarean sections over the last two decades, there has been a growing awareness of the post-surgical obstetric long-term sequelae (i.e., uterine scar defects and abnormal placentation) following this surgical procedure. Knotless barbed suture is an absorbable bidirectional and unidirectional monofilament, characterized by the presence of "barbs" along its length. After being introduced in gynecology, the favorable features of the knotless barbed suture, such as the uniform distribution of tensile force, provide the rationale for studying its benefits in obstetric surgery. Recently, our research group has investigated a double-layer barbed suture ("fishbone" suture) for closing the uterine wall during cesarean section by a case-control study, reporting a low incidence of uterine scar defects and a reduced size of defects in women who had developed them (NCT04825821). In the near future, large prospective studies are strongly awaited to investigate reproductive outcomes and long-term sequelae after cesarean section performed with knotless barbed suture.
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Tahermanesh K, Mirgalobayat S, Aziz-Ahari A, Maleki M, Hashemi N, Samimi M, Fazel Anvari-Yazdi A, Shahriyaripour R, Pecks U, Allahqoli L, Alkatout I. Babu and Magon uterine closure technique during cesarean section: A randomized double-blind trial. J Obstet Gynaecol Res 2021; 47:3186-3195. [PMID: 34131999 DOI: 10.1111/jog.14889] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 05/22/2021] [Accepted: 05/29/2021] [Indexed: 11/29/2022]
Abstract
AIM We compared the effectiveness of the Babu and Magon uterine closure technique and unlocked double-layer uterine closure on the integrity and thickness of the uterine scar. METHODS A randomized double-blind trial was performed at Hazrat-e Rasoul -e-Akram Hospital, Tehran, Iran, from March 2018 to December 2019, in 72 pregnant women who were candidates for cesarean section for the first time. Women were randomly assigned to the Babu and Magon uterine closure technique (intervention group, n = 34) or double-layer closure of the uterine incision (control group, n = 38). The primary outcome of the study was the frequency of myometrial defects at the site of the scar (niche), and a large niche. Secondary outcomes, including the time taken for uterine closure and postpartum hemorrhage (early and late), were compared between groups. RESULTS Adjacent myometrium thickness (AMT) between the two groups was not statistically significant. A niche was reported in 23.5% (8/34) and 50% (19/38) of women in the intervention and controls, respectively (p = 0.02). A large niche was reported in 2.9% (1/34) and 23.7% (9/38) of women in the intervention and controls, respectively (p < 0.01). The duration of uterine closure was not statistically significant between the two groups. Hemoglobin levels did not differ significantly between groups during the first 24 h post-surgery. CONCLUSION The results of the study showed that the technique of uterine closure is one of the main potential determinants of myometrial healing. The Babu and Magon uterine closure technique seems to lead to tissue alignment during suturing and consequently cause better myometrial healing, although this issue calls for well-founded longer studies of appropriate design.
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Affiliation(s)
- Kobra Tahermanesh
- Endometriosis Research Center, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Shahla Mirgalobayat
- Endometriosis Research Center, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Alireza Aziz-Ahari
- Department of Radiology, Rasoul Akram Hospital, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Maryam Maleki
- School of Medicine, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Neda Hashemi
- Endometriosis Research Center, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Mansooreh Samimi
- Department of Gynecology and Obstetrics, School of Medicine, Kashan University of Medical Sciences, Kashan, Iran
| | - Abbas Fazel Anvari-Yazdi
- Division of Biomedical Engineering, College of Engineering, University of Saskatchewan, Saskatoon, Canada
| | - Roya Shahriyaripour
- Endometriosis Research Center, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Ulrich Pecks
- Department of Obstetrics and Gynecology, University Hospitals Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Leila Allahqoli
- School of Public Health, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Ibrahim Alkatout
- Department of Obstetrics and Gynecology, University Hospitals Schleswig-Holstein, Campus Kiel, Kiel, Germany
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Harjee R, Khinda J, Bedaiwy MA. Reproductive Outcomes Following Surgical Management for Isthmoceles: A Systematic Review. J Minim Invasive Gynecol 2021; 28:1291-1302.e2. [PMID: 33839308 DOI: 10.1016/j.jmig.2021.03.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/11/2021] [Accepted: 03/28/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To evaluate the efficacy of surgical management for isthmoceles in patients presenting with secondary infertility. DATA SOURCES A systematic search was performed in MEDLINE, EMBASE, and Cochrane Library databases from inception to May 2020. The search was limited to studies published in English. METHODS OF STUDY SELECTION After the removal of duplicates, 3380 articles were screened for inclusion independently by 2 authors. These 2 authors assessed for studies which focused on women of reproductive age with a diagnosed isthmocele and secondary infertility who underwent any surgical intervention for defect repair with at least 1 of the goals being fertility restoration. TABULATION, INTEGRATION, AND RESULTS A total of 13 studies, comprising of 1 randomized controlled trial, 6 prospective case series, and 6 retrospective case series describing 234 patients who underwent surgical management for an isthmocele and secondary infertility were included. The methodologic quality of the included studies was assessed independently by both reviewers. Next, the data extraction was performed independently and then compared to ensure no discrepancies. A total of 188 patients were treated by hysteroscopy, 36 by laparoscopy, 7 by laparotomy, and 3 through a vaginal approach. In total, 153 of the 234 patients (65.4%) achieved pregnancy across all studies within their respective study periods. Pregnancy rates in the randomized controlled trial were 21 of 28 (75%) for those treated by hysteroscopy compared with 9 of 28 (32%) for those untreated. Among the studies reporting pregnancy outcomes, 101 of 116 (87.1%) pregnancies resulted in a live birth. The incidence of adverse events was 2%, including the risk of reoperation. CONCLUSION The results of this systematic review suggest that the surgical treatment of an isthmocele, particularly through hysteroscopy, in patients with residual myometrial thickness of at least 2.5 mm, may be effective in treating isthmocele-associated secondary infertility with a relatively low complication rate. Further high-quality studies are needed because of the small sample sizes and observational nature of most available data.
