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CAESAREAN SCAR DEFECT
1.
CAESAREAN SCAR DEFECT Prof. Aboubakr Elnashar Benha university hospital, Egypt ABOUBAKR ELNASHAR CONTENTS 1. INTRODUCTION 2. PREVALENCE 3. RISK FACTORS 4. CLINICAL PRESENTATION 5. DIAGNOSIS 6. MANAGEMENT 7. PREVENTION 7 ABOUBAKR ELNASHAR
2.
INTRODUCTION ▪ Terms ▪ Uterine niche, uterine isthmocele, caesarean scar defect, uterine dehiscence and diverticulum, caesarean niche, and caesarean delivery scar pouch. ▪ Define ▪ An iatrogenic pouch-like defect at the site of previous caesarean scar due to defective tissue healing. ▪ Radiologically ▪ A triangular, hypoechoic or anechoic area at scar site. ▪ An indentation at the site of CS with a depth of at least 2 mm (European Niche Taskforce, 2019), ABOUBAKR ELNASHAR PREVALENCE ▪ Up to 70% women with previous CS ▪ With TVS: 24–70% ▪ With gel/saline instillation sonohysterography (SHG): 56– 84% ▪ With sonohysterography done 6 months post-CS: 45.6% ▪ An underestimation because ▪ Many asymptomatic ▪ Clinicians may not recognize niche as a cause of symptoms due to unawareness. ▪ Increases with increasing number of previous CS. ABOUBAKR ELNASHAR
3.
RISK FACTORS ▪ Niche forms due to poor healing of caesarean scar. I. Surgery factors: 1. Timing of CS: ▪ Cervical dilatation of >5 cm, >5 h duration of labour& advanced foetal station: large niche {thinner or lesser vascularized myometrium: inadequate healing} ▪ Longer active labour prior to emergency CS: increases risk (OR, 1.06). ▪ However, there is no difference between elective and emergency CS. ABOUBAKR ELNASHAR 2. Level Of Uterine Incision ▪ Lower uterine incision towards the cervix: poor healing { ▪ mucus secreted by cervical glands interferes with myometrial approximation. ▪ Mucus gradually increases the niche size} ▪ CS done in advanced labour after cervical effacement and also creation of uterovesical fold of peritoneum influence the level of uterine incision. ABOUBAKR ELNASHAR
4.
3. Uterine Closure Techniques a. Single-layer, decidua sparing closure technique: incomplete closure, compared to single full thickness closure. ▪ 95% patients with niches had single-layer closure without closing peritoneum. ❖ To minimize risk: 1. Proper anatomical approximation without tissue strangulation 2. If muscular edges are thick, they are best approximated by including deeper part in the first layer and the remaining superficial cut edges in the second layer. ABOUBAKR ELNASHAR Single-layer closure of the uterus may increase niche formation due to greater risk of incomplete closure. ABOUBAKR ELNASHAR
5.
b. Non-perpendicular sutures: 1. An irregular myometrium closure 2. Locking sutures or very tight second layer: ischemic necrosis: poorly healed scar: niche formation. ▪ Ischaemia by locking sutures is the single greatest risk factor for niche development. ❖ To minimize risk: Double-layer uterine closure using non- locking sutures is the optimal closure technique that results in thicker residual myometrium (Stegwee et al, 2018). ABOUBAKR ELNASHAR c. Suboptimal surgical techniques: ▪ Inadequate haemostasis ▪ Tissue ischemia, devascularization ▪ Excessive tissue manipulation contribute to poor scar healing and adhesions: niche. ABOUBAKR ELNASHAR
6.
4. Adhesions ▪ Adhesion formation with abdominal wall pulls the uterine scar towards abdominal wall, exerting counteracting force opposite to the direction of retracting uterine scar tissue: impaired wound healing 5. Retroflexed Uterus ▪ Effect of gravity on uterine corpus also increases counteracting forces. ▪ Large niches are mostly found with retroflexed uterus ABOUBAKR ELNASHAR Counteracting forces on CS uterine scar, due to retraction of adhesions between the uterine scar and the abdominal wall in a retroflected uterus: impair wound healing and increase the formation of niches. ABOUBAKR ELNASHAR
7.
