An isthmocele, a cesarean scar defect or uterine niche, is any indentation representing myometrial discontinuity or a triangular anechoic defect in the anterior uterine wall, with the base communicating to the uterine cavity, at the site of a previous cesarean section scar. It can be classified as a small or large defect, depending on the wall thickness of the myometrial deficiency. Although usually asymptomatic, its primary symptom is abnormal or postmenstrual bleeding, and chronic pelvic pain may also occur. Infertility, placenta accrete or praevia, scar dehiscence, uterine rupture, and cesarean scar ectopic pregnancy may also appear as complications of this condition. The risk factors of isthmocele proven to date include retroflexed uterus and multiple cesarean sections. Nevertheless, factors such as a lower position of cesarean section, incomplete closure of the hysterotomy, early adhesions of the uterine wall and a genetic predisposition may also contribute to the development of a niche. As there are no definitive criteria for diagnosing an isthmocele, several imaging methods can be used to assess the integrity of the uterine wall and thus diagnose an isthmocele. However, transvaginal ultrasound and saline infusion sonohysterography emerge as specific, sensitive and cost-effective methods to diagnose isthmocele. The treatment includes clinical or surgical management, depending on the size of the defect, the presence of symptoms, the presence of secondary infertility and plans of childbearing. Surgical management includes minimally invasive approaches with sparing techniques such as hysteroscopic, laparoscopic or transvaginal procedures according to the defect size.
PMID 31166450 31166450 DOI 10.1590/1806-9282.65.5.714 10.1590/1806-9282.65.5.714
Cite this article
Kremer, T. G., Ghiorzi, I. B., & Dibi, R. P. (2019). Isthmocele: an overview of diagnosis and treatment. Revista da Associacao Medica Brasileira (1992), 65(5), 714-721. https://doi.org/10.1590/1806-9282.65.5.714
Kremer TG, Ghiorzi IB, Dibi RP. Isthmocele: an overview of diagnosis and treatment. Rev Assoc Med Bras (1992). 2019;65(5):714-721. doi:10.1590/1806-9282.65.5.714
Kremer, Thaysa Guglieri, et al. "Isthmocele: an overview of diagnosis and treatment." Revista da Associacao Medica Brasileira (1992), vol. 65, no. 5, 2019, pp. 714-721.
To compare outcomes of vaginal surgery in women with moderate or severe symptomatic cesarean scar defect (with or without residual myometrium).
Retrospective cohort study.
Gynecology department of a teaching hospital. Fifty-three women, between January 2014 and December 2019, underwent vaginal surgery for symptomatic 20 women with moderate defect (with residual myometrium) and 33 with severe defect (without residual myometrium). Vaginal surgical approach to repair cesarean scar defect. MAIN surgery by comparing the myometrial residual thickness before and after surgery. The secondary objectives were evaluation of vaginal surgery efficacy on symptoms resolution, per and postoperative courses, and subsequent fertility. Failure rate was evaluated as the need for a second surgery. After vaginal surgery, the residual myometrium significantly increased from 2.4 mm ± 0.9 mm to 6.6 mm ± 2.4 mm (p <.01) in the moderate group and from 0 mm to 4.4 mm ± 2.2 mm (p <.01) in the severe group. The prevalence of abnormal uterine bleeding was significantly reduced after surgery in both groups (p <.01). Pelvic pain was significantly reduced only in the moderate group (p <.01). The rate of complications (5% vs 9.1%) and second surgery (15% vs 24.2%) were not significantly different between moderate and severe groups, respectively. The median time to conceive (7 months vs 12 months); pregnancy rates (84.6% vs 68.2%); and live birth rates (76.9% vs 50%) were not statistically significant in the moderate and severe groups respectively, with 90% of pregnancies occurring naturally. Women delivered by cesarean section at 38 weeks of gestation in both groups, and no uterine rupture was reported. Despite the absence of residual myometrium, vaginal repair of severe cesarean scar defect was effective in increasing myometrial thickness, in relieving bleeding symptoms, and in allowing to achieve pregnancy.
