Review Article

Treatment for Uterine Isthmocele, A Pouchlike Defect at the Site of a

Cesarean Section Scar
Antonio Setubal, MD, João Alves, MD, Filipa Osório, MD, Adalgisa Guerra, MD,
Rodrigo Fernandes, MD, Jaime Albornoz, MD, and Zacharoula Sidiroupoulou, MD
From the Hospital da Luz, Lisboa, Portugal (Drs. Setubal, Alves, Osório, and Guerra), Instituto do Câncer da Cidade de São Paulo/Faculdade de Medicina
da Universidade de São Paulo Instituto do Câncer do Estado de São Paulo, São Paulo, Brazil (Dr. Fernandes), Clinica Las Condes, Santiago, Chile
(Dr. Albornoz), and General Surgery Department, Hospital São Francisco Xavier, Centro Hospitalar Lisboa Ocidental, Lisboa, Portugal
(Dr. Sidiroupoulou).

ABSTRACT An isthmocele appears as a fluid pouchlike defect in the anterior uterine wall at the site of a prior cesarean section and ranges
in prevalence from 19% to 84%, a direct relation to the increase in cesarean sections performed worldwide. Many defini-
tions have been suggested for the dehiscence resulting from cesarean sections, and we propose standardization with a single
term for all cases—isthmocele. Patients are not always symptomatic, but symptoms typically include intermittent abnormal
bleeding, pain, and infertility. Pregnancy complications that result from an isthmocele include ectopic pregnancy, low im-
plantation, and uterine rupture. Magnetic resonance imaging and transvaginal ultrasound are the gold standard imaging techniques
for diagnosis. Surgical treatment of an isthmocele is still a controversial issue but should be offered to symptomatic women
or the asymptomatic patient who desires future pregnancy. When surgery is the treatment choice, laparoscopy guided by
hysteroscopy, hysteroscopy alone, or vaginal repair are the best options depending on the isthmocele’s characteristics and
surgeon expertise. Journal of Minimally Invasive Gynecology (2018) 25, 38–46 © 2017 AAGL. All rights reserved.
Keywords: Cesarean scar dehiscence; Hysteroscopy; Laparoscopy; Vaginal repair