▪ Laparoscopic image of a uterus with a large niche, illumination of the hysteroscopic light in the niche can be seen directly under the adhesions attached to the niche. Adhesions between the niche and the abdominal wall seen during laparoscopy (a), owing to the diaphany of the combined hysteroscopy it can be seen that the adhesions are located at the deepest point of the niche. ▪ Hysteroscopic image of the combined of a part of the large niche surface be seen in (b). ▪ Laparoscopic view on adhesions between the lower uterine segment and the bladder at the site of a niche. ABOUBAKR ELNASHAR II. Patient Factors 1. Genetic predisposition contributes to impaired healing, poor haemostasis, inflammation, or adhesion formation, post- operative infection 2. Gestational diabetes (odds ratio, 1.73), previous CS (OR, 3.14) are independent risk factors. 3. Advanced BMI (OR,1.06) • Risk increases by 6% for every additional unit increase in BMI. ABOUBAKR ELNASHAR
8.
CLINICAL PRESENTATION ▪ Most asymptomatic ▪ 30% are symptomatic. = gynecologic complications 1. Bleeding: ▪ Post-menstrual Spotting ▪ ≥ 2 d of intermenstrual spotting, or ≥2 d of brownish discharge after the end of menstruation if bleeding duration ≥7 d (discharge is normal if bleeding duration is <7 d) ▪ Most predominant symptom seen in 30–55% women at 6–12 months post CS ▪ {1. collected menstrual blood. The anterior edge of niche obstructs flow of menstrual blood 2. Poor contractility of surrounding fibrosed muscle retains it which is then discharged gradually}. ABOUBAKR ELNASHAR ▪ Prolonged Bleeding ▪ Impaired menstrual drainage: prolonged flow. ▪ Since not yet specified, it may be described as AUB-N as per FIGO-PALMCOEIN nomenclature of AUB ▪ Intermittent Spotting ▪ In situ blood formation in the niche, evidenced by free erythrocytes in scar: intermenstrual spotting. ▪ Midcycle Intrauterine Fluid Accumulation ▪ {excess mucus formation by retained blood} ▪ approximately 45% women. ABOUBAKR ELNASHAR
9.
2. Pain ▪ Dysmenorrhea (40–50%) ▪ Chronic pelvic pain (35%), ▪ Dyspareunia (18%) or suprapubic pain. ▪ {abnormal myocontraction to empty niche contents} ▪ Size of the niche is important, with larger niches being more likely to present with pain 3. Secondary Infertility ▪ {chronic inflammation by residual blood or peri-ovulatory fluid accumulation interfering with sperm penetration, fertilization and implantation}. ▪ large niche interfere with conception similar to hydrosalpinx. ABOUBAKR ELNASHAR 4. Problems in IVF ▪ Difficult ET in 20% women with niche undergoing IVF, due to a distorted anatomy, specially in a retroflexed uterus ▪ Chances of unsuccessful IVF are higher 5. Bladder Dysfunction ▪ Local accumulation of fluid and scarring: dysfunction due to proximity of niche to the bladder ▪ Prospective studies did not support this. 6. Scar Abscess ▪ rare, it has been reported even up to 6 years after CS ▪ {residual blood and mucus that gets infected}. ABOUBAKR ELNASHAR
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▪ Obstetric Complications in Future Pregnancy 1. Caesarean Scar Ectopic Pregnancy: Pregnancy may implant in the niche 2. Placenta accrete 3. Scar dehiscence and uterine rupture. ABOUBAKR ELNASHAR DIAGNOSIS ▪ Diagnostic criteria: No consensus ▪ An anechoic space at least 1 mm deep (vertical distance between base and apex), ▪ with or without fluid, and ▪ at least 2 mm deep in the myometrium at caesarean scar site clinches the diagnosis. ABOUBAKR ELNASHAR
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1. Niche Size And Residual Myometrium ▪ Residual myometrial thickness (RMT) is the vertical distance between uterine serosa and apex of defect ▪ Large niches are defined when ▪ RMT is<50% of adjacent myometrium or ▪ ≤2.2 mm on TVS or ▪ ≤2.5 mm with SHG. ▪ ≤ 3 mm (Marotta et al,2015) ▪ Total defect: Absent residual myometrium ABOUBAKR ELNASHAR Anechoic area at the site of a previous cesarean section. This niche is usually triangular-shaped 3D view of the niche 2-D ultrasound showing uterus, cervix, niche (n) measuring 1 cm, collection in the niche (C) and bladder (B) ABOUBAKR ELNASHAR
