Instruments and Techniques
Hysteroscopic Treatment of Symptomatic Cesarean-induced Isthmocele: A Prospective Study

https://doi.org/10.1016/j.jmig.2014.09.011Get rights and content

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.

Section snippets

Materials and Methods

This prospective study (Canadian Task Force classification III) was performed from December 2007 through October 2013 on 120 consecutive patients with isthmoceles at Clinica Mediterranea (Naples), St Orsola Hospital (Bologna), and Agostino Gemelli Hospital (Rome). Only symptomatic patients were included in the study. Clinical characteristics of the study population are described in Table 1. One hundred eighteen patients had postmenstrual abnormal uterine bleeding for 2 to 13 days after

Results

An isthmocele appears as a triangular or oval-shaped shadow in the anterior uterine wall, with transonic content of variable size (Fig. 1). Fig. 2, Fig. 3 show a pocket in the middle or upper cervical channel, respectively, where blood is retained and then slowly released. Figure 2 highlights the anterior border trapping the blood, whereas Figure 3 shows the edge of the isthmocele where the blood is collected and the second posterior border, which usually (but not always) corresponds to the

Discussion

The gynecologic sequelae caused by deficient uterine scar healing after cesarean section are only recently being identified and described 5, 6, 7. These include conditions such as postmenstrual abnormal uterine bleeding (PAUB), chronic pelvic pain, infertility, and cesarean scar ectopic pregnancy as well as a potentially higher risk of complications during gynecologic procedures, such as uterine evacuation, hysterectomy, endometrial ablation, and insertion of an intrauterine device. In

References (21)

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

Cited by (92)

  • Cesarean scar disorder: Management and repair

    2023, Best Practice and Research: Clinical Obstetrics and Gynaecology
  • Aetiology, risk factors and preventive strategies for niche development: A review

    2023, Best Practice and Research: Clinical Obstetrics and Gynaecology
  • Improvement of symptoms after hysteroscopic isthmoplasty in women with abnormal uterine bleeding and expected pregnancy: A prospective study

    2022, Journal of Gynecology Obstetrics and Human Reproduction
    Citation Excerpt :

    According to Wang et al. [27] and Xie et al. [28], the mean surgical time which was defined as the whole procedure, including preoperative preparations, were 30.2 min (range 18–52 min) and 25 min (range 20–35 min), respectively. Raimondo et al. [12] recorded only the time required for N of the lesions, and it took 8 ± 2.1 min (range 7–8.6 min). Using Raimondo's definition, our average surgical duration was 17.4 ± 3.5 min (range 10–25 min).

View all citing articles on Scopus

The authors declare no conflict of interest.

View full text