Isthmocele Repair (Hysteroscopic)
Hysteroscopic isthmocele repair is a minimally invasive surgical procedure that addresses a cesarean scar defect (isthmocele or niche) by resecting the thin residual myometrial layer at the defect's inferior edge from inside the uterine cavity, reducing the niche depth and improving drainage of retained menstrual blood. Surgeons perform the procedure with a resectoscope or operative hysteroscope, without abdominal incisions. It represents the less invasive of the two primary surgical approaches to isthmocele correction.12
Patient selection governs which cases are appropriate for the hysteroscopic route. A residual myometrial thickness of at least 2.5 to 3 mm at the defect is generally required before hysteroscopic resection; thinner walls carry a risk of bladder injury or perforation during the procedure. The primary indication is symptomatic postmenstrual spotting or abnormal uterine bleeding attributable to blood pooling in the niche, rather than fertility concern alone. When the presenting complaint is primarily bleeding and the wall thickness is sufficient, the hysteroscopic approach can resolve symptoms with shorter recovery time than laparoscopic repair.34
The limitation of the hysteroscopic approach is that it does not reconstruct the uterine wall. It shaves the defect rather than closing it. Residual myometrial thickness after the procedure may be no greater than before, and the structural integrity of the lower uterine segment for future pregnancy is not restored. For couples who desire subsequent pregnancy, particularly after a previous uterine rupture, uterine scar dehiscence, or when myometrial thickness is already marginal, laparoscopic repair with full-thickness reconstruction offers more complete correction.35
See also: isthmocele, isthmocele repair (laparoscopic), operative hysteroscopy.
Cited in this entry
- Isthmocele: an overview of diagnosis and treatment. https://www.scielo.br/j/ramb/a/sybvcWWJG8F7tL7yB8RH3DQ/?lang=en
- The Use of Hysteroscopy for the Diagnosis and Treatment of Intrauterine Pathology. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2020/03/the-use-of-hysteroscopy-for-the-diagnosis-and-treatment-of-intrauterine-pathology
- Isthmocele: From Risk Factors to Management. https://pmc.ncbi.nlm.nih.gov/articles/PMC10416161/
- Presentation of isthmocoele and its management options: a review. https://www.gynaecology-obstetrics-journal.com/presentation-of-isthmocoele-and-its-management-options-a-review/
- Tanimura S, Funamoto H, Hosono T, et al. New diagnostic criteria and operative strategy for cesarean scar syndrome: Endoscopic repair for secondary infertility caused by cesarean scar defect. https://rrmacademy.org/library/new-diagnostic-criteria-and-operative-strategy-for-cesarean-scar-syndrome-endosc-recqwwtcnpsmidfw0/
This content is for educational purposes only and does not constitute medical advice. Consult an RRM clinician or healthcare provider for guidance specific to your situation.