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Affiliation(s)
- Rahana Harjee
- Department of Obstetrics & Gynaecology (Dr. Harjee); Faculty of Medicine (Mr. Khinda); Division of Reproductive Endocrinology & Infertility, Department of Obstetrics & Gynaecology (Dr. Bedaiwy), University of British Columbia, Vancouver, British Columbia, Canada
| | - Jaskaran Khinda
- Department of Obstetrics & Gynaecology (Dr. Harjee); Faculty of Medicine (Mr. Khinda); Division of Reproductive Endocrinology & Infertility, Department of Obstetrics & Gynaecology (Dr. Bedaiwy), University of British Columbia, Vancouver, British Columbia, Canada
| | - Mohamed A Bedaiwy
- Department of Obstetrics & Gynaecology (Dr. Harjee); Faculty of Medicine (Mr. Khinda); Division of Reproductive Endocrinology & Infertility, Department of Obstetrics & Gynaecology (Dr. Bedaiwy), University of British Columbia, Vancouver, British Columbia, Canada.
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Karakuş R, Karakuş SS, Güler B, Ünver G, Özkaya E. Myometrial thickness overlying cesarean scar pregnancy is significantly associated with isthmocele formation in the third month of the postoperative period. Turk J Obstet Gynecol 2021; 18:37-43. [PMID: 33715331 PMCID: PMC7962161 DOI: 10.4274/tjod.galenos.2021.65288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Objective: To determine some associated factors for isthmocele formation 3 months after the treatment of cesarean scar pregnancy (CSP). Materials and Methods: This is a prospective consecutive case series of CSP managed by fertility preservation modalities at a single tertiary care center from May 2016 to March 2019 (n=95). Patients with a diagnosis of CSP were identified and followed prospectively to collect data on the patients’ demographics; detailed medical, surgical, and social history; symptoms; imaging and laboratory parameters at the time of CSP diagnosis and during treatment; treatment modalities, myometrial thickness; and outcomes in terms of isthmocele formation. Results: Mean myometrial thickness overlying scar pregnancy was significantly lower in the group with isthmocele formation, and the mean gestational age of scar pregnancy was also significantly lower in the group with isthmocele formation following treatment of scar pregnancy (p<0.05). Multivariate regression analysis was conducted to determine associations between certain variables and isthmocele development, which revealed that the gestational age of scar pregnancy and myometrial thickness were significantly associated with isthmocele formation. Conclusion: Myometrial thickness and gestational age of scar pregnancy were significantly associated with isthmocele formation 3 months after treatment.
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Affiliation(s)
- Resul Karakuş
- University of Health Sciences Turkey, Zeynep Kamil Women and Children's Diseases Training and Research Hospital, Clinic of Obstetrics and Gynecology, İstanbul, Turkey
| | - Sultan Seren Karakuş
- University of Health Sciences Turkey, Zeynep Kamil Women and Children's Diseases Training and Research Hospital, Clinic of Obstetrics and Gynecology, İstanbul, Turkey
| | - Burak Güler
- University of Health Sciences Turkey, Zeynep Kamil Women and Children's Diseases Training and Research Hospital, Clinic of Obstetrics and Gynecology, İstanbul, Turkey
| | - Gökhan Ünver
- University of Health Sciences Turkey, Zeynep Kamil Women and Children's Diseases Training and Research Hospital, Clinic of Obstetrics and Gynecology, İstanbul, Turkey
| | - Enis Özkaya
- University of Health Sciences Turkey, Zeynep Kamil Women and Children's Diseases Training and Research Hospital, Clinic of Obstetrics and Gynecology, İstanbul, Turkey
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Kathopoulis N, Chatzipapas I, Samartzis K, Theodora M, Lardou I, Protopapas A. Laparoscopic management of cesarean scar pregnancy: Report of two cases with video-presentation of different operative techniques and literature review. J Gynecol Obstet Hum Reprod 2021; 50:102066. [PMID: 33484933 DOI: 10.1016/j.jogoh.2021.102066] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 01/06/2021] [Accepted: 01/07/2021] [Indexed: 11/30/2022]
Abstract
Cesarean scar pregnancy (CSP) is a rare form of ectopic pregnancy. We present two different techniques of laparoscopic management of CSP, with the concomitant repair of the coexisting uterine isthmocele. The first case is a combination of diagnostic hysteroscopy and laparoscopic extraction of conception products, and the second technique is a combination of laparoscopy and guided Dilation & Curettage. We also conducted a thorough review of the literature to present all cases of laparoscopic treatment of CSP, focusing on the surgical technique, the operation outcome, and the future pregnancies. Laparoscopy is a potential effective treatment of CSP.
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Affiliation(s)
- Nikolaos Kathopoulis
- Endoscopic Surgery Unit, 1st Department of Obstetrics & Gynecology, National and Kapodistrian University of Athens, "Alexandra" Hospital, Athens, Greece.