It has been 30 years since the World Health Organiza-
tion released a statement warning about the high rate of
cesarean sections [1] and recommending a maximum 15%
rate of surgical intervention. Despite this, the United States
reported an increase of 50% in cesarean sections from 1996
to 2007 [2], and other countries such as Brazil reported an
overall cesarean section rate of 45% and a private practice
rate of 81% [3]. The choice of delivery method is a complex
topic based on physical and psychological health, social and
cultural context, and quality of maternity care. However, it
is imperative for patients to be informed of the risks of both
vaginal and cesarean deliveries [4].
An isthmocele, also called a niche, cesarean scar defect,
or cesarean scar dehiscence, is a pouchlike defect of the an-
terior uterine isthmus at the site of a prior cesarean section
[5], which was first described by Morris in 1995 [6] and treated
The authors declare that they have no conflict of interest.
Corresponding author: João Alves, MD, Hospital da Luz, Avenida Lusíada,
100, Lisboa, 1500-650 Lisboa, Portugal.
E-mail: jmiguelalves@gmail.com
Submitted June 15, 2017. Accepted for publication September 5, 2017.
Available at www.sciencedirect.com and www.jmig.org
1553-4650/$ — see front matter © 2017 AAGL. All rights reserved.
https://doi.org/10.1016/j.jmig.2017.09.022
first laparoscopically by Jacobson et al in 2003 [7]. The first
scar defect ever reported was in 1975 when Stewart et al [8]
noted that preoperative hysterography or pelvic arteriogra-
phy might help with diagnosis and that the uterus could be
saved by excision of the lower segment scar. The world-
wide prevalence of isthmoceles out of all cesarean sections
ranges from 19% to 84% [9–13], but this may be underes-
timated because of asymptomatic patients and a lack of
clinician awareness. Sonohysterography (SHG) identified a
higher number of patients with isthmoceles (56%–78%) than
transvaginal ultrasound (24%–69%) as noted by van der Voet
et al [14].
Symptoms
Many patients with isthmoceles are asymptomatic, and pa-
tients might consult with different physicians before the correct
diagnosis is found. The most frequent complaint relates to
intermittent postmenstrual bleeding. The isthmocele func-
tions as a reservoir collecting blood during menstruation, with
irregular menses that can persist from 2 to 12 days [15].
Vervoort et al [16] and van der Voet et al [14] reported that
28.9% to 30% of patients with isthmoceles experienced
Setubal et al. A Review of Uterine Isthmocele Treatment
abnormal bleeding compared with 6.9% of patients without
it. In addition, women with an isthmocele defect greater in
size than half of the adjacent myometrium reported abnor-
mal uterine bleeding more frequently [17]. Because of other
more common causes of irregular menstruation, clinicians
might not identify this specific symptom to be related to the
scar defect.
Several authors [10,18,19] have described isthmoceles as
a cause of infertility, stating deficient sperm motility and im-
plantation. Pain and dysmenorrhea are general symptoms
common to numerous gynecologic causes. The relationship
between isthmoceles and pain is not clear but could be related
to abnormal myocontraction caused by physiological irregu-
larities and continuous efforts of the uterus to empty the
contents of the isthmocele. Wang et al [20] found a signifi-
cant relationship among dysmenorrhea, the width of the defect,
and abnormal bleeding. Van der Voet et al [14] reported a
97% improvement in pain when isthmoceles were resected
hysteroscopically. The incidence of ectopic pregnancies im-
planted in the myometrium at the site of the isthmocele is
reported to be approximately 1 in 1886 to 2216 pregnancies
[21–23]. With the development of the fetus and expansion
of the gestational sac, the walls of the isthmocele might
rupture, presenting a risk to both the mother and the fetus.
There are more than 30 options to treat ectopic pregnancy
in the myometrium including methotrexate injection; removal
by means of the vaginal, hysteroscopy, laparotomy, or lapa-
roscopy approach; or hysterectomy [23]. The choice depends
on the patient’s desire for future fertility and team expertise.
Imaging
An isthmocele is typically diagnosed on transvaginal
sonography or SHG and appears as a wedge-shaped an-
echoic area with a depth of at least 1 mm and an indentation
of the myometrium of at least 2 mm in the uterine isthmus
at the cesarean section scar site [19]. Ultrasound is used to
measure the depth and size (longitudinal) of the dehiscent
scar and the thickness of the residual myometrium covering
the dehiscence. The prevalence of cesarean scar defects in
randomly selected women with previous cesarean sections
was found more frequently with SHG compared with trans-
vaginal sonography (56%–84% vs 24%–70%) [19].
Magnetic resonance imaging is useful to evaluate the thick-
ness of the lower uterine segment, the depth of the isthmocele,
and the content of the endometrial and niche cavity (Fig. 1).
It allows the evaluation of other associated pathologies such
as adenomyosis or adnexal, uterine, or pelvic diseases.
Methods
We searched PubMed, Cochrane Review, Clinical Trials,
and Scholar Google for studies published between 1980 and
July 2017 using the following keywords and Medical Subject
Headings: isthmocele, cesarean scar defect, uterine scar defect,
pouch, sacculation niche, and surgery. Articles published in
39
English, French, Spanish, and Portuguese languages were se-
lected. All published articles with a clinical description of the
treatment of an isthmocele were selected, excluding case
reports, review articles, and video reports. Video and case
reports of treatment not previously described were in-
cluded. Two-hundred fifteen studies were found. We excluded
175 studies that did not address isthmocele management; we
excluded another 10 studies because they were review ar-
ticles or previously published video or case reports. Two case
reports were included because of their innovative descrip-
tion of isthmocele management (Fig. 2). The studies were
analyzed according to the Preferred Reporting Items for Sys-
tematic Reviews and Meta-Analyses statement and The
Cochrane Collaboration’s Risk of Bias Tools for Non-
Randomized Studies.
Results
Tables 1 and 2 describe all included studies and the type
of treatment for each study [5,16,18,24–50].
Isthmocele Treatments
Medical Treatment
Zhang et al [26] have published a study on the use of oral
contraceptives with estrogen and progesterone in 18 pa-
tients and have found it to be effective regarding the duration
of menses (reducing from 10 days to 5 days). Other authors
[24,25] have also described oral contraceptives to be effec-
tive in reducing bleeding disorders. Florio et al [25] have
described less bleeding and less pain after the use of oral con-
traceptives or hysteroscopic resection with better results in
women undergoing hysteroscopic correction compared with
oral contraceptives. The use of an intrauterine device with
levonorgestrel (Mirena; Bayer, Whippany, NJ) has not shown
a benefit in these women [26], but a short follow-up of only
6 months was reported. The main disadvantage to using oral
contraception is avoiding pregnancy. Thus, the best medical
treatment for women with isthmoceles who do not want to
become pregnant seems to be oral contraception.
Vaginal
Surgery by means of the vagina has been described by
Zhang et al [26,42] and others [33,37,39,46–48]. According
to Zhang et al [26,42], once the cervix was grasped by 2
forceps, diluted bovine pituitary hormones were injected
subepithelially at the cervicovaginal junction to determine
tissue planes and reduce minor bleeding. The incision was
made where the hormone was injected, and the bladder was
then deflected off the anterior cervix. Once identified at the
uterine isthmus, the isthmocele was excised and repaired.
Zhang [42] has reported no complications (14 patients). This
technique requires surgical expertise to avoid damaging the
surrounding organs. It also necessitates that the isthmocele
is not too high or vaginal correction would be difficult. Results
40 Journal of Minimally Invasive Gynecology, Vol 25, No 1, January 2018

