[en] OBJECTIVE: To evaluate the effect of laparoscopic isthmocele repair on isthmocele-related symptoms and/or fertility-related problems. The residual myometrial thickness before and after subsequent cesarean section was also evaluated. DESIGN: Retrospective, case series. SETTING: Public university hospital. POPULATION: Women with isthmocele (residual myometrium < 5 mm) complaining of abnormal uterine bleeding, chronic pelvic pain or secondary infertility not otherwise specified. METHODS: Women's complaints and the residual myometrium were assessed pre-operatively and at three to six months post-operatively. In patients who conceived after surgery, the latter was measured at least six months after delivery by cesarean section. MAIN OUTCOME MEASURES: Resolution of the main symptom three to six months after surgery and persistence of laparoscopic repair benefits after subsequent cesarean section were considered as primary outcome measures. RESULTS: Overall, 31 women underwent laparoscopic isthmocele repair. The success rates of the surgery as improvement of abnormal uterine bleeding, chronic pelvic pain and secondary infertility were 71.4% (10 of 14), 83.3% (10 of 12) and 83.3% (10 of 12), respectively. Mean residual myometrial thickness increased significantly from 1.77 mm pre-operatively to 6.67 mm, three to six months post-operatively. Mean myometrial thickness in patients who underwent subsequent cesarean section (N = 7) was 4.49 mm. In this sub-group, there was no significant difference between the mean myometrial thickness measured after the laparoscopic isthmocele repair and that measured after the subsequent cesarean section. None of these patients reported recurrence of their symptoms after delivery. CONCLUSION: Our findings suggest that the laparoscopic isthmocele excision and repair is an appropriate approach for the treatment of isthmocele-related symptoms when done by skilled laparoscopic surgeons. The benefit of this new surgical approach seems to persist even after a subsequent cesarean section. Further investigations and prospective studies are required to confirm this finding.
Disciplines :
Médecine de la reproduction (Gynécologie, andrologie, obstétrique)
World Health Organization; Human Resource Planning. WHO Statement on Caesarean Section Rates; World Health Organization: Geneva, Switzerland, 2015.
Häger, R.M.; Daltveit, A.K.; Hofoss, D.; Nilsen, S.T.; Kolaas, T.; Øian, P.; Henriksen, T. Complications of cesarean deliveries: Rates and risk factors. Am. J. Obstet. Gynecol. 2004, 190, 428–434. [CrossRef] [PubMed]
Tulandi, T.; Cohen, A. Emerging manifestations of cesarean scar defect in reproductive-aged women. J. Minim. Invasive Gynecol. 2016, 23, 893–902. [CrossRef] [PubMed]
Chantraine, F.; Langhoff-Roos, J. Abnormally Invasive Placenta–AIP. Awareness and pro-active management is necessary. Acta Obstet. Gynecol. Scand. 2013, 92, 369–371. [CrossRef] [PubMed]
Jauniaux, E.; Chantraine, F.; Silver, R.M.; Langhoff-Roos, J. FIGO Placenta Accreta Diagnosis and Management Expert Consensus Panel. FIGO consensus guidelines on placenta accreta spectrum disorders: Epidemiology. Int. J. Gynaecol. Obstet. 2018, 140, 265–273. [CrossRef] [PubMed]
Bij de Vaate, A.J.; Van der Voet, L.F.; Naji, O.; Witmer, M.; Veersema, S.; Brölmann, H.A.; Bourne, T.; Huirne, J.A. Prevalence, potential risk factors for development and symptoms related to the presence of uterine niches following Cesarean section: Systematic review. Ultrasound Obstet. Gynecol. 2014, 43, 372–382. [CrossRef] [PubMed]
Badr, D.A.; Al Hassan, J.; Wehbe, G.S.; Ramadan, M.K. Uterine body placenta accreta spectrum: A detailed literature review. Placenta 2020, 95, 44–52. [CrossRef] [PubMed]
