DOI: https://doi.org/10.18370/2309-4117.2019.50.8-11

Outcomes after hysteroscopic repair of symptomatic isthmocele: a single center experience in Ukraine

T. F. Tatarchuk, N. V. Kosei, B. V. Khabrat, T. M. Tutchenko, L. М. Zenkina, M. I. Hlamazda, N. M. Yevtushenko

Abstract


Рurpose of the study was to evaluate the influence of Isthmocele (IC) hysteroscopic repair on symptoms (abnormal uterine bleeding, dysmenorrhea) in premenopausal patients with residual myometrium thickness more than 2.4 mm and to assess myometrial thickness 3, 6 and 12 month post surgery.

Materials and methods. It was a prospective case series of symptoms evaluation and myometrium thickness following hysteroscopic IC repair in premenopausal women not willing to conceive. Diagnosis of IC was based on 2D transvaginal ultrasound and symptom evaluation. Symptom frequency and residual myometrium thickness by ultrasound were evaluated before hysteroscopic repair and after 3, 6 and 12 months after it in patients with IC as single possible cause of symptoms.

Results. In the period from January 2017 to January 2018 there were 32 cases of symptomatic IC in premenopausal women. 8 (25%) of them had coexisting uterine pathology that could cause AUB, these women were not included in hysteroscopic treatment efficacy analysis. Thus 24 patients with residual myometrium thickness of more than 2.4mm and not willing to conceive underwent hysteroscopic repaire of IC. Three months after surgery, most patients reported a complete relief of symptoms: abnormal uterine bleeding reduced from 33.3% (8 patients) to 4.2% (1 patient); intermenstrual bleeding form 75% (18 patients) to 12.5% (3 patients); dysmenorrhea – from 91.7% (22 patients) to 29.2 (7 patients). This effect was even more prominent after 6 and 12 months. Average residual myometrium thickness values changed in the following way: 3.6 ± 0.9 before surgery; 4.9 ± 1.2 mm after 3 months; 5.9 ± 1.0 mm after 6 month and 6.5 ± 1.1 mm after 12 months.

Conclusion. Hysteroscopic repair of IC is a technically feasible, safe and highly effective procedure for symptoms (abnormal uterine bleeding, pelvic pain, dysmenorrhea) in women with other uterine pathology excluded and not willing to conceive. Efficacy and specific features technical performance and medical treatment in cases with coexisting adenomyosis and other uterine pathology are to be defined in future studies as such cases are frequent.


Keywords


isthmocele; transvaginal ultrasound; adenomyosis; abnormal uterine bleeding; dysmenorrhea; hysteroscopy

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References


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van der Voet, L., Vervoort, A., Veersema, S., et al. “Minimally invasive therapy for gynaecological symptoms related to a niche in the caesarean scar: a systematic review.” BJOG An Int J Obstet Gynaecol 121 (2014): 145–56. doi: 10.1111/1471-0528.12537

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Gubbini, G., Centini, G., Nascetti, D., et al. “Surgical Hysteroscopic Treatment of Cesarean-Induced IC in Restoring Fertility: Prospective Study.” J Minim Invasive Gynecol 18 (2011): 234–7. doi: 10.1016/J.JMIG.2010.10.011

Fabres, C., Arriagada, P., Fernandez, C., et al. “Surgical treatment and follow-up of women with intermenstrual bleeding due to cesarean section scar defect.” J Minim Invasive Gynecol 12 (2005): 25–8. doi: 10.1016/j.jmig.2004.12.023

Raimondo, G., Grifone, G., Raimondo, D., et al. “Hysteroscopic treatment of symptomatic cesarean-induced IC: a prospective study.” J Minim Invasive Gynecol 22 (2015): 297–301. doi: 10.1016/j.jmig.2014.09.011

Wang, C.-J., Huang, H.-J., Chao, A., et al. “Challenges in the transvaginal management of abnormal uterine bleeding secondary to cesarean section scar defect.” Eur J Obstet Gynecol Reprod Biol 154 (2011): 218–22. doi: 10.1016/j.ejogrb.2010.10.016

Chang, Y., Tsai, E.M., Long, C.Y., et al. “Resectoscopic treatment combined with sonohysterographic evaluation of women with postmenstrual bleeding as a result of previous cesarean delivery scar defects.” Am J Obstet Gynecol 200 (2009): 370.e1–370.e4. doi: 10.1016/j.ajog.2008.11.038