Fig. 1
A magnetic resonance image of an isthmocele. On the left is the sagittal T2 view of the female pelvis with the thickness of the anterior uterine wall. On
the right are axial and sagittal T2 sequences with longitudinal, anteroposterior, and transversal diameters of the saccular defect.

show that menstruation duration diminishes after treatment
[26] and myometrial thickness increases [42].
Most patients have symptom relief (reported between 85%
and 93%) and minor if any complications after this surgical
approach. Xie et al [33] and Zhang et al [26,42] have noted
a resulting 22% pregnancy rate.
Laparotomy
Schepker et al [49] have described laparotomy as a com-
plete resection of the dehiscent myometrium and a 2-layered
suture with 2-0 to 4-0 Vicryl interrupted sutures (Ethicon,
Somerville, NJ). It is important to correct the myometrial
wound margins layer by layer (“‘edge-to-edge’”) as well as
hemostasis [49]. Other groups have reported the same pro-
cedure with good clinical results (i.e., a shorter duration of
menstrual period and improved fertility) [39,50]. No com-
plications have been noted [39,49], and Jeremy et al [39] have
described a 71% pregnancy rate after laparotomy.
Hysteroscopy
Several articles have reported hysteroscopic treatment of
isthmoceles [5,16,18,25–35]. Xie et al [33] have reported 1
of the largest series with 77 patients with hysteroscopic treat-
ment. Using monopolar electrical current for cutting and
coagulation and sterile preparation, the cervix was dilated to
12 mm. The hysteroscope (Figs. 3 and 4) was then introduced
Setubal et al. A Review of Uterine Isthmocele Treatment 41