Ramadan, M.K.; Ramadan, K.; El Tal, R.; Salem Wehbe, G.R.; Itani, S.; Badr, D.A. How safe is high-order repeat cesarean delivery? An 8-year single-center experience in Lebanon. J. Obstet. Gynaecol. Res. 2020, 46, 1370–1377. [CrossRef] [PubMed]
Ramadan, M.K.; Kassem, S.; Itani, S.; Sinno, L.; Hussein, S.; Chahin, R.; Badr, D.A. Incidence and risk factors of uterine scar dehiscence identified at elective repeat cesarean delivery: A case-control study. J. Clin. Gynecol. Obstet. 2018, 7, 37–42. [CrossRef]
Stegwee, S.I.; Beij, A.; de Leeuw, R.A.; Mokkink, L.B.; van der Voet, L.F.; Huirne, J.A. Niche-related outcomes after caesarean section and quality of life: A focus group study and review of literature. Qual. Life Res. 2019, 29, 1013–1025. [CrossRef] [PubMed]
Van der Voet, L.F.; de Vaate, A.B.; Veersema, S.; Brölmann, H.A.; Huirne, J.A. Long-term complications of caesarean section. The niche in the scar: A prospective cohort study on niche prevalence and its relation to abnormal uterine bleeding. BJOG Int. J. Obstet. Gynaecol. 2014, 121, 236–244. [CrossRef] [PubMed]
Kremer, T.G.; Ghiorzi, I.B.; Dibi, R.P. Isthmocele: An overview of diagnosis and treatment. Rev. Assoc. Méd. Bras. 2019, 65, 714–721. [CrossRef]
Sipahi, S.; Sasaki, K.; Miller, C.E. The minimally invasive approach to the symptomatic isthmocele—What does the literature say? A step-by-step primer on laparoscopic isthmocele–excision and repair. Curr. Opin. Obstet. Gynecol. 2017, 29, 257–265. [CrossRef]
Van der Voet, L.; Veersema, S.; Schoot, B.; Huirne, J. Unusual Hysteroscopic Situations: Caesarean Niche and Retained Placental tissue. In Diagnostic and Operative Hysteroscopy; Connor, M., Clark, T., Eds.; Cambridge University Press: Cambridge, UK, 2020; pp. 193–203.
Vitale, S.G.; Ludwin, A.; Vilos, G.A.; Török, P.; Tesarik, J.; Vitagliano, A.; Lasmar, R.B.; 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. [CrossRef] [PubMed]
Donnez, O.; Donnez, J.; Orellana, R.; Dolmans, M.M. Gynecological and obstetrical outcomes after laparoscopic repair of a cesarean scar defect in a series of 38 women. Fertil. Steril. 2017, 107, 289–296. [CrossRef]
Vervoort, A.J.; Vissers, J.; Hehenkamp, W.J.; Brölmann, H.A.; Huirne, J.A. The effect of laparoscopic resection of large niches in the uterine caesarean scar on symptoms, ultrasound findings and quality of life: A prospective cohort study. BJOG Int. J. Obstet. Gynaecol. 2018, 125, 317–325. [CrossRef]
Zhu, Q.; He, X.; Jiang, L.; Liang, G.; Zhu, C.; Pan, H.; Zhang, J.; Huirne, J.A. Effectiveness of hysteroscopic resection of a uterine caesarean niche can be predicted: A prospective cohort study. Sci. Rep. 2020, 10, 17424. [CrossRef]
Jacobson, M.T.; Osias, J.; Velasco, A.; Charles, R.; Nezhat, C. Laparoscopic repair of a uteroperitoneal fistula. JSLS J. Soc. Laparoendosc. Surg. 2003, 7, 367. [CrossRef]
Zhang, X.; Yang, M.; Wang, Q.; Chen, J.; Ding, J.; Hua, K. Prospective evaluation of five methods used to treat cesarean scar defects. Int. J. Gynecol. Obstet. 2016, 134, 336–339. [CrossRef]
Florio, P.; Filippeschi, M.; Moncini, I.; Marra, E.; Franchini, M.; Gubbini, G. Hysteroscopic treatment of the cesarean-induced isthmocele in restoring infertility. Curr. Opin. Obstet. Gynecol. 2012, 24, 180–186. [CrossRef]
Gubbini, G.; Centini, G.; Nascetti, D.; Marra, E.; Moncini, I.; Bruni, L.; Petraglia, F.; Florio, P. Surgical hysteroscopic treatment of cesarean-induced isthmocele in restoring fertility: Prospective study. J. Minim. Invasive Gynecol. 2011, 18, 234–237. [CrossRef] [PubMed]