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SHG of the isthmocele before surgery showing a 2.3 mm residual myometrium. ABOUBAKR ELNASHAR SHG of the isthmocele 23 months after surgery showing a 2.9 mm residual myometrium. ABOUBAKR ELNASHAR
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2. Shape ▪ Most defects are triangular or semicircular ▪ Round, oval, droplet shape and inclusion cysts described. ▪ An inward protrusion, i.e. internal scar surface bulging toward uterine cavity ▪ Outward protrusion, i.e. external scar surface bulging toward bladder or peritoneal cavity or ▪ Inward retraction, i.e. external scar surface dimpled toward the myometrium. 3. Other Features ▪ Concavity, abnormal vascularity, visible serosa, cyst- or polyp-like structure should also be mentioned. ABOUBAKR ELNASHAR Main niche and vesicovaginal fold. (a) Red and green areas represent main niche and blue area represents branch. (b) Green line indicates plica vesicouterina or uterovesical fold, while red line indicates vesicovaginal fold. ABOUBAKR ELNASHAR
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Position of calipers for different sonographic measurements of uterine niche in the sagittal plane. ABOUBAKR ELNASHAR Position of calipers for sonographic measurement of width of uterine niche in transverse plane. Both largest width and width at niche base should be measured. ABOUBAKR ELNASHAR
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▪ European Niche Taskforce consensus,2019 recommended the following measurements: ▪ Depth and width of the hypoechoic defect in sagittal plane ▪ Length of the defect in transverse plane ▪ Residual myometrial defect in the sagittal plane ▪ Did not specify any assessment for morphology of a niche ABOUBAKR ELNASHAR ▪ In the sagittal plane ▪ Length ▪ Depth: starting from uterine cavity to the apex of the niche. ▪ Residual myometrium is measured from the apex of the niche to the serosa: crucial in planning surgery. ▪ Adjacent myometrial thicknesses ▪ In the transverse plane ▪ Width ▪ any branches. If present, should be investigated ▪ distance of the niche from uterovesical fold ▪ distance of the niche from external os which is important in planning appropriate surgery. ABOUBAKR ELNASHAR
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(a) In sagittal view, a sonographic defect of at least 2 mm associated with a residual myometrial thickness of <5 mm defines the presence of a niche on TVS. (b–d) Essential sonographic measurements including length (i.), depth (ii.), RMT (iii.), adjacent myometrial thickness (iv.), niche to vesicouterine fold (v.) and niche to level of external cervical os (vi.). If present, branches are treated separately with regard to depth and RMT measurements. ABOUBAKR ELNASHAR ▪ Methods of visualization ▪ HSG ▪ TVS, SHG, GHS ▪ 3-D US ▪ MRI ▪ Hysteroscopy ABOUBAKR ELNASHAR
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1. TVS ▪ The first diagnostic tool available to most clinicians when investigating a woman with abnormal uterine bleeding ▪ More easily accessible in most clinical settings ▪ Less-invasive imaging modality ▪ The presence of fluid in the niche, would obviate the need for additional gel or saline instillation. ▪ {fluid is commonly seen during the midfollicular phase, niche evaluation should be done between D7 and 14 of the cycle. ABOUBAKR ELNASHAR 2. SHG ▪ SHG is the investigation of choice. 1. More accurate: Higher prevalence (45% vs. 22%) 2. Sensitivity & specificity of TVS when compared to SHG are 49% and 100%, respectively. 3. Niches missed with TVS are usually small though they can be clinically relevant. ▪ SHG at 6–12 w post-partum when scar is incompletely healed ▪ facilitates recognition of scar and small niches ▪ aided by the thin endometrium during breastfeeding. ABOUBAKR ELNASHAR