Fig. 2 Table 1
The Preferred Reporting Items for Systematic Reviews and Meta-
The Type of Treatment for Isthmoceles
Analyses flowchart.
Type of Treatment Studies
Records identified through database search
n = 215
Expectant Vervoort et al, 2015 [16]
Articles excluded Hormonal Tahara et al, 2006 [24]
n = 175
Florio et al, 2011 [25]
Zhang et al, 2016 [26]
Full text articles assessed for eligibility Hysteroscopic Gubbini et al, 2008 [5]
n = 40
Vervoort et al, 2015 [16]
Excluded review Gubbini et al, 2011 [18]
articles, case reports,
and video reports Fabres et al, 2005 [27]
n = 10 Chang et al, 2009 [28]
Studies included in the review Florio et al, 2011 [25]
n = 30
Wang et al, 2011 [29]
Feng et al, 2012 [30]
Li et al, 2014 [31]
Perez-Medina et al, 2014 [32]
under direct visualization, and after determining the loca- Xie et al, 2014 [33]
tion of the isthmocele, a cutting loop was used to remove the Raimondo et al, 2015 [34]
fibrotic tissue flap under the pouchlike defect, from the bottom Tanimura et al, 2015 [35]
of the defect to the endocervical canal. The remainder of the Zhang et al, 2016 [26]
pouch was cauterized [33]. Hysteroscopic treatment seems Laparoscopy Donnez et al, 2008 [36]
Klemm et al, 2005 [37]
useful in cases of infertility, as described by Tanimura et al
Yalcinkaya et al, 2011 [38]
[35]. No complications have been noted although Raimondo
Jeremy et al, 2013 [39]
et al [34] have reported 16 of 120 patients with the same symp- Marotta et al, 2013 [40]
toms postoperatively. Li et al, 2014 [31]
Tanimura et al, 2015 [35]
Laparoscopy Nirgianakis et al, 2016 [41]
The first laparoscopic repair of a uteroperitoneal fistula Zhang et al, 2016 [26]
Zhang, 2016 [42]
caused by cesarean section was performed by Jacobson et al
Liu et al, 2016 [43]
[7]. A skilled laparoscopic surgeon can use conventional lapa-
Akdemir et al, 2017 [44]
roscopy or robotic-assisted surgery to correct an isthmocele. Donnez et al, 2017 [45]
The surgical technique (Figs. 5–7) was described by Donnez Vaginal Klemm et al, 2005 [37]
et al in 2008 [36], and his group has recently published a large Luo et al, 2012 [46]
prospective series with 38 patients [45]. The surgical tech- Jeremy et al, 2013 [39]
nique was described as using carbon dioxide laser, the scar Chen et al, 2014 [47]
was opened from one end to the other, and fibrotic tissue was Xie et al, 2014 [33]; Zhang et al, 2016 [26]
excised from the edges of the defect to access the healthy Zhang, 2016 [42]
myometrium [45]. Before closing, a Hegar probe (Skalar Sur- Zhou et al, 2016 [48]
gical Instruments, West Chester, PA) was inserted into the Levonorgestrel system Zhang et al, 2016 [26]
Laparotomy Jeremy et al, 2013 [39]
cervix to preserve continuity of the cervical canal with the
Schepker et al, 2015 [49]
uterus [45]. Multiple layers of separate sutures were used to
Pomorski et al, 2017 [50]
achieve double-layer closure, and the peritoneum was then
closed [45].
The critical step of this procedure is to correctly identify
the isthmocele, which can be accomplished using the fol- endocervical canal and forwarded blindly at the level of the
lowing techniques: hysteroscopy to evaluate the uterine cavity uterine isthmus. This maneuver distended the isthmocele on
and the defect; if the isthmocele is not identified by laparos- the uterine wall. The continuing pressure led to a “hooking
copy, hysteroscopy can be repeated; and the tip light of the effect,” which defined the defect more, allowing it to be per-
hysteroscopic instrument can be inserted into the defect. forated under laparoscopic visualization. This method has been
Donnez et al [45] used the dimmed light of the laparo- described by Api et al [51] in a case report and named the
scopic instrument concomitantly to illuminate the “slip and hook technique” to locate the isthmocele. After-
hysteroscopic light through the scar. If at this point the ward, the scar tissue can be completely excised and the dilator
isthmocele was not correctly identified, a number 6 Hegar pulled back gently as a guide for suturing the myometrium
dilator (Skalar Surgical instruments) was placed in the and preserving the continuity of the cervical canal (Figs. 5–7).
 42
Table 2
A Description of the Articles Found