To evaluate the efficacy of surgical management for isthmoceles in patients presenting with secondary infertility. A systematic search was performed in MEDLINE, EMBASE, and Cochrane Library databases from inception to May 2020. The search was limited to studies published in English. After the removal of duplicates, 3380 articles were screened for inclusion independently by 2 authors. These 2 authors assessed for studies which focused on women of reproductive age with a diagnosed isthmocele and secondary infertility who underwent any surgical intervention for defect repair with at least 1 of the goals being fertility restoration. TABULATION, INTEGRATION, A total of 13 studies, comprising of 1 randomized controlled trial, 6 prospective case series, and 6 retrospective case series describing 234 patients who underwent surgical management for an isthmocele and secondary infertility were included. The methodologic quality of the included studies was assessed independently by both reviewers. Next, the data extraction was performed independently and then compared to ensure no discrepancies. A total of 188 patients were treated by hysteroscopy, 36 by laparoscopy, 7 by laparotomy, and 3 through a vaginal approach. In total, 153 of the 234 patients (65.4%) achieved pregnancy across all studies within their respective study periods. Pregnancy rates in the randomized controlled trial were 21 of 28 (75%) for those treated by hysteroscopy compared with 9 of 28 (32%) for those untreated. Among the studies reporting pregnancy outcomes, 101 of 116 (87.1%) pregnancies resulted in a live birth. The incidence of adverse events was 2%, including the risk of reoperation. The results of this systematic review suggest that the surgical treatment of an isthmocele, particularly through hysteroscopy, in patients with residual myometrial thickness of at least 2.5 mm, may be effective in treating isthmocele-associated secondary infertility with a relatively low complication rate. Further high-quality studies are needed because of the small sample sizes and observational nature of most available data.
SurgeryCesarean Scar Defect RepairIsthmocele Diagnosis and ManagementLong-Term Scar Complications
Open Access
The aim of the present study was to perform a comprehensive review of the literature to provide a complete and clear picture of isthmocele-a hypoechoic area within the myometrium at the site of the uterine scar of a previous cesarean section-by exploring in depth every aspect of this condition. A comprehensive review of the literature was performed to identify the most relevant studies about this topic. Every aspect of isthmocele pathophysiology, clinical symptoms, classification, and diagnosis. Its treatment, both medical and surgical, has also been reported according to the actual literature data. Cesarean section is the most common surgical procedure performed worldwide, and one of the consequences of this technique is isthmocele. A single and systematic classification of isthmocele is needed to improve its diagnosis and management. Further studies should be performed to better understand its pathogenesis.
SurgeryCesarean Scar Defect RepairScar Defect ManifestationsCesarean Scar Defect and Fertility
The objective of this study was to evaluate the prevalence of cesarean scar defects and its clinical manifestations in reproductive-aged women. We performed a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement using keywords of "cesarean scar defect, uterine scar defect, uterine diverticulum niche, isthmocele, pouch, or sacculation" and their combination. Thirty-two trials met the inclusion criteria. Cesarean scar defects are commonly found on ultrasound examination (24%-88%). Their presence could be asymptomatic or related to postmenstrual spotting, postmenstrual bleeding, or infertility. The prevalence of this condition is related to the number of cesarean deliveries. Hysteroscopic repair of a cesarean scar defect or isthmoplasty is associated with an improvement in uterine bleeding in 59% to 100% of cases and a pregnancy rate of 77.8% to 100%. An improvement in uterine bleeding after vaginal repair occurred in 89% to 93.5% of cases. Laparoscopic repair led to uterine bleeding improvement in 86% of cases and a pregnancy rate of 86%. The association between cesarean scar defect and infertility, pelvic pain, and dysmenorrhea require more studies. Treatment of uterine scar defects should be performed after eliminating other causes of postmenstrual bleeding or infertility. Hysteroscopic isthmoplasty appears to be the most popular treatment. However, in the absence of randomized trials, the efficacy of different surgical approaches remains to be seen. Until we have concrete evidence, the treatment should be reserved for selective cases.