| | - Ioannis Chatzipapas
- Endoscopic Surgery Unit, 1st Department of Obstetrics & Gynecology, National and Kapodistrian University of Athens, "Alexandra" Hospital, Athens, Greece
| | - Konstantinos Samartzis
- Endoscopic Surgery Unit, 1st Department of Obstetrics & Gynecology, National and Kapodistrian University of Athens, "Alexandra" Hospital, Athens, Greece
| | - Marianna Theodora
- Unit of Gynecological Ultrasound, 1st Department of Obstetrics & Gynecology, National and Kapodistrian University of Athens, "Alexandra" Hospital, Athens, Greece
| | - Ioanna Lardou
- Endoscopic Surgery Unit, 1st Department of Obstetrics & Gynecology, National and Kapodistrian University of Athens, "Alexandra" Hospital, Athens, Greece
| | - Athanasios Protopapas
- Endoscopic Surgery Unit, 1st Department of Obstetrics & Gynecology, National and Kapodistrian University of Athens, "Alexandra" Hospital, Athens, Greece
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Kulshrestha V, Agarwal N, Kachhawa G. Post-caesarean Niche ( Isthmocele) in Uterine Scar: An Update. J Obstet Gynaecol India 2020; 70:440-6. [PMID: 33417629 DOI: 10.1007/s13224-020-01370-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [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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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Mashiach R, Burke YZ. Optimal Isthmocele Management: Hysteroscopic, Laparoscopic, or Combination. J Minim Invasive Gynecol 2021; 28:565-74. [PMID: 33152531 DOI: 10.1016/j.jmig.2020.10.026] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [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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Hosseini R, Mansoorli S, Pirjani R, Eslamian L, Rabiee M. A comparison of the effects of Two suture materials on isthmocele formation: A cohort study. J Gynecol Obstet Hum Reprod 2021; 50:101933. [PMID: 33068769 DOI: 10.1016/j.jogoh.2020.101933] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 09/25/2020] [Accepted: 09/30/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Cesarean scar defects (CSD) are a problem that may lead to complications and excessive cost. The optimal way to suture the uterus is a matter of debate. The aim of this study was to evaluate the effect of two suture materials on cesarean scar niches. STUDY DESIGN This was a cohort study that allocated women into two groups: uterotomy closure with vicryl or catgut sutures. Transvaginal ultrasound (TVUS) was performed six months after the cesarean section (CS) to assess the scar. RESULTS Totally, 250 patients enrolled in this study. After six months, 20 (18.2 %) patients in the catgut suture group and 13 (9.3 %) patients in the vicryl group had isthmocele according to their sonography reports. The prevalence of isthmocele was higher in the catgut group (p = 0.03). The residual myometrial thickness was greater in the vicryl group (4.98 cm ± 2.18) compared to the catgut suture group (3.70 cm ± 1.50; p = 0.001). The prevalence of postoperative gynecological sequelae such as postmenstrual spotting and pain were similar between the two groups. CONCLUSION Vicryl sutures were associated with a lower risk of CSD formation in comparison with catgut sutures.
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Abstract
OBJECTIVES The disruption or defect of the myometrium in the uterine scar of a cesarean section (CS) has been known by various names, such as uterine niche, isthmocele, deficient uterine scar, scar pouch, or diverticulum. Symptomatology, risk factors for niche development, and available treatment modalities have been recently studied. However, the histologic features of this disease remain unknown. METHODS The histologic features of eight uterine niches are thoroughly described and a summary of the most important aspects of the uterine niche literature is provided. Five cases of CS scars without niche formation are comparatively examined. RESULTS Most uterine niches harbor endocervical mucosa, often cystically dilated and/or an atrophic or disorganized endometrial mucosa of lower uterine segment origin. Regenerative epithelial atypia and fibroblastic stromal reaction are frequent features. No granulomatous reaction, important inflammation, or hemorrhage is seen. CS scars without niche formation do not harbor endocervical mucosa or inclusion cysts, fibroblastic stroma, or regenerative atypia. CONCLUSIONS As more prospective studies of uterine niche development and treatment will be conducted, a detailed pathologic report with the criteria proposed herein can be designed.
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Affiliation(s)
| | - Celine Chauleur
- Gynecology and Obstetrics Department, University Hospital of Saint-Etienne, Saint-Etienne, France
| | | | | | - Thomas Corsini
- Gynecology and Obstetrics Department, University Hospital of Saint-Etienne, Saint-Etienne, France
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Asoglu MR, Celik C, Ozturk E, Cavkaytar S, Bahceci M. Impact of Isthmocele on Assisted Reproductive Treatment Outcomes: An Age-matched Retrospective Study. J Minim Invasive Gynecol 2020; 28:1113-1120. [PMID: 33038520 DOI: 10.1016/j.jmig.2020.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 09/01/2020] [Accepted: 10/04/2020] [Indexed: 10/23/2022]
Abstract
STUDY OBJECTIVE To evaluate whether the presence of an ultrasonographic visible isthmocele has an impact on the chance of pregnancy in women undergoing embryo transfer. DESIGN Age-matched retrospective study. SETTING Private-assisted reproductive center. PATIENTS The study included a total of 150 patients with a history of cesarean delivery with 75 isthmocele cases and 75 controls. All patients underwent embryo transfer from January 2017 through June 2018. The diagnosis of isthmocele was based on transvaginal ultrasound assessment. Isthmocele was defined as an anechoic indentation on the previous cesarean scar at the midsagittal plane, with a depth of >1 mm. INTERVENTIONS Embryo transfer. MEASUREMENTS AND MAIN RESULTS The groups were similar in patient and treatment characteristics. The live birth rate was 44% in the isthmocele group and 46.7% in the control group (odds ratio [OR] 0.89; 95% confidence interval [CI], 0.47-1.71; p = .743). The clinical pregnancy rates were 49.3% and 50.7%, respectively (OR, 0.94; 95% CI, 0.50-1.79; p = .870). The miscarriage rate was greater in the isthmocele group (8%) than in the control group (4%); however, it did not reach statistical significance (OR, 2.09; 95% CI, 0.50-8.67; p = .302). The multiple pregnancy rate was similar between the groups (8% vs 5.3%, respectively; OR, 1.54; 95% CI, 0.41-5.70; p = .513). The groups were also similar in ectopic pregnancy rates (p = .560). These outcomes remained similar when adjusted for potential confounders on the regression analysis. CONCLUSION Isthmocele does not seem to have a significant impact on the chance of pregnancy in assisted reproductive treatment settings. However, the embryo transfer procedure may be more difficult in the presence of an isthmocele.