Treatment Authors Study Type Risk of Bias Limitations Number of

Patients Treated
Hysteroscopic Fabres et al, 2005 [27] Retrospective Serious No clear definition of inclusion criteria, no clear description of assessment 24
outcome, no correction of confounders
Vaginal/laparoscopy Klemm et al, 2005 [37] Retrospective Critical Small number of patients, no clear definition of inclusion criteria, no uniform 5
surgical procedure
Hormonal Tahara et al, 2006 [24] Retrospective Serious No clear definition of inclusion and exclusion criteria, no clear definition of 11
abnormal uterine bleeding, posttreatment evaluation is not reported
Laparoscopic Donnez et al, 2008 [36] Retrospective Serious Small number of patients, follow-up assessment incomplete 3
Hysteroscopic Gubbini et al, 2008 [5] Prospective Critical No clear definition of inclusion and exclusion criteria, no clear definition of 26
treatment outcome
Hysteroscopic Chang et al, 2009 [28] Prospective Serious No clear description of evaluation of posttreatment outcome, no information on 22
cohort follow-up
Hysteroscopic/ Florio et al, 2011 [25] Retrospective Critical No clear definition of population, no information on criteria for treatment options, 41
hormonal no clear description of evaluation of pre- and posttreatment outcome, different
evaluation of treatment groups
Hysteroscopic Gubbini et al, 2011 [18] Prospective Critical No clear definition of population, no clear definition of inclusion and exclusion 41
cohort criteria

Journal of Minimally Invasive Gynecology, Vol 25, No 1, January 2018

Hysteroscopic Wang et al, 2011 [29] Retrospective Critical No clear definition of population, no inclusion criteria, different evaluation of pre- 57
and posttreatment outcome
Laparoscopy robot Yalcinkaya et al, 2011 [38] Retrospective Critical Small number of patients, outcomes assessment not complete 2
Hysteroscopy Feng et al, 2012 [30] Retrospective Critical No clear definition of niche, no clear definition of treatment outcome, no clear 57
validation of outcome, no correction for confounders
Vaginal Luo et al, 2012 [46] Retrospective Critical No clear definition of population, no clear definition of inclusion criteria 42
Laparotomy/ Jeremy et al, 2013 [39] Retrospective Critical Small number of patients and different surgical approaches, no correction for 14
laparoscopy vaginal confounders
Laparoscopy Marotta et al, 2013 [40] Retrospective Critical No clear definition of population, no clear definition of scar defect 13
Vaginal Chen et al, 2014 [47] Retrospective Critical No clear definition of population, no clear definition of scar defect 64
Hysteroscopic Li et al, 2014 [31] Retrospective Critical No clear inclusion criteria, different treatments associated to different inclusion 41
laparoscopy criteria making comparison not possible
Hysteroscopic Perez-Medina et al, 2014 [32] Retrospective Critical No clear inclusion criteria, outcomes not accurate 22
Vaginal/ hysteroscopy Xie et al, 2014 [33] Retrospective Critical No clear definition of scar defect, no information on criteria for treatment options, 77
different evaluation of pre- and posttreatment outcome, no clear validation of
outcome
(Continued)
 Setubal et al.
A Review of Uterine Isthmocele Treatment
Table 2
Continued