Abacjew-Chmylko, A., Wydra, D.G., Olszewska, H. “Hysteroscopy in the treatment of uterine cesarean section scar diverticulum: A systematic review.” Adv Med Sci 62 (2017): 230–9. doi: 10.1016/J.ADVMS.2017.01.004

Muzii, L., Domenici, L., Lecce, F., et al. “Clinical outcomes after resectoscopic treatment of cesarean-induced IC: a prospective case-control study.” Eur Rev Med Pharmacol Sci 21 (2017): 3341–6. Available from: [http://www.ncbi.nlm.nih.gov/pubmed/28829510], last accessed Dec 13, 2019.

Vegas Carrillo de Albornoz, A., Lopez Carrasco, I., Montero Pastor, N., et al. “Outcomes after Hysteroscopic Treatment of Symptomatic ICs in Patients with Abnormal Uterine Bleeding and Pelvic Pain: A Prospective Case Series.” Int J Fertil Steril 13 (2019): 108–12. doi:10.22074/ijfs.2019.5704


GOST Style Citations


1. Petrozza, J.C. “Defining a systematic approach to cesarean scar defects.” Fertil Steril 111 (2019): 475. doi: 10.1016/j.fertnstert.2019.01.010

2. Morris, H. “Surgical pathology of the lower uterine segment caesarean section scar: is the scar a source of clinical symptoms?” Int J Gynecol Pathol 14 (1995): 16–20. Available from: [http://www.ncbi.nlm.nih.gov/pubmed/7883420], last accessed Apr 6, 2019.

3. Chestnut, D.H. “Cesarean delivery on maternal request: implications for anesthesia providers.” Int J Obstet Anesth 15 (2006): 269–72. doi: 10.1016/j.ijoa.2006.06.009

4. Pacheco, L.A., Resta, L., Tinelli, A., et al. “The Cesarean Scar Complications.” In: Manag. Ther. Late Pregnancy Complicat. Springer International Publishing. Cham (2017): 317–37. doi: 10.1007/978-3-319-48732-8_19

5. van der Voet, L., de Vaate, A.B., Veersema, S., et al. “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 An Int J Obstet Gynaecol 121 (2014): 236–44. doi: 10.1111/1471-0528.12542

6. Tower, A.M., Frishman, G.N. “Cesarean Scar Defects: An Underrecognized Cause of Abnormal Uterine Bleeding and Other Gynecologic Complications.” J Minim Invasive Gynecol 20 (2013): 562–72. doi: 10.1016/j.jmig.2013.03.008

7. Vikhareva Osser, O., Jokubkiene, L., Valentin, L. “High prevalence of defects in Cesarean section scars at transvaginal ultrasound examination.” Ultrasound Obstet Gynecol 34 (2009): 90–7. doi: 10.1002/uog.6395

8. Pyra, K., Rio Tinto, H., Woźniak, S., Polskie Towarzystwo Ultrasonograficzne. Journal of ultrasonography (2018). Available from: [http://yadda.icm.edu.pl/yadda/element/bwmeta1.element.psjd-46a2ca29-1723-46cd-aa43-e318eacbce2d], last accessed Apr 8, 2019.

9. Drouin, O., Bergeron, T., Beaudry, A., et al. “Ultrasonographic Evaluation of Uterine Scar Niche before and after Laparoscopic Surgical Repair: A Case Report.” Am J Perinatol Reports 04 (2014): e65–e68. doi: 10.1055/s-0034-1376187

10. Jordans, I.P.M., de Leeuw, R.A., Stegwee, S.I., et al. “Sonographic examination of uterine niche in non-pregnant women: a modified Delphi procedure.” Ultrasound Obstet Gynecol 53 (2019): 107–15. doi: 10.1002/uog.19049

11. El-Toukhy, T. “Treatment of post-caesarean niche: the accumulation of evidence.” BJOG An Int J Obstet Gynaecol 125 (2018): 335. doi:10.1111/1471-0528.14823

12. Setubal, A., Alves, J., Osorio, F., et al. “Treatment for Uterine IC, A Pouchlike Defect at the Site of a Cesarean Section Scar.” J Minim Invasive Gynecol 25 (2018). doi: 10.1016/j.jmig.2017.09.022

