Hysteroscopic management of symptomatic cesarean scar defects

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The incidence of cesarean scar defect is on the rise with a rising cesarean delivery rate. According to the Center for Disease Control, the current cesarean section rate in the US is 31.9%.

For many years, cesarean scar defect was an accidental finding on hysterosalpingogram and pelvic sonogram, but since last two decades, it has been associated with post-menstrual spotting and bleeding.

The collected blood may result in inflammation leading to chronic pelvic pain, dysmenorrhea, dyspareunia, and vaginal discharge. It also causes secondary sterility possibly because of change in the endometrial milieu which lead to altered cervical mucus, sperm transport and interfere with embryo implantation. It is also responsible for obstetrical complications including abnormal placentation, scar dehiscence, and uterine rupture.

It was in the early 2000s when studies reported resolution of symptoms following surgical management of the defects. Three different routes have been described for the surgical management of cesarean scar defect or isthmocele: laparoscopic; hysteroscopic (when the residual myometrium is equal to or > 3 mm); and vaginal.

No randomized controlled trials have been published to establish the efficacy of one method over another. Some surgeons favor the hysteroscopic method because of its minimally invasive nature, quick recovery, and better resolution of symptoms. Complications involve injury to bladder, incomplete repair and persistence of symptoms.

To avoid these complications most surgeons, prefer this method when the residual myometrium is 3 mm thick or do the repair under ultrasound guidance. A randomized trial by Vervoort et al., comparing hysteroscopic repair vs., expectant management has shown significant improvement in pain and post-menstrual spotting after the repair.

Gubbini et al., have published two case series evaluating the efficacy of hysteroscopic repair of isthmocele in the resolution of postmenstrual symptoms and treatment of secondary infertility.

In the first series all 41 patients (100%) patients conceived with 24 months of completion of hysteroscopic isthmocele repair and in the second series, 26 patients with the defect underwent repair, of whom 7 out of 9 patients with secondary infertility became pregnant.

Those doing laparoscopic repair argue that this approach results in complete and proper resection of the scar tissue followed by the proper approximation of the overlying myometrium. Antagonists argue that the procedure is more invasive and has the inherent risk of bladder injury during separation along with incomplete resolution of symptoms. Evidence so far has demonstrated both methods to be equally effective in reducing symptoms and improving fertility.

In the August issue of Journal Fertility and Sterility, Sanders and Murji have presented two case series with a meticulous video showing hysteroscopic resection of the cesarean scar defect. The video begins with definition, symptoms, and identification of cesarean isthmocele and then proceeds to describe the two cases.

The video systematically identifies the anatomy, resecting the defect cephalad and then caudad, and ablation of the defect at its base.

Here is the video about Hysteroscopic Repair of Cesarean Scar Isthmocele

Flashback: Laparoscopic repair of Cesarean Scar Isthmocele

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A minimal invasive approach in management of symptomatic post–cesarean section isthmocele: a video case report.

courtesy: researchgate.net 

The cesarean section scar defect, also known as an isthmocele, is a reservoir-like pouch defect on the anterior wall of the uterus, located at the site of a previous cesarean delivery scar. It exact incidence is unknown because of scarcity of data about the condition.

It is commonly found on ultrasound examination (24%-88%). It could range from just thinning of the uterine myometrium to large defects leading to complete absence of myometrium.

It could present with abnormal uterine bleeding(AUB), pelvic pain and infertility in post-operative period. Several obstetric complications such as scar dehiscence, placenta accreta, and ectopic scar pregnancy are increasingly reported along with rising cesarean rates.

It is commonly repaired by vaginal surgery, operative hysteroscopic, combined laparoscopic-vaginal, or minimal invasive laparoscopic approach.  In absence of randomized studies, the efficacy of these approaches or superiority of one over another is not known.

A review of data showed that hysteroscopy is able to correct the scar defect but does not increase the uterine wall thickness, whereas laparoscopy is able to increase the uterine wall thickness.  

This video case report by Aimi G. et al. published in June issue of Fertility and Sterility describes a minimal invasive laparoscopic approach for correcting the scar defect.

A 36-year-old woman with history of 2 previous section presented with persistent postmenstrual spotting and chronic pelvic pain. A transvaginal sonography identified a 20.0 × 15.6 mm defect at the place of previous scar with a 2.6 mm remaining myometrial thickness over the defect.

In this case Isthmocele excision and myometrial repair was performed laparoscopically. After mobilization of the bladder, the isthmocele was identified by transrectal intraoperative sonography. Once identified, the isthmocele pouch was excised and contents drained. The cesarean section scar is excised with the help of cold scissors till healthy myometrium is visible. The defect was closed with a single layer of interrupted 2-0 Vycril sutures. A Hegar dilator was placed in cervix to maintain the continuity of uterus with the cervix.  Finally, visceral peritoneum was closed. Total operative time was 70 minutes.

Post operatively the patient made an uneventful recovery and was discharged home on 2 post-op day. A follow up sonography at 40 days after surgery with transvaginal and transabdominal route showed a complete repair of defect. At 3 months follow-up, postmenstrual spotting and chronic pelvic pain also resolved completely.

The authors concluded that, a laparoscopic approach is procedure of choice when repairing large isthmocele with severe myometrial thinning.  

Here is the video of the surgery