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Affiliation(s)
| | - Cem Celik
- Bahceci Umut Assisted Reproduction Center (Drs. Celik, Ozturk, and Cavkaytar); Department of Obstetrics and Gynecology, School of Medicine, Uskudar University (Dr. Celik), Istanbul, Turkey
| | - Ebru Ozturk
- Bahceci Umut Assisted Reproduction Center (Drs. Celik, Ozturk, and Cavkaytar)
| | - Sabri Cavkaytar
- Bahceci Umut Assisted Reproduction Center (Drs. Celik, Ozturk, and Cavkaytar)
| | - Mustafa Bahceci
- Bahceci Fulya Assisted Reproduction Center (Drs. Asoglu and Bahceci)
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Yoon R, Sasaki K, Miller CE. Laparoscopic Excision of Cesarean Scar Pregnancy with Scar Revision. J Minim Invasive Gynecol 2020; 28:746-747. [PMID: 32603870 DOI: 10.1016/j.jmig.2020.06.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 06/15/2020] [Accepted: 06/18/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To demonstrate our technique for robot-assisted laparoscopic ectopic pregnancy excision and concomitant scar revision. DESIGN We present a stepwise narrated demonstration of our primary laparoscopic technique. SETTING Although cesarean scar pregnancy is rare, it leads to life-threatening complications and often emergent hysterectomy [1,2]. Because of its rarity, there is a scarcity of centers with high-volume experience with its treatment, and no standardized diagnostic or management guidelines are yet available [3,4]. Recent evidence suggests that primary surgical management may be superior to medical or radiologic management as the latter methods carry a high reintervention rate [5]. An additional consideration in selecting a treatment method is a patient's plans for future fertility, as cesarean scar defects are associated with secondary infertility. Evidence shows that repair of cesarean scar defects decreases the likelihood of future recurrence and secondary infertility, thus it may be pertinent to select a management strategy that allows for the accomplishment of both ectopic pregnancy removal and defect revision. We present our primary laparoscopic approach to ectopic pregnancy excision and revision of the cesarean scar defect using techniques rooted in evidence and robust experience. INTERVENTIONS Robot-assisted laparoscopic excision of a cesarean scar ectopic pregnancy with concomitant scar revision demonstrating key strategies to minimize blood loss and preserve future fertility. (1) A laparoscopic approach allows for concomitant ectopic pregnancy removal followed by cesarean scar revision. (2) Generous use of dilute vasopressin and purposeful application of electrosurgical energy provides hemostasis without the use of more invasive measures such as vascular clips or uterine artery balloons. (3) A multilayer closure is associated with a lower risk of wedge defect formation and uterine rupture. (4) Diagnostic hysteroscopy is a useful tool for identifying the location of the scar defect, assessing for an adequate repair, and identifying potential additional uterine pathology. CONCLUSION Primary laparoscopic management is not only the most effective method with the lowest complication rates but is an approach that allows for simultaneous repair and revision of the cesarean scar defect. We demonstrate easily adaptable techniques for maintaining hemostasis, minimizing injury to normal myometrium, and creating multilayer closures that lead to successful revisions with minimal impact to subsequent fertility.
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Affiliation(s)
- Rachel Yoon
- Department of Obstetrics and Gynecology, Advocate Lutheran General Hospital (Dr. Yoon); The Advanced Gynecologic Institute (Drs. Sasaki and Miller), Park Ridge, Illinois
| | - Kirsten Sasaki
- Department of Obstetrics and Gynecology, Advocate Lutheran General Hospital (Dr. Yoon); The Advanced Gynecologic Institute (Drs. Sasaki and Miller), Park Ridge, Illinois
| | - Charles E Miller
- Department of Obstetrics and Gynecology, Advocate Lutheran General Hospital (Dr. Yoon); The Advanced Gynecologic Institute (Drs. Sasaki and Miller), Park Ridge, Illinois.
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Casadio P, Gubbini G, Franchini M, Morra C, Talamo MR, Magnarelli G, Paradisi R, Florio P, Seracchioli R. Comparison of Hysteroscopic Cesarean Scar Defect Repair with 26 Fr Resectoscope and 16 Fr Mini-resectoscope: A Prospective Pilot Study. J Minim Invasive Gynecol 2020; 28:314-319. [PMID: 32512208 DOI: 10.1016/j.jmig.2020.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 05/30/2020] [Accepted: 06/02/2020] [Indexed: 01/03/2023]
Abstract
STUDY OBJECTIVE Several studies have been published on hysteroscopic treatment of cesarean scar defect using the 26 Fr resectoscope. This study compared the effects of the 26 Fr resectoscope with those of the 16 Fr mini-resectoscope in terms of efficacy, safety profile, and peri- and postoperative complications. DESIGN A prospective cohort study. SETTING Tertiary care university hospital (S. Orsola-Malpighi, Bologna, Italy). PATIENTS Three hundred and nine women having symptoms and with a cesarean scar defect diagnosis were divided into 2 groups according to a temporal criterion: from March 2012 to March 2015, 155 consecutive women (control group) underwent isthmoplasty with the 26 Fr resectoscope (Karl Storz, Tuttlingen, Germany), whereas from April 2015 to March 2018, 154 consecutive women (study group) underwent isthmoplasty with the 16 Fr mini-resectoscope (Gubbini system, Tontarra Medizintechnik, Tuttlingen, Germany). INTERVENTIONS One hundred and fifty-five women (control group) underwent isthmoplasty with the 26 Fr resectoscope, and 154 women (study group) underwent isthmoplasty with the 16 Fr mini-resectoscope. The so-called "channel-like" 360° endocervical resection technique was applied. MEASUREMENTS AND MAIN RESULTS The isthmoplasty time with the 2 resectoscopes, excluding cervical dilatation, was similar (p = .25), whereas the overall surgical time was shorter in the case of the mini-resectoscope. The use of the 16 Fr mini-resectoscope was significantly associated with a reduced volume of distension medium used (p <.001) and a lower fluid absorption (p <.001). A significant increase (p = .01) in postoperative complications in the control group (9/155; 5.8%) compared with the study group (1/154; 0.7%) was also found. No significant reduction in discharge time was observed between the 2 groups (p = .13). Patient satisfaction immediately after surgery was significantly higher (p <.001) in the study group than in the control group. CONCLUSION Isthmoplasty with a 16 Fr mini-resectoscope seems to be as effective as isthmoplasty with a 26 Fr resectoscope in reducing postmenstrual abnormal uterine bleeding and suprapubic pelvic pain. It is associated with a significant reduction in overall surgical time owing to the non-necessity of performing cervical dilatation. The 16 Fr mini-resectoscope facilitates surgery in small anatomical spaces such as the cervical canal and reduces the complication rate linked to blind maneuvers not respecting the uterine anatomy.