13. Keag, O.E., Norman, J.E., Stock, S.J. “Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: Systematic review and meta-analysis.” PLOS Med 15 (2018): e1002494. doi: 10.1371/journal.pmed.1002494

14. Gurol-Urganci, I., Bou-Antoun, S., Lim, C.P., et al. “Impact of Caesarean section on subsequent fertility: a systematic review and meta-analysis.” Hum Reprod 28 (2013): 1943–52. doi:10.1093/humrep/det130

15. Iannone, P., Nencini, G., Bonaccorsi, G., et al. “IC: From Risk Factors to Management.” RBGO Gynecol Obstet 41 (2019): 044–52. doi: 10.1055/s-0038-1676109

16. Antila-Langsjo, R.M., Maenpaa, J.U., Huhtala, H.S., et al. “Cesarean scar defect: a prospective study on risk factors.” Am J Obstet Gynecol 219 (2018): 458.e1-458.e8. doi: 10.1016/j.ajog.2018.09.004

17. van der Voet, L., Vervoort, A., Veersema, S., et al. “Minimally invasive therapy for gynaecological symptoms related to a niche in the caesarean scar: a systematic review.” BJOG An Int J Obstet Gynaecol 121 (2014): 145–56. doi: 10.1111/1471-0528.12537

18. Morris, H. “Surgical pathology of the lower uterine segment caesarean section scar: is the scar a source of clinical symptoms?” Int J Gynecol Pathol 14 (1995): 16–20. Available from: [http://www.ncbi.nlm.nih.gov/pubmed/7883420], last accessed Apr 8, 2019.

19. Gubbini, G., Centini, G., Nascetti, D., et al. “Surgical Hysteroscopic Treatment of Cesarean-Induced IC in Restoring Fertility: Prospective Study.” J Minim Invasive Gynecol 18 (2011): 234–7. doi: 10.1016/J.JMIG.2010.10.011

20. Fabres, C., Arriagada, P., Fernandez, C., et al. “Surgical treatment and follow-up of women with intermenstrual bleeding due to cesarean section scar defect.” J Minim Invasive Gynecol 12 (2005): 25–8. doi: 10.1016/j.jmig.2004.12.023

21. Raimondo, G., Grifone, G., Raimondo, D., et al. “Hysteroscopic treatment of symptomatic cesarean-induced IC: a prospective study.” J Minim Invasive Gynecol 22 (2015): 297–301. doi: 10.1016/j.jmig.2014.09.011

22. Wang, C.-J., Huang, H.-J., Chao, A., et al. “Challenges in the transvaginal management of abnormal uterine bleeding secondary to cesarean section scar defect.” Eur J Obstet Gynecol Reprod Biol 154 (2011): 218–22. doi: 10.1016/j.ejogrb.2010.10.016

23. Chang, Y., Tsai, E.M., Long, C.Y., et al. “Resectoscopic treatment combined with sonohysterographic evaluation of women with postmenstrual bleeding as a result of previous cesarean delivery scar defects.” Am J Obstet Gynecol 200 (2009): 370.e1–370.e4. doi: 10.1016/j.ajog.2008.11.038

24. Abacjew-Chmylko, A., Wydra, D.G., Olszewska, H. “Hysteroscopy in the treatment of uterine cesarean section scar diverticulum: A systematic review.” Adv Med Sci 62 (2017): 230–9. doi: 10.1016/J.ADVMS.2017.01.004

25. Muzii, L., Domenici, L., Lecce, F., et al. “Clinical outcomes after resectoscopic treatment of cesarean-induced IC: a prospective case-control study.” Eur Rev Med Pharmacol Sci 21 (2017): 3341–6. Available from: [http://www.ncbi.nlm.nih.gov/pubmed/28829510], last accessed Dec 13, 2019.

26. Vegas Carrillo de Albornoz, A., Lopez Carrasco, I., Montero Pastor, N., et al. “Outcomes after Hysteroscopic Treatment of Symptomatic ICs in Patients with Abnormal Uterine Bleeding and Pelvic Pain: A Prospective Case Series.” Int J Fertil Steril 13 (2019): 108–12. doi:10.22074/ijfs.2019.5704





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