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3. GIS ▪ Gold standard for assessing a niche ▪ Higher detection rates compared with TVS. ▪ Adjusting pressure with the transvaginal probe to assess fluid shift, or using Doppler. ▪ To facilitate and optimise imaging ABOUBAKR ELNASHAR 4. Hysteroscopic appearances ▪ concavities in the isthmus with a prominent distal ridge, breech of the mucosa to varying depths, lateral branches, the presence of abnormal vascular patterns, and the presence of cyst-like or polypoid structures. 5. Laparoscopy ▪ ballooning of the lower segment often associated with dense adhesions to the bladder or anterior abdominal wall. ABOUBAKR ELNASHAR
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(A) TVS Sagittal view: The CSD corresponds to an anechoic area (arrow) measuring 14.41 mm in length and 8.13 mm in depth. RMT is 1.78 mm. (B) MRI: Sagittal view of a T2- weighted showing a large CSD covered with a thin layer of myometrium (arrow). Dense adhesions (ellipse) can be seen between the anterior uterine wall and abdominal wall at some distance from the CSD. (C) Hysteroscopy: Dendritic blood vessels (arrows) on the surface of the CSD. (D) Hysteroscopy: Old blood retention on the right lateral part of the CSD (arrow). ABOUBAKR ELNASHAR (a) Mid-sagittal plane; (b) transversal plane; (c) schematic diagram of a niche; (d) niche seen by hysteroscopy, the internal os is out of the scope of this picture. ABOUBAKR ELNASHAR
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MANAGEMENT ▪ Indications of treatment: ▪ only in symptomatic women presenting with ▪ Secondary infertility ▪ Previous scar ectopic ▪ Recurrent miscarriage ▪ AUB and bothersome post-menstrual spotting. ▪ However, efficacy of treatment is yet to be ascertained. ▪ Routine repair of incidentally diagnosed niche with no plans for future childbearing is not recommended. Treatment options for a uterine niche are as follows: ABOUBAKR ELNASHAR Marotta et al, 2013 ABOUBAKR ELNASHAR
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A. Medical Treatment ▪ Hormonal therapy symptomatically relieves AUB. ▪ Oral contraceptives are suitable if pregnancy is not desired. ▪ LNGIUS was not found to decrease menstrual length ▪ Symptoms related to menstrual bleeding should be managed medically in the first instance with usual hormone treatment, unless contemplating conception ABOUBAKR ELNASHAR B. Uterine Sparing Surgical Treatment ▪ Conservative surgical interventions should be considered after eliminating other causes of presenting symptoms. ▪ The options include either ▪ Resection by hysteroscopic route or ▪ Excision plus repair by ▪ Transabdominal: ▪ Laparotomy ▪ Laparoscopic ▪ Robotic ▪ Vaginal route ABOUBAKR ELNASHAR
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I. Hysteroscopic Niche Resection or Isthmoplasty 1. Resection ▪ of only distal rim, or both distal and proximal edges with resectoscope using bipolar or unipolar current ▪ facilitates drainage of menstrual blood, though it inevitably increases niche size. 2. Coagulation ▪ of fragile vessels at the base or even entire niche with ball electrode. ▪ Fulgurating base prevents in situ fluid/blood collection. ▪ At the end of procedure, flow and pressure of distending medium can be reduced to ensure adequate haemostasis. ABOUBAKR ELNASHAR Hysteroscopy surgery: (1) view of the cesarean scar defect (2) resection of the fibrotic tissue of the inferior part of the scar (3) local fulguration of the dilated blood vessels and endometrial glands (4) final view ABOUBAKR ELNASHAR