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Affiliation(s)
- Paolo Casadio
- Gynecology and Human Reproduction Physiopathology Unit, S. Orsola Hospital, University of Bologna (Drs. Casadio, Morra, Talamo, Magnarelli, Paradisi, and Seracchioli)
| | - Giampietro Gubbini
- Department of Gynecology, Madre Fortunata Toniolo Clinic, Bologna (Dr. Gubbini)
| | - Mario Franchini
- Department of Obstetrics and Gynecology, Tuscany Health Agency, Florence (Dr. Franchini)
| | - Ciro Morra
- Gynecology and Human Reproduction Physiopathology Unit, S. Orsola Hospital, University of Bologna (Drs. Casadio, Morra, Talamo, Magnarelli, Paradisi, and Seracchioli).
| | - Maria Rita Talamo
- Gynecology and Human Reproduction Physiopathology Unit, S. Orsola Hospital, University of Bologna (Drs. Casadio, Morra, Talamo, Magnarelli, Paradisi, and Seracchioli)
| | - Giulia Magnarelli
- Gynecology and Human Reproduction Physiopathology Unit, S. Orsola Hospital, University of Bologna (Drs. Casadio, Morra, Talamo, Magnarelli, Paradisi, and Seracchioli)
| | - Roberto Paradisi
- Gynecology and Human Reproduction Physiopathology Unit, S. Orsola Hospital, University of Bologna (Drs. Casadio, Morra, Talamo, Magnarelli, Paradisi, and Seracchioli)
| | - Pasquale Florio
- Department of Obstetrics and Gynecology, S. Jacopo Hospital, Pistoia (Dr. Florio), Italy
| | - Renato Seracchioli
- Gynecology and Human Reproduction Physiopathology Unit, S. Orsola Hospital, University of Bologna (Drs. Casadio, Morra, Talamo, Magnarelli, Paradisi, and Seracchioli)
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Gurbuz AS, Gode F, Ozcimen N. Non-Invasive Isthmocele Treatment: A New Therapeutic Option During Assisted Reproductive Technology Cycles? J Clin Med Res 2020; 12:307-314. [PMID: 32489506 PMCID: PMC7239582 DOI: 10.14740/jocmr4140] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 04/17/2020] [Indexed: 12/26/2022] Open
Abstract
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.
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Affiliation(s)
- Ali Sami Gurbuz
- Department of Obstetrics and Gynaecology, KTO Karatay University Medical Faculty, Konya, Turkey.,Novafertil IVF Center, Konya, Turkey
| | - Funda Gode
- Department of Obstetrics and Gynecology, Bahcesehir University Medical Faculty, Istanbul, Turkey
| | - Necati Ozcimen
- Department of Obstetrics and Gynaecology, KTO Karatay University Medical Faculty, Konya, Turkey
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Nyangoh Timoh K, Enderle I, Leveque J, Lavoue V. [Robotic-assisted laparoscopy using hysteroscopy treatment of a residual cesarean scar pregnancy and isthmocele]. Gynecol Obstet Fertil Senol 2020; 48:460-461. [PMID: 32156670 DOI: 10.1016/j.gofs.2020.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Indexed: 06/10/2023]
Affiliation(s)
- K Nyangoh Timoh
- Department of Obstetrics and Gynecology, Rennes Hospital. Rennes University 1, Rennes, France; Université de Rennes 1, 2, avenue de Professeur Léon-Bernard, 35000 Rennes, France; Équipe thématique SAFE, CIC 1414, Rennes, France.
| | - I Enderle
- Department of Obstetrics and Gynecology, Rennes Hospital. Rennes University 1, Rennes, France; Université de Rennes 1, 2, avenue de Professeur Léon-Bernard, 35000 Rennes, France; Équipe thématique SAFE, CIC 1414, Rennes, France
| | - J Leveque
- Department of Obstetrics and Gynecology, Rennes Hospital. Rennes University 1, Rennes, France; Université de Rennes 1, 2, avenue de Professeur Léon-Bernard, 35000 Rennes, France; Équipe thématique SAFE, CIC 1414, Rennes, France
| | - V Lavoue
- Department of Obstetrics and Gynecology, Rennes Hospital. Rennes University 1, Rennes, France; Université de Rennes 1, 2, avenue de Professeur Léon-Bernard, 35000 Rennes, France; Équipe thématique SAFE, CIC 1414, Rennes, France
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Vitale SG, Ludwin A, Vilos GA, Török P, Tesarik J, Vitagliano A, Lasmar RB, Chiofalo B. From hysteroscopy to laparoendoscopic surgery: what is the best surgical approach for symptomatic isthmocele? A systematic review and meta-analysis. Arch Gynecol Obstet 2020; 301:33-52. [PMID: 31989288 DOI: 10.1007/s00404-020-05438-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 01/13/2020] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Salvatore Giovanni Vitale
- Obstetrics and Gynecology Unit, Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy.