Treatment Authors Study Type Risk of Bias Limitations Number of

Patients Treated
Hysteroscopy Raimondo et al, 2015 [34] Prospective Critical No clear definition of population, no clear definition of scar defect, no clear 120
definition of inclusion and exclusion criteria
Laparotomy Schepker et al, 2015 [49] Retrospective Critical Small number of patients, no clear inclusion criteria, no correction for 13
confounders
Hysteroscopic Tanimura et al, 2015 [35] Prospective Critical No clear definition of population, no clear definition of treatment outcome, no 22
laparoscopy cohort correction of confounders
Hysteroscopy wait Vervoort et al, 2015 [16] Prospective Low Inconsistent outcomes of imaging and pregnancy Stillincourse
and see randomized
Laparoscopy Nirgianakis et al, 2016 [41] Retrospective Critical No clear definition of population, no clear inclusion and exclusion criteria, no 21
correction for confounders
Vaginal hysteroscopy Zhang et al, 2016 [26] Prospective Critical No clear definition of population, no clear inclusion and exclusion criteria, no 142
combined oral correction for confounders
contraceptive
intrauterine system
Transvaginal Zhang, 2016 [42] Retrospective High No clear definition of population, no information on criteria for treatment options, 124
laparoscopy no clear inclusion criteria, no correction of confounders
Laparoscopy Liu et al, 2016 [43] Retrospective Critical No clear definition of cesarean scar defect, no correction for confounder, no clear 49
inclusion and exclusion criteria
Transvaginal Zhou et al, 2016 [48] Retrospective Moderate No correction for confounders 121
Laparoscopic with Akdemir et al, 2017 [44] Case report Critical Case report, need more experience 1
Foley catheter
Laparoscopic Donnez et al, 2017 [45] Prospective Moderate No correction for confounders 38
Laparotomy Pomorski et al, 2017 [50] Retrospective Critical No clear definition of population, no clear inclusion criteria, small number of 7
patients

43
44 Journal of Minimally Invasive Gynecology, Vol 25, No 1, January 2018

Fig. 3 Fig. 5
The location of the isthmocele by hysteroscopy. With bipolar resectoscopy, A transillumination view by laparoscopy; the view is from laparoscopy
endometrial and scar tissue surrounding the isthmocele is removed. without any light enabling the visualization of the defect with the help
of hysteroscopy light through the defect.

Fig. 6
Laparoscopic tissue removal, a view of the vesicouterine pouch with scar
tissue being pulled and resected with cold scissors.

In recent years, several articles described isthmocele treat-

ment using laparoscopy [26,31,35–45]. It is the preferred
method of treatment if the residual myometrium is <3 mm
[40]. Clinical symptoms are generally improved, and the thick-
ness of the myometrium is also increased.

Fig. 4
Removal of the defect by hysteroscopy; bipolar resectoscopy resects scar
tissue in the isthmocele.

