Assessment and surgical management strategy for isthmocele following cesarean section
DOI:
https://doi.org/10.15574/PP.2025.4(104).9097Keywords:
cesarean section, isthmocele, uterine scar defect, residual myometrial thickness (RMT), hysteroscopy, laparoscopic metroplasty, ultrasound diagnosticsAbstract
In modern gynecology, isthmocele (cesarean scar defect - CSD) has evolved from an "incidental finding" to a clinically significant pathology requiring a clear diagnostic and therapeutic algorithm. Literature data from 2019-2024 highlight a direct correlation between Cesarean section techniques, specifically low uterine incision and suturing methods, and defect formation. Key clinical challenges include abnormal uterine bleeding in up to 85% of cases, secondary infertility, and chronic pelvic pain.
Aim - to develop a stratification algorithm for the surgical treatment of isthmocele based on ultrasound criteria for residual myometrial thickness (RMT) and the patient's clinical presentation.
A comprehensive examination for patients with CSD has been developed. It was found that ultrasonography is the primary diagnostic tool for determining the morphological parameters of the niche. RMT was identified as the key indicator. It was demonstrated that clinical symptomatology correlates with the dimensions of the defect: abnormal uterine bleeding was observed in the majority of patients (37-85%), while infertility and pelvic pain were identified in 11-39% and 18-33% of cases, respectively. A differentiated management approach has been proposed: conservative observation is recommended for patients with an asymptomatic defect, regardless of the niche size. In cases of severe symptoms and large defects, surgical correction is indicated. The feasibility of laparoscopic metroplasty was determined for cases where the RMT exceeded 3 mm. This approach allowed not only for the elimination of the niche but also for the reinforcement of the uterine wall, significantly reducing the risk of complications compared to isolated hysteroscopic resection.
Conclusions. Successful treatment of isthmocele depends on the standardization of ultrasound criteria and a multidisciplinary approach. Stratifying patients based on RMT measurements allows for the selection of an optimal strategy - ranging from a "wait-and-watch" approach to minimally invasive laparoscopic correction. Implementing laparoscopic access when the myometrial thickness is >3 mm is a pathogenetically sound method that ensures the restoration of anatomical integrity and improves reproductive outcomes.
The authors declare that there is no conflict of interest.
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