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Hysteroscopic excision: a. CSD with uterine synechiae formation within the cavity b. CSD with a distal ridge c. after resection and rollerball coagulation ABOUBAKR ELNASHAR Hysteroscopic resection e. The superior and inferior edges of the CSD are resected (arrows), and the bottom of the defect (triangles) is fulgurated or electrocoagulated. f. Final view after hysteroscopic resection of the CSD. ABOUBAKR ELNASHAR
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Remodeling(hysteroscopic): Reshaping the isthmocele so that it becomes asymptomatic ABOUBAKR ELNASHAR ▪ Complications ▪ Uterine perforation ▪ Bladder injury especially if overlying RMT<3 mm, ▪ Cervical incompetence with proximal rim resection ▪ Uterine rupture in subsequent pregnancies ▪ Bladder safety can be ensured by ▪ intraoperative ultrasound guidance and ▪ filling bladder with methylene blue as shown in HysNiche trial ABOUBAKR ELNASHAR
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II. Niche Repair ▪ Repair is the preferred method when RMT is <3 mm ▪ involves 1. Identification of defect by simultaneous ▪ Hysteroscopy ▪ Hegar’s dilator, ▪ Intracervical foley’s catheter, ▪ Transvaginal or transrectal ultrasound 2. Excision of fibrotic tissue from the edges 3. Re-approximation in 2 Layers ▪ by ▪ Transabdominal: laparotomy, laparoscopic,robotic route ▪ Vaginal route. ABOUBAKR ELNASHAR Repairing (laparoscopic, vaginal or laparotomic): ▪ Adhesiolysis ▪ cutting, debridement ▪ suturing of the isthmocele ABOUBAKR ELNASHAR
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Laparotomy repair a bulge prior to incision b after incision over niche c after excision of fibrotic tissue from the niche edges ABOUBAKR ELNASHAR Laparoscopic repair: ▪ A transillumination view by laparoscopy; the view is from laparoscopy without any light enabling the visualization of the defect with the help of hysteroscopy light through the defect. ▪ Laparoscopic tissue removal, a view of the vesicouterine pouch with scar tissue being pulled and resected with cold scissors ▪ Laparoscopic suturing of the defect after isthmocele resection suturing the defect in double-layer suture enabling a thicker and stronger uterine wall ABOUBAKR ELNASHAR
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Laparoscopic repair ▪ view on a mucus-containing large niche that is located in the lower cervix. ▪ Mucus is expelled during a laparoscopic niche resection after dissection of the bladder and opening of the niche ABOUBAKR ELNASHAR Laparoscopic repair: a. view of the cesarean scar with a probe inserted into the endocervix. The residual myometrium covering the scar is very thin (arrow). b. cesarean section scar defect cavity (arrows) c. first layer of suture (arrows) d. second layer of suture (arrows). ABOUBAKR ELNASHAR
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Laparoscopic repair (1) identification of the affected area (2) bladder dissection (3) opening of the scar (4) first-layer suture (5) second-layer suture (6) final view Vaginal ABOUBAKR ELNASHAR ▪ Vervoort’s technique ▪ Laparoscopic repair combined with hysteroscopy ▪ Round ligament plication in extremely retroflexed uterus ▪ using hyaluronic acid as adhesion barrier. ▪ Nirgianakis’ ‘Rendezvous technique ▪ laparoscopy light source is put of with simultaneous hysteroscopy light eliciting the ‘Halloween sign’ or ‘positive diaphanoscopy’ or transillumination where hysteroscopy light shines through the defect ABOUBAKR ELNASHAR
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a. Dense adhesions (arrows) between the anterior uterine wall and anterior abdominal wall b. CSD (between arrows). No adhesions are visible between the CSD and the bladder c. Complete resection of fibrotic tissue (arrows) is essential to ensure further healing d. first-layer suture before the knots are tightened e. second-layer suture before the knots are tightened f. after covering the suture with a bladder peritoneal flap. ABOUBAKR ELNASHAR ▪ ‘slip and hook’ technique ▪ Hegar dilator is placed in cervical canal and is blindly slipped anteriorly to bulge out and perforate the defect under laparoscopic vision ▪ Donnez technique ▪ large isthmoceles are excised laparoscopically using CO2 laser ▪ round ligaments shortening in retroflexed uterus. ABOUBAKR ELNASHAR
