A novel hysteroscopic technique in the correction of isthmocele

a prospective randomized study

Abstract

Background: Many obstetric and gynecological complications are attributed to the presence of an isthmocele, also known as a ‘niche’ or ‘Cesarean scar defect (CSD)’ which arises due to a defect in the healing of a Cesarean section scar at the isthmic level. The authors in this study sought to evaluate the effect of a new hysteroscopic technique in the correction of isthmocele regarding improvement of CSS, sonographic CSD parameters and incidence of spontaneous pregnancy.

Methods: The study was conducted on 100 females in whom transvaginal ultrasound showed a depth scar defect of at least 2 mm and a residual myometrium of at least 3 mm. They were then randomized to one of two groups: Group A (50 cases) received hysteroscopic correction of isthmocele using the new technique & Group B (50 cases) did not receive hysteroscopic correction & received only medical treatment and expectant management for pregnancy. Participants were invited to visit the outpatient department at 1, 3, and 6 months after surgery to evaluate the niche depth and residual myometrial thickness, improvement of cesarean scar symptoms and incidence of spontaneous pregnancy.

Results: The mean improvement of postmenstrual spotting days in group A in the 1st, 3rd, and 6th months after hysteroscopic surgery was 2.16, 1.5, and 1 day respectively, which was significantly higher compared to 4.66, 4.16, and 3.78 days in the control group B, respectively (P < 0.001). Spontaneous pregnancy was observed in 21 patients (42%) in group A and in 12 patients (24.0%) in group B, p value = 0.056.

Conclusion: The new four-step hysteroscopic approach of isthmocele repair was significantly superior to expectant management in infertile women with a symptomatic niche with a RMT ≥ 3 mm in terms of higher pregnancy rates and clinical improvement of CSD syndrome.

Keywords: Isthmocele; Hysteroscope; Post-menstrual spotting