Hysteroscopic Repair of Cesarean Scar Isthmocele

Authors:
Ari P Sanders, MD; Ally Murji, MD MPH

Abstract:

Objective:
To demonstrate an approach to the hysteroscopic repair of cesarean scar isthmocele and discuss its association with secondary infertility.

Design:
A step-by-step explanation of the procedure with surgical video footage.

Setting:
Academic medical center

Patient(s):
Two patients undergoing hysteroscopic repair of symptomatic cesarean scar isthmoceles. Surgical candidates for this procedure include patients with a symptomatic isthmocele and a residual myometrial thickness of at least 3mm confirmed with pre-operative imaging.

Intervention(s):
Operative hysteroscopy is performed using a step-wise approach: 1) identification of relevant anatomy; 2) resection of the cephalad edge of fibrosis; 3) resection of the caudad edge of fibrosis; 4) ablation of the isthmocele base.

Main Outcome Measure(s):
Restoration of the contour between the uterine cavity and cervical canal.

Result(s):
Hysteroscopic resection of cesarean scar isthmocele is successfully performed in both cases presented. Postoperatively, both patients had resolution of their symptoms.

Conclusion(s):
The surgical approach presented in this video can result in the successful revision of a cesarean scar isthmocele. Current literature supports a role for hysteroscopic isthmoplasty in treating isthmocele-related abnormal uterine bleeding. However, more evidence is required on the safety of conceiving following hysteroscopic isthmoplasty, and its use in the setting of secondary infertility.