Fig. 7
Laparoscopic suturing of the defect after isthmocele resection suturing
the defect in double-layer suture enabling a thicker and stronger uterine
wall.
Setubal et al. A Review of Uterine Isthmocele Treatment
Complications after laparoscopy have been reported by Liu
et al [43], with 5 of 49 patients remaining symptomatic. No
perioperative complications were reported. A pregnancy rate
of 44% has been reported by Donnez et al [45].
Discussion
With the growing number of cesarean section deliveries
in the last 30 years, pregnancy complications have in-
creased substantially, resulting in a complication of
isthmoceles. Still unknown to many gynecologists, patient
symptoms have been uniform (e.g., abnormal menstrual bleed-
ing, pain, spotting, and secondary infertility), in addition to
myometrial thickness and defect shape being consistent.
A variety of approaches include laparotomy, laparos-
copy, hysteroscopy, vaginal repair, and various combined
techniques with no statistically superior outcome noted in the
literature. There is no consensus on the types of defect that
would benefit from treatment. Also, there is no gold stan-
dard treatment for isthmoceles. Vaginal repair has similar
efficacy compared with laparoscopic correction. The vaginal
approach also seems to be superior to hysteroscopy in clin-
ical efficacy but with a longer operating time [33].
There is a trending opinion that patients with a smaller
isthmocele could be treated hysteroscopically (2.5 mm ac-
cording to Jeremy et al [39] and 3.0 mm described by Marotta
et al [40]). On the other hand, those with a larger isthmocele
(with less than 2.5–3.0 mm residual myometrium) and risk
of perforation during hysteroscopy could be better treated by
laparoscopy or vaginally. This is especially important in pa-
tients interested in pregnancy because of the risk of uterine
perforation [52]. For this reason, the purpose, risks, and ben-
efits of the surgical treatment should always be discussed with
the patient. Lack of treatment is an option that should be dis-
cussed as well as the impact it would have on the patient’s
gynecologic future. The choice between vaginal or laparo-
scopic correction should be made based on patient fertility
desire, surgeon expertise, and lack of evidence favoring either
approach [42].
Conclusion
Surgical treatment of isthmoceles should be offered to
symptomatic women who want to preserve the uterus and pos-
sibly to asymptomatic women who are planning a future
pregnancy. We propose the use of laparoscopy, vaginal surgery,
or hysteroscopy to treat isthmoceles. Until now, no treat-
ment has been proved superior to the other, and options should
be carefully discussed with the patient. Further prospective
multicenter and comparative studies are warranted to clarify
benefits of each surgical treatment and the type of treat-
ment that best suits each patient.
45
References
1. Robson SJ, de Costa CM. Thirty years of the World Health Organiz-
ation’s target caesarean section rate: time to move on. Med J Aust.
2017;206:181–185.
2. Barber EL, Lundsberd L, Belanger K, Pettker CM, Funai EF, Illuzzi
JL. Contributing indications to the rising cesarean delivery rate. Obstet
Gynecol. 2011;118:29–38.
3. Barros AJ, Santos IS, Matijasevich A, et al. Patterns of deliveries in a
Brazilian birth cohort: almost universal cesarean sections for the better-
off. Rev Saude Publica. 2011;45:635–643.
4. Merry L, Semenic S, Gyorkos TW, Fraser W, Gagnon AJ. Predictors
of unplanned cesareans among low-risk migrant women from low- and
middle-income countries living in Montreal, Canada. Birth. 2016;43:209–
219.
5. Gubbini G, Casadio P, Marra E. Resectoscopic correction of the
“isthmocele” in women with postmenstrual abnormal uterine bleeding
and secondary infertility. J Minim Invasive Gynecol. 2008;15:172–
175.
6. Morris H. Surgical pathology of the lower uterine segment caesarean
section scar: is the scar a source of clinical symptoms? Int J Gynecol
Pathol. 1995;14:16–20.
7. Jacobson MT, Osias J, Velasco A, Charles R, Nezhat C. Laparoscopic