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▪ Vaginal route ▪ Can be undertaken by experienced surgeons when niche is not at higher level. ▪ After reflecting bladder from cervix, niche is identified, excised and hysterotomy closed in two layers. ▪ Cost-effective with shorter operation time. ▪ Simultaneous hysteroscopy to visualize niche by transillumination and single-port laparoscopy-assisted vaginal repair is also described. ABOUBAKR ELNASHAR ▪ Preference of the Route ▪ All effective, and no particular TT modality superior to the other in a recent systematic review of 30 studies ▪ Hysteroscopic resection: smaller niches of <2.5–3 mm with RMT>3 mm ▪ Vaginal route is preferred when niche is at the lower level. ▪ Transabdominal approach preferred for ▪ large defects residual myometrium is<3 mm as bladder can be mobilized out of surgical field offering better niche visualization with lesser bladder injury. ▪ Women desiring future pregnancy since uterine wall thickness and strength increase. ABOUBAKR ELNASHAR
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▪ Among transabdominal routes ▪ laparoscopy and robotic surgery offer advantages of being minimally invasive with lesser morbidity. ▪ Incidental endometriosis is reported in 21% women; hence, consent for correction of any associated pathology should also be taken if transabdominal route is planned. ❑ Hysterectomy offers definitive treatment for niche-related gynecological symptoms ABOUBAKR ELNASHAR ▪ Macroscopic image of a uterus with a niche, removed by laparoscopy because of AUB and dysmenorrhoea. ▪ Note that the adhesions are located at the deepest point of (a relatively small) niche. (A) Sagittal view of a frozen section from a hysterectomy specimen. A shallow depression covered with a thick layer of myometrium (rectangle) at the level of the supposed site of CS (B) Sagittal view of a frozen section from a hysterectomy specimen. A deep anterior defect covered with a thin layer of myometrium (rectangle) can be seen at the level of the supposed site of CS (C) Enlarged view of the shallow depression from A (D) Enlarged view of the deep anterior defect from B (E) Actin immunostaining in a hysterectomy specimen. The muscular density of myometrium covering CSD is similar to adjacent healthy myometrium (F) Actin immunostaining in an excised CSD. The muscular density of myometrium covering the CSD is significantly decreased compared with adjacent healthy myometrium. ABOUBAKR ELNASHAR
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▪ Outcomes of Surgical Management of Post-caesarean Niche ▪ Hysteroscopic niche resection ▪ Pain improvement in 97% ▪ Reduces post-menstrual spotting by a median of 3.8 days ▪ Complete resolution of AUB in 72.4% cases ▪ AUB gets cured in 87.5% patients within first month and 96.8% patients in the second month after surgery ▪ 5% patients may have recurrence ABOUBAKR ELNASHAR ▪ Laparoscopic repair: ▪ Vervoort’s study:101 women with large niche&<3 mm RMT ▪ 79% had symptom relief ▪ 83.3% women felt very satisfied ▪ Post-menstrual spotting reduced by 7 days at 6 months, ▪ Dysmenorrhea reduced ▪ Myometrial thickness increased ▪ Donnez study ▪ 93% symptom-free ▪ increase in mean myometrial thickness from 1.4 to 9.6 mm at 3-month follow-up, ▪ 44% pregnancy rate in infertile women, all delivered at ABOUBAKR ELNASHAR
