Original article
Resectoscopic Correction of the “Isthmocele” in Women with Postmenstrual Abnormal Uterine Bleeding and Secondary Infertility

https://doi.org/10.1016/j.jmig.2007.10.004Get rights and content

Abstract

Study Objective

The obstetric complications that a cesarean delivery may produce have been known and studied for a long time. In the last few years, new correlations with some gynecologic disturbances also emerged, such as postmenstrual abnormal uterine bleeding (PAUB), and with some cases of secondary infertility. This is due to the presence of a diverticulum on the anterior wall of the uterine isthmus or of the cervical canal at the site of a previous cesarean delivery scar. The aim of our study was to assess the effectiveness of a hysteroscopic surgical technique to correct this anatomic defect and therefore eliminate the symptoms.

Design

A prospective study (Canadian Task Force classification III).

Setting

Private clinic and university hospital.

Patients

Twenty-six patients who previously had 1 or more cesarean deliveries, were evaluated from 2001 to 2005 for postmenstrual uterine bleeding and secondary infertility in 9 patients. All patients had a “niche” (which we defined as “isthmocele”) principally on the isthmus-superior third of cervical canal (18/26), but on the lower cervical tract too (8/26). All of them underwent resectoscopic correction of the “isthmocele.”

Interventions

Hysteroscopic resection of the edges and the bottom of the defect until the complete removal of the fibrotic scar tissue showing the muscular tissue below, using a cutting loop and pure cutting current. Aimed electrocoagulation of the bottom of the pouch with a roller-ball to avoid the in situ production of blood.

Measurements and Main Results

The anatomic defect in 100% of patients treated (26/26) was repaired, thus solving the symptom. Seven of 9 patients with secondary infertility became pregnant.

Conclusions

The “isthmocele” represents a possible consequence of one or more cesarean deliveries and may be symptomatic in some women. It is a defect that can be easily diagnosed by hysteroscopy and successfully treated by resectoscopic technique.

Section snippets

Materials and Methods

This study was conducted at the private clinic “Madre Fortunata Toniolo” and at the Department of Gynaecology and Obstetrics I of the University Hospital S. Orsola-Malpighi in Bologna. Our 26 study patients, aged 29 to 42 years, who previously underwent cesarean section deliveries (the number of previous cesarean deliveries ranged from 1–3), were studied from 2001 through 2005 because of postmenstrual abnormal uterine bleeding (PAUB). Nine of them had secondary infertility, too. All patients

Results

The office hysteroscopic follow-up, using the same setting of the preoperative diagnostic hysteroscopy, confirmed the success of the surgical procedure in correcting the previous anatomic defect and in reconstructing the cervical canal in the interested tract. There was a replacement by the endocervical mucosa. Only a partially cicatrized “fovea” remained. The clinical outcome was the resolution of PAUB in all cases. Seven of 9 patients who desired another pregnancy became pregnant

Discussion

Diagnostic hysteroscopy, with both gas and solution as a distension medium, allow us to identify the “isthmocele” as a pouchlike anatomic defect on the anterior wall of the isthmus or of the cervical canal, at its superior third or less frequently at its mean-inferior third. More precisely, the defect appeared anteriorly near the right as an outcome of the physiological uterine involution after delivery. The benefit of using the physiological solution as a medium of distension is to wash the

Conclusions

A cesarean section scar may have some reproductive and gynecologic consequences, such as abnormal postmenstrual uterine bleeding, entering into the differential diagnosis with other causes of bleeding disorders. The office hysteroscopic examination allows us to easily identify the described isthmic defect, because it is not very invasive and extremely accurate. The resectoscopic surgery represents the choice treatment of the “isthmocele,” guaranteeing excellent results in terms of therapeutic

References (14)

There are more references available in the full text version of this article.

Cited by (137)

  • Cesarean scar disorder: Management and repair

    2023, Best Practice and Research: Clinical Obstetrics and Gynaecology
  • Can uterine niche be prevented?

    2022, Journal of Gynecology Obstetrics and Human Reproduction
View all citing articles on Scopus

The authors have no commercial, proprietary, or financial interest in the products or companies described in this article.

Available at www.sciencedirect.com and www.jmig.org

View full text