repair of a uteroperitoneal fistula. JSLS. 2003;7:367–369.
8. Stewart KS, Evans TW. Recurrent bleeding from the lower segment
scar–a late complication of Caesarean section. Br J Obstet Gynaecol.
1975;82:682–686.
9. Osser OV, Jokubkiene L, Valentin L. High prevalence of defects in Ce-
sarean section scars at transvaginal ultrasound examination. Ultrasound
Obstet Gynecol. 2009;34:90–97.
10. Bij de Vaate AJ, van der Voet LF, Naji O, et al. Prevalence, potential
risk factors for development and symptoms related to the presence of
uterine niches following Cesarean section: systematic review. Ultra-
sound Obstet Gynecol. 2014;43:372–382.
11. Armstrong V, Hansen WF, Van Voorhis BJ, Syrop CH. Detection of
cesarean scars by transvaginal ultrasound. Obstet Gynecol. 2003;101:61–
65.
12. Ofili-Yebovi D, Ben-Nagi J, Sawyer E, et al. Deficient lower-segment
Cesarean section scars: prevalence and risk factors. Ultrasound Obstet
Gynecol. 2008;31:72–77.
13. Rozenberg P, Goffinet F, Phillippe HJ, Nisand I. Ultrasonographic mea-
surement of lower uterine segment to assess risk of defects of scarred
uterus. Lancet. 1996;347:281–284.
14. van der Voet LF, Vervoort AJ, Veersema S, BijdeVaate AJ, Brolmann
HA, Huirne JA. Minimally invasive therapy for gynaecological symp-
toms related to a niche in the caesarean scar: a systematic review. BJOG.
2014;121:145–156.
15. Tower AM, Frishman GN. Cesarean scar defects: an underrecognized
cause of abnormal uterine bleeding and other gynecologic complica-
tions. J Minim Invasive Gynecol. 2013;20:562–572.
16. Vervoort AJ, Van der Voet LF, Witmer M, et al. The HysNiche trial:
hysteroscopic resection of uterine caesarean scar defect (niche) in pa-
tients with abnormal bleeding, a randomised controlled trial. BMC
Womens Health. 2015;15:103–111.
17. van der Voet LF, Bij de Vaate AM, Veersema S, Brölmann HA, Huirne
JA. Long-term complications of caesarean section. The niche in the scar:
a prospective cohort study on niche prevalence and its relation to ab-
normal uterine bleeding. BJOG. 2014;121:236–244.
18. Gubbini G, Centini G, Nascetti D, et al. Surgical hysteroscopic treat-
ment of cesarean-induced isthmocele in restoring fertility: prospective
study. J Minim Invasive Gynecol. 2011;18:234–237.
19. Tulandi T, Cohen A. Emerging manifestations of cesarean scar defect
in reproductive-aged women. J Minim Invasive Gynecol. 2016;23:893–
902.
20. Wang CB, Chiu WW, Lee CY, Sun YL, Lin YH, Tseng CJ. Cesarean
scar defect: correlation between Cesarean section number, defect size,
46
clinical symptoms and uterine position. Ultrasound Obstet Gynecol.
2009;34:85–89.
21. Fylstra DL. Ectopic pregnancy within a cesarean scar: a review. Obstet
Gynecol Surv. 2002;57:537–543.
22. Fylstra DL. Hysteroscopy and suction evacuation of cesarean scar preg-
nancies: a case report and review. J Obstet Gynaecol Res. 2014;40:853–
857.
23. Birch Petersen K, Hoffmann E, Rifbjerg Larsen C, Svarre Nielsen H.
Cesarean scar pregnancy: a systematic review of treatment studies. Fertil
Steril. 2016;105:958–967.
24. Tahara M, Shimizu T, Shimoura H. Preliminary report of treatment with
oral contraceptive pills for intermenstrual vaginal bleeding secondary
to a cesarean section scar. Fertil Steril. 2006;86:477–479.
25. Florio P, Gubbini G, Marra E, et al. A retrospective case-control study
comparing hysteroscopic resection versus hormonal modulation in treat-
ing menstrual disorders due to isthmocele. Gynecol Endocrinol.
2011;27:434–438.
26. Zhang X, Yang M, Wang Q, Chen J, Ding J, Hua K. Prospective eval-
uation of five methods used to treat cesarean scar defects. Int J Gynaecol
Obstet. 2016;134:336–339.
27. Fabres C, Arriagada P, Fernandez C, Mackenna A, Zegers F, Fernandez
E. Surgical treatment and follow-up of women with intermenstrual bleed-
ing due to cesarean section scar defect. J Minim Invasive Gynecol.
2005;12:25–28.
28. Chang Y, Tsai EM, Long CY, Lee CL, Kay N. Resectoscopic treat-
ment combined with sonohysterographic evaluation of women with
postmenstrual bleeding as a result of previous cesarean delivery scar
defects. Am J Obstet Gