Isthmocele Repair (Hysteroscopic)
Hysteroscopic isthmocele repair is a minimally invasive surgery that addresses a cesarean scar defect from inside the uterus. The surgeon trims away the thin layer of muscle at the lower edge of the defect (the isthmocele, or niche).
This step makes the niche shallower and helps trapped menstrual blood drain. The surgeon uses a resectoscope or operative hysteroscope, a thin instrument that works inside the uterus. The procedure requires no incisions in the abdomen.
It is the less invasive of the two main surgeries for an isthmocele.12
Before this surgery, the remaining muscle wall at the defect usually needs to be at least 3 mm thick. A thinner wall raises the risk of bladder injury or a hole in the uterus (perforation). Some case series accept a wall as thin as 2.5 mm.3
The main reason for this surgery is bleeding, not fertility concerns alone. The bleeding is spotting after periods or other abnormal bleeding from blood that pools in the niche.
In some women, bleeding is the main problem and the wall is thick enough. In that case, this approach can resolve symptoms. Recovery is shorter than with laparoscopic repair.45
The limitation of this approach is that it does not rebuild the uterine wall. It shaves the defect rather than closing it.
The wall may be no thicker after surgery than before. The lower part of the uterus does not regain strength for a future pregnancy.
For couples who want another pregnancy, laparoscopic repair provides a more complete correction. Laparoscopic surgery works through small incisions in the abdomen. It rebuilds the full thickness of the wall. This advantage matters most after a previous uterine rupture or scar separation (dehiscence), or when the wall is already thin.43
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
- 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/
- 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/
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.