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▪ (A, C, E) Sagittal view of T2-weighted MRI showing a thin RMT; arrows) covering a deep CSD ▪ (B, D, F) Sagittal view of postoperative T2- weighted MRI after laparoscopic repair. The defect is corrected and RMT is significantly increased at the level of the isthmus (arrows). ABOUBAKR ELNASHAR ▪ Calzolari, in a retrospective study (n=35), noted ▪ Isthmocele as the primary cause of infertility in 45.7% ▪ all women were relieved of AUB and pain ▪ 56.3% conceived after hysteroscopic isthmoplasty. ▪ Women who failed to conceive had higher BMI, higher isthmocele grade, higher number of prior CS and advanced age. ▪ Pregnancy rate varied from 22–71% in various studies. ABOUBAKR ELNASHAR
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▪ Enderle study: retrospective series of 18 surgically treated ▪ Poor obstetric outcomes with 55% miscarriages ▪ Hysteroscopy had poorer results as miscarriage occurred in 3/4 patients. ▪ One patient who underwent transvaginal repair delivered vaginally; others underwent CS ▪ Another study ▪ Pregnancy rate of 71% as 10/14 infertile women conceived including six spontaneous pregnancies after laparotomy, laparoscopy or vaginal approach ▪ Eight had CS; one had vaginal delivery, and one aborted, with no case of placenta accrete or rupture. ABOUBAKR ELNASHAR PREVENTION OF NICHE FORMATION ▪ Primary prevention by minimize CS rates ▪ Secondary prevention by adopting correct surgical techniques ensuring thicker residual myometrium and strong scar ABOUBAKR ELNASHAR
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(a) Recommended traditional judicious double layer closure with the first continuous non-locking suture to include minimal decidua (< 5 mm) and about two-thirds of inner myometrium; and second nonlocking suture taking upper half of myometrium would correct eversion of myometrial edges. This used to be the long- standing practice in UK more than a decade ago. Care should be taken not to make the edges of the incision ischemic. (b) One-layer closure could interpose decidua in between inner myometrium and the superficial myometrial edges can often be seen to be everted (not in good apposition). (c) The current popular technique in UK. The transverse myometrial bites of second layer are taken with the needle travelling back and forth on either side of incision which seem partly akin to “figure-of-eight” haemostatic/devascularizing sutures. It is easy to be paradoxically reassured by the apparent (excessive) apposition and sense of security derived from very tight sutures. Ischemic necrosis is likely to be causative in CS defect. ABOUBAKR ELNASHAR ABOUBAKR ELNASHAR
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▪ A recent study in 138 women demonstrated that uterine closure using far-far-near-near double-layer unlocked technique may benefit in reducing isthmocele formation and ensuring sufficient residual myometrium (Kalem et al, 2019) Top view of tissue sutured by far-far, near-near suture technique. chematic representation of far- ar, near-near uture technique. ABOUBAKR ELNASHAR CONCLUSION ▪ Risk factors: ▪ potentially iatrogenic ▪ With increasing caesarean delivery rates, niche-related problems are predicted to rise ▪ Diagnosis: ▪ requires high index of suspicion. ▪ significant morbidity in at least one-third of women ▪ Prevention: ▪ non-locking double layer closure of the uterus with inclusion of the innermost decidua ▪ careful surgical prowess to avoid a low incision. ABOUBAKR ELNASHAR
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▪ Treatment: ▪ For bleeding symptoms, hormonal treatment is preferable, whereas subfertility may require surgical correction ▪ Surgery not recommended as first-line option for menstrual symptoms. ▪ Hysteroscopic resection is preferred for smaller niches with RMT > 3 mm, ▪ Niche located lower down can be treated transvaginally ▪ Transabdominal approach is preferred for large defects and in women desiring future pregnancy. ▪ Surgery is very effective, not without substantial risk, and should be performed only by experienced surgeons. ABOUBAKR ELNASHAR ABOUBAKR ELNASHAR
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