| | - Artur Ludwin
- Department of Gynecology and Oncology, Jagiellonian University, Krakow, Poland.,Ludwin & Ludwin Gynecology, Private Medical Center, Krakow, Poland
| | - George Angelos Vilos
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Péter Török
- Faculty of Medicine, Institute of Obstetrics and Gynaecology, University of Debrecen, Debrecen, Hungary
| | | | - Amerigo Vitagliano
- Unit of Gynecology and Obstetrics, Department of Women and Children's Health, University of Padua, Padua, Italy
| | - Ricardo Bassil Lasmar
- Department of Surgery and Specialities, Federal Fluminense University, Niterói, Brazil
| | - Benito Chiofalo
- Gynecologic Oncology Unit, Department of Experimental Clinical Oncology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
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Vigueras Smith A, Cabrera R, Zomer MT, Ribeiro R, Talledo R, Kondo W. Combined Laparoscopic-Hysteroscopic Isthmoplasty Using the Rendez-vous Technique Guided Step by Step. J Minim Invasive Gynecol 2020; 27:1469-1470. [PMID: 31917331 DOI: 10.1016/j.jmig.2019.12.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 12/16/2019] [Accepted: 12/30/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To demonstrate the surgical technique of Rendez-vous isthmoplasty for the treatment of symptomatic cesarean scar defect. In this video, the authors show the complete procedure in a step-by-step manner to standardize and facilitate the comprehension and performance of the procedure in a simple and safe way. DESIGN Step-by-step video demonstration of the surgical technique. SETTING Private hospital in Curitiba, Paraná, Brazil. INTERVENTIONS The patient is a 36-year-old woman without any comorbidities, G3 C3, and with radiologic transvaginal ultrasound diagnosis of isthmocele grade 3 (over 25 mm) identified in the superior third of the cervical canal. The main steps of combined laparoscopic-hysteroscopic isthmoplasty using the Rendez-vous technique are described in detail. A combined laparoscopic-hysteroscopic approach was performed. Under general anesthesia, the patient was placed in 0° supine decubitus, with her arms alongside her body. Operative setup included 15 mm Hg pneumoperitoneum, created using the closed Veress technique, and 4 trocars: a 10-mm trocar at the umbilicus for a 0° laparoscope, a 5-mm trocar in the right iliac fossa, a 5-mm trocar in the left iliac fossa, and a 5-mm trocar in the suprapubic area. The procedure begins after a systematic exploration of the pelvic and abdominal cavities. Step 1: Identification of key anatomic landmarks and exposure of the operation field. Step 2: By carrying out blunt and sharp dissection with cold scissors or a harmonic scalpel, the visceral peritoneal layer over the isthmus area is opened, a vesicouterine space is developed, and the bladder is pushed down at least 2 cm from the lower edge of the isthmocele. Step 3: Final Phrase: By hysteroscopic exploration of the cervical canal using the vaginoscopic approach, identification and delimitation of the isthmocele its performed by recognizing the diverticular mucosal hyperplasia, and then the hysteroscopic light is pointed directly toward the cephalic limit of the scar defect. Step 4: Laparoscopic lights are decreased in intensity and the "Halloween sign" is identified (hysteroscopic transillumination). The light of the hysteroscope is pointed to the top of the cesarean scar defect allowing the laparoscopist to identify the upper and lower edges of the scar. Step 5: Laparoscopic resection of all scar tissue, excision of all the edges of the pseudo cavity. Step 6: Adequate intracorporeal suturing technique, with a 2-layer myometrial repair using intracorporeal running and interrupted stitches of polydioxanone 2-0, is done, while ensuring preservation of the cavity by not including the endometrial tissue in the myometrial suture [1-3]. Step 7: Installation of the methylene blue dye to locate any leakage. The surgery ended without any intraoperative complications and within 60 minutes. The patient was discharged on the first day postoperatively and became pregnant 6 months after surgery, with a final C-section delivery of a healthy term newborn at 39-weeks gestational age. CONCLUSION Combined Rendez-vous isthmoplasty is feasible, safe, and effective in experienced hands, giving the surgeon a comprehensive evaluation of the anatomy of the isthmocele, and increasing the odds of a complete resection and restoration of the anatomy [4-7]. In this patient, the procedure was uneventful, without any intra- or postoperative complications, and the symptoms were completely controlled.
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Affiliation(s)
- Andres Vigueras Smith
- Department of Gynecological Surgery, Vita Batel Hospital (Drs. Vigueras Smith, Cabrera, Tessmann Zomer, Talledo, and Kondo); Department of Gynecological Surgery, Minimal Invasive Surgery and Oncology Unit, Erasto Gardner Hospital (Dr. Reitan), Curitiba, Brazil.
| | - Ramiro Cabrera
- Department of Gynecological Surgery, Vita Batel Hospital (Drs. Vigueras Smith, Cabrera, Tessmann Zomer, Talledo, and Kondo); Department of Gynecological Surgery, Minimal Invasive Surgery and Oncology Unit, Erasto Gardner Hospital (Dr. Reitan), Curitiba, Brazil
| | - Monica Tessmann Zomer
- Department of Gynecological Surgery, Vita Batel Hospital (Drs. Vigueras Smith, Cabrera, Tessmann Zomer, Talledo, and Kondo); Department of Gynecological Surgery, Minimal Invasive Surgery and Oncology Unit, Erasto Gardner Hospital (Dr. Reitan), Curitiba, Brazil
| | - Reitan Ribeiro
- Department of Gynecological Surgery, Vita Batel Hospital (Drs. Vigueras Smith, Cabrera, Tessmann Zomer, Talledo, and Kondo); Department of Gynecological Surgery, Minimal Invasive Surgery and Oncology Unit, Erasto Gardner Hospital (Dr. Reitan), Curitiba, Brazil
| | - Renzo Talledo
- Department of Gynecological Surgery, Vita Batel Hospital (Drs. Vigueras Smith, Cabrera, Tessmann Zomer, Talledo, and Kondo); Department of Gynecological Surgery, Minimal Invasive Surgery and Oncology Unit, Erasto Gardner Hospital (Dr. Reitan), Curitiba, Brazil
| | - William Kondo
- Department of Gynecological Surgery, Vita Batel Hospital (Drs. Vigueras Smith, Cabrera, Tessmann Zomer, Talledo, and Kondo); Department of Gynecological Surgery, Minimal Invasive Surgery and Oncology Unit, Erasto Gardner Hospital (Dr. Reitan), Curitiba, Brazil
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López Rivero LP, Jaimes M, Camargo F, López-Bayghen E. Successful treatment with hysteroscopy for infertility due to isthmocele and hydrometra secondary to cesarean section: A case report. World J Clin Cases 2019; 7:753-758. [PMID: 30968040 PMCID: PMC6448083 DOI: 10.12998/wjcc.v7.i6.753] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 02/04/2019] [Accepted: 02/26/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND An isthmocele is a scar defect in the uterine wall due to a cesarean section. Its prevalence is unknown, but it has been associated with secondary infertility. Here, we present a case where the patient suffered from an isthmocele that was associated with persistent hydrometra, which developed during in vitro fertilization.
CASE SUMMARY The patient underwent hysteroscopic surgery, which successfully resolved the isthmocele as well as the hydrometra. Afterward, two high-quality, euploid embryos, determined by morphological assessment and pre-implantation genetic diagnostic testing, were transferred. This resulted in uterine pregnancy, as determined byserum β-human chorionic gonadotropin levels on day 14 (180 mU/mL) and ultrasound-confirmed presence of a gestational sac with a positive embryocardia at week 6. The pregnancy reached 36 wk without any complications, and the product was born in good health. We report a successful isthmocele treatment in a patient with secondary infertility, in which the isthmocele was the cause of persistent hydrometra.
CONCLUSION Hydrometra caused by secondary cesarean is an infertility factor, which can be corrected by hysteroscopy plus ablation of the isthmocele.
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Affiliation(s)
| | - Miguel Jaimes
- Instituto de Infertilidad y Genética México SC, Ingenes México City 05320, México
| | - Felipe Camargo
- Instituto de Infertilidad y Genética México SC, Ingenes México City 05320, México
| | - Esther López-Bayghen
- Departamento de Toxicología, Centro de Investigación de Estudios, México City 07360, México
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Candiani M, Ferrari SM, Marotta E, Tandoi I, Ottolina J, Salvatore S. Mini-invasive transvaginal repair of isthmocele: a video case report. Fertil Steril 2019; 111:828-830. [PMID: 30853089 DOI: 10.1016/j.fertnstert.2018.12.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 12/10/2018] [Accepted: 12/12/2018] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Massimo Candiani
- Gynecology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Elena Marotta
- Gynecology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Iacopo Tandoi
- Gynecology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Jessica Ottolina
- Gynecology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Salvatore
- Gynecology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Munro MG, Critchley HOD, Fraser IS. The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions. Int J Gynaecol Obstet 2018; 143:393-408. [PMID: 30198563 DOI: 10.1002/ijgo.12666] [Citation(s) in RCA: 328] [Impact Index Per Article: 54.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 07/23/2018] [Accepted: 09/06/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND The International Federation of Gynecology and Obstetrics (FIGO) systems for nomenclature of symptoms of normal and abnormal uterine bleeding (AUB) in the reproductive years (FIGO AUB System 1) and for classification of causes of AUB (FIGO AUB System 2; PALM-COEIN) were first published together in 2011. The purpose was to harmonize the definitions of normal and abnormal bleeding symptoms and to classify and subclassify underlying potential causes of AUB in the reproductive years to facilitate research, education, and clinical care. The systems were designed to be flexible and to be periodically reviewed and modified as appropriate. OBJECTIVES To review, clarify, and, where appropriate, revise the previously published systems. METHODOLOGY AND OUTCOME To a large extent, the process has been an iterative one involving the FIGO Menstrual Disorders Committee, as well as a number of invited contributions from epidemiologists, gynecologists, and other experts in the field from around the world between 2012 and 2017. Face-to-face meetings have been held in Rome, Vancouver, and Singapore, and have been augmented by a number of teleconferences and other communications designed to evaluate various aspects of the systems. Where substantial change was considered, anonymous voting, in some instances using a modified RAND Delphi technique, was utilized.
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Affiliation(s)
- Malcolm G Munro
- Departments of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, University of California, Los Angeles, CA, USA
- Kaiser Permanente, Los Angeles Medical Center, Los Angeles, CA, USA
| | - Hilary O D Critchley
- MRC Centre for Reproductive Health, The University of Edinburgh, The Queen's Medical Research Institute, Edinburgh, UK
| | - Ian S Fraser
- School of Women's and Children's Health, Royal Hospital for Women, University of New South Wales, Randwick, NSW, Australia
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Park IY, Kim MR, Lee HN, Gen Y, Kim MJ. Risk factors for Korean women to develop an isthmocele after a cesarean section. BMC Pregnancy Childbirth 2018; 18:162. [PMID: 29764452 PMCID: PMC5952596 DOI: 10.1186/s12884-018-1821-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 05/02/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The increase in number of cesarean section (CS) operations has resulted in an increase in cases of isthmocele development. The objective of this study is to determine the risk factors for isthmocele development after CS. METHODS Isthmocele measurements were taken for 404 women with a history of at least one low transverse CS. The following potential risk factors were investigated: patient's age at CS, cause of CS, weeks of gestation at CS, premature rupture of membrane (PROM), phase of labor, type suture (single/double layer), operation time, uterine flexion (anteversion/retroversion), and blood transfusion during operation. A transvaginal ultrasound was carried out to examine the isthmocele in the uterus after CS, including the shape of the isthmocele, residual myometrial thickness, depth and width of isthmocele, cervical thickness, location of the isthmocele, and clinical characteristics. RESULTS In our study population, the isthmocele had a prevalence of 73.8%. Most isthmocele had a triangular (65.4%) or semicircular shape (10.4%). The presence of an isthmocele was significantly associated with repeat CS, premature rupture of membrane (PROM), short operation time, and extent of cervix dilatation at CS. The risk of isthmocele was low in women who had placenta previa totalis (PPT), twin, a long operation time, or a transfusion during the operation. CONCLUSIONS In our study, isthmocele development was significantly associated with repeat CS, PROM, a short operation time, and the extent of cervix dilatation at CS. Therefore, PROM prevention and a more careful uterine closure are needed to reduce the risk of developing an isthmocele after CS.
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Affiliation(s)
- I Y Park
- Department of Obstetrics and Gynecology, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - M R Kim
- Department of Obstetrics and Gynecology, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - H N Lee
- Department of Obstetrics and Gynecology, College of Medicine, Bucheon St. Mary's Hospital, The Catholic University of Korea, 327 Sosa-ro, Bucheon, Gyeonggi-do, 14647, Republic of Korea
| | - Y Gen
- Department of Obstetrics and Gynecology, College of Medicine, Bucheon St. Mary's Hospital, The Catholic University of Korea, 327 Sosa-ro, Bucheon, Gyeonggi-do, 14647, Republic of Korea
| | - M J Kim
- Department of Obstetrics and Gynecology, College of Medicine, Bucheon St. Mary's Hospital, The Catholic University of Korea, 327 Sosa-ro, Bucheon, Gyeonggi-do, 14647, Republic of Korea.