Vervoort, A.J.; Uittenbogaard, L.B.; Hehenkamp, W.J.; Brölmann, H.; Mol, B.W.; Huirne, J.A. Why Do Niches Develop in Caesarean Uterine Scars? Hypotheses on the Aetiology of Niche Development Editorial Comment. Obstet. Gynecol. Surv. 2016, 71, 83–84. [CrossRef]
Van der Voet, L.F.; Jordans, I.P.; Brölmann, H.A.; Veersema, S.; Huirne, J.A. Changes in the uterine scar during the first year after a caesarean section: A prospective longitudinal study. Gynecol. Obstet. Investig. 2018, 83, 164–170. [CrossRef] [PubMed]
Hayakawa, H.; Itakura, A.; Mitsui, T.; Okada, M.; Suzuki, M.; Tamakoshi, K.; Kikkawa, F. Methods for myometrium closure and other factors impacting effects on cesarean section scars of the uterine segment detected by the ultrasonography. Acta Obstet. Gynecol. Scand. 2006, 85, 429–434. [CrossRef] [PubMed]
Stegwee, S.I.; Jordans, I.P.; Van Der Voet, L.F.; Bongers, M.Y.; De Groot, C.J.; Lambalk, C.B.; De Leeuw, R.A.; Hehenkamp, W.J.; Van De Ven, P.M.; Bosmans, J.E.; et al. Single-versus double-layer closure of the caesarean (uterine) scar in the prevention of gynaecological symptoms in relation to niche development—The 2Close study: A multicentre randomised controlled trial. BMC Pregnancy Childbirth 2019, 19, 1–11. [CrossRef]
Başbuğ, A.; Doğan, O.; Ellibeş Kaya, A.; Pulatoğlu, Ç.; Çağlar, M. Does suture material affect uterine scar healing after cesarean section? Results from a randomized controlled trial. J. Investig. Surg. 2019, 32, 763–769. [CrossRef] [PubMed]
Stegwee, S.I.; van der Voet, L.F.; Ben, A.J.; de Leeuw, R.A.; van de Ven, P.M.; Duijnhoven, R.G.; Bongers, M.Y.; Lambalk, C.B.; de Groot, C.J.M.; Huirne, J.A.F. Effect of single-versus double-layer uterine closure during caesarean section on postmenstrual spotting (2Close): Multicentre, double-blind, randomised controlled superiority trial. BJOG Int. J. Obstet. Gynaecol. 2021, 128, 866–878. [CrossRef] [PubMed]
Jurkovic, D.; Knez, J.; Appiah, A.; Farahani, L.; Mavrelos, D.; Ross, J.A. Surgical treatment of Cesarean scar ectopic pregnancy: Efficacy and safety of ultrasound-guided suction curettage. Ultrasound Obstet. Gynecol. 2016, 47, 511–517. [CrossRef]
Bij de Vaate, A.J.; Brölmann, H.A.; Van Der Voet, L.F.; Van Der Slikke, J.W.; Veersema, S.; Huirne, J.A. Ultrasound evaluation of the Cesarean scar: Relation between a niche and postmenstrual spotting. Ultrasound Obstet. Gynecol. 2011, 37, 93–99. [CrossRef]
Regnard, C.; Nosbusch, M.; Fellemans, C.; Benali, N.; Van Rysselberghe, M.; Barlow, P.; Rozenberg, S. Cesarean section scar evaluation by saline contrast sonohysterography. Ultrasound Obstet. Gynecol. 2004, 23, 289–292. [CrossRef]
Vikhareva Osser, O.; Jokubkiene, L.; Valentin, L. High prevalence of defects in Cesarean section scars at transvaginal ultrasound examination. Ultrasound Obstet. Gynecol. 2009, 34, 90–97. [CrossRef] [PubMed]
Vikhareva Osser, O.; Jokubkiene, L.; Valentin, L. Cesarean section scar defects: Agreement between transvaginal sonographic findings with and without saline contrast enhancement. Ultrasound Obstet. Gynecol. 2010, 35, 75–83. [CrossRef]
Thurmond, A.S.; Harvey, W.J.; Smith, S.A. Cesarean section scar as a cause of abnormal vaginal bleeding: Diagnosis by sonohysterography. J. Ultrasound Med. 1999, 18, 13–16. [CrossRef] [PubMed]
Marotta, M.L.; Donnez, J.; Squifflet, J.; Jadoul, P.; Darii, N.; Donnez, O. Laparoscopic repair of post-cesarean section uterine scar defects diagnosed in nonpregnant women. J. Minim. Invasive Gynecol. 2013, 20, 386–391. [CrossRef]
Pan, Y.; Liu, M.B. The value of hysteroscopic management of cesarean scar pregnancy: A report of 44 cases. Taiwan J. Obstet. Gynecol. 2017, 56, 139–142. [CrossRef] [PubMed]