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Cohen SB, Mashiach R, Baron A, Goldenberg M, Schiff E, Orvieto R, Bouaziz J. Feasibility and efficacy of repeated hysteroscopic cesarean niche resection. Eur J Obstet Gynecol Reprod Biol 2017; 217:12-17. [PMID: 28829973 DOI: 10.1016/j.ejogrb.2017.08.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 08/01/2017] [Accepted: 08/06/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Cesarean-induced niche can cause symptoms such as abnormal postmenstrual bleeding, pain and associated infertility. Hysteroscopic niche resection is usually a successful treatment, but can result in a failure to improve symptoms or symptoms can recur. In the present study we aim to evaluate the feasibility, effectiveness, and safety of a second hysteroscopic niche resection for patients in whom an initial hysteroscopic resection failed to improve symptoms. STUDY DESIGN This retrospective cohort study (Canadian Task Force classification II-2) hospital tell hashomer (tertiary center) included all patients who underwent a second hysteroscopic niche resection between 2011 and 2015. MEASUREMENTS Fertility,obstetric outcomes, clinical outcome and complications were compared between the first surgery and the second RESULTS: Eight patients underwent a second hysteroscopy after failure of the first hysteroscopy to resolve symptoms or after recurrence of symptoms. Abnormal uterine bleeding (AUB) was the most common symptom, occurring in all patients. The average number of days of bleeding per cycle were significantly reduced following the second surgery [14.50 (range 8-21days) vs 11.75 (range 8-20days), respectivelyp=0.009]. The second surgery improved symptoms in 6 out of the 8 patients with AUB and 1 of 2 patients with pain. There were no significant differences in fertility and obstetric outcomes between the first and the second surgery and no complications were reported during any of the surgeries. CONCLUSION Reintervention with a second hysteroscopic niche resection is both feasible and effective treatment option following a failed first attempt or recurrence of symptoms. The second surgery improved symptoms, especially AUB, with no consequent detrimental effect on obstetric outcomes on our series.
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Affiliation(s)
- Shlomo B Cohen
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, and Sackler Faculty of Medicine, Tel - Aviv University, Tel-Hashomer 52621, Israel; Herzeliya Medical Center, Herzeliya By the Sea, 46851, Israel
| | - Roy Mashiach
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, and Sackler Faculty of Medicine, Tel - Aviv University, Tel-Hashomer 52621, Israel
| | - Alexandra Baron
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, and Sackler Faculty of Medicine, Tel - Aviv University, Tel-Hashomer 52621, Israel
| | - Motti Goldenberg
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, and Sackler Faculty of Medicine, Tel - Aviv University, Tel-Hashomer 52621, Israel
| | - Eyal Schiff
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, and Sackler Faculty of Medicine, Tel - Aviv University, Tel-Hashomer 52621, Israel
| | - Raoul Orvieto
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, and Sackler Faculty of Medicine, Tel - Aviv University, Tel-Hashomer 52621, Israel
| | - Jerome Bouaziz
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, and Sackler Faculty of Medicine, Tel - Aviv University, Tel-Hashomer 52621, Israel.
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Delaine M, Lecointre L, Akladios CY, Hummel M, Host A, Garbin O. [Laparoscopic treatment of cesarean scar pouch - A case series study of 9 patients]. ACTA ACUST UNITED AC 2017; 45:262-268. [PMID: 28476591 DOI: 10.1016/j.gofs.2017.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 03/21/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To study the effects of laparoscopic repair of isthmoceles acquired after a cesarean section on symptoms and fertility. METHODS This retrospective case series study included symptomatic women (abnormal uterine bleeding and/or pelvic pain and/or infertility) suffering from a large isthmocele and treated laparoscopically in our center. The surgical procedure consisted in resecting the pouch and suturing the scar in 2 layers. The patient follow-up has been realised through the postoperative control, the medical file and a survey, and concerned the evolution of the symptoms and fertility. RESULTS Nine patients have been included, all suffering from large isthmoceles, diagnosed by transvaginal ultrasound associated with hysteroscopy, hysterosalpingography or MRI. Postoperatively, the symptoms disappeared in 78% of the patients. There have been 4 spontaneous pregnancies in 4 patients, 3 of them had been diagnosed with infertility. The median patient medical follow-up lasted 28 months. CONCLUSION The diagnosis of a large isthmocele in patients suffering from invalidant symptoms and infertility should lead to consider a surgical treatment which is an efficient and surgically safe procedure.
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Affiliation(s)
- M Delaine
- Unité de chirurgie gynécologique, pôle de gynécologie obstétrique, hôpitaux universitaires de Strasbourg, Strasbourg, France.
| | - L Lecointre
- Unité de chirurgie gynécologique, pôle de gynécologie obstétrique, hôpitaux universitaires de Strasbourg, Strasbourg, France
| | - C Y Akladios
- Unité de chirurgie gynécologique, pôle de gynécologie obstétrique, hôpitaux universitaires de Strasbourg, Strasbourg, France
| | - M Hummel
- Unité de chirurgie gynécologique, pôle de gynécologie obstétrique, hôpitaux universitaires de Strasbourg, Strasbourg, France
| | - A Host
- Unité de chirurgie gynécologique, pôle de gynécologie obstétrique, hôpitaux universitaires de Strasbourg, Strasbourg, France
| | - O Garbin
- Unité de chirurgie gynécologique, pôle de gynécologie obstétrique, hôpitaux universitaires de Strasbourg, Strasbourg, France
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Raimondo G, Grifone G, Raimondo D, Seracchioli R, Scambia G, Masciullo V. Hysteroscopic treatment of symptomatic cesarean-induced isthmocele: a prospective study. J Minim Invasive Gynecol 2015; 22:297-301. [PMID: 25285773 DOI: 10.1016/j.jmig.2014.09.011] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Revised: 09/23/2014] [Accepted: 09/27/2014] [Indexed: 11/20/2022]
Abstract
An isthmocele, also known as a cesarean scar defect, is an emerging condition that typically affects women with a history of previous cesarean section, and its presence is a novel under-recognized cause of postmenstrual abnormal uterine bleeding and/or pelvic pain. The incidence of symptoms and their resolution after hysteroscopic surgery were evaluated prospectively in 120 consecutive isthmocele patients. Patients included only symptomatic premenopausal women. Transvaginal ultrasound and office hysteroscopy were used to diagnose isthmocele. Operative hysteroscopy was performed to correct the cesarean scar defect, and histologic findings were evaluated. Correction of an isthmocele via operative hysteroscopy was successful in all cases evaluated. Isthmoplasty resulted in the resolution of postmenstrual abnormal uterine bleeding and suprapubic pelvic pain in 80% of patients. In the remaining cases, 7% of patients had an improvement of symptoms, whereas 13% did not obtain any relief. Considering the recent diagnostic recognition of isthmoceles, we conclude that surgical treatment of this pathology by operative hysteroscopy may represent the best choice in symptomatic women because of its minimal invasiveness and beneficial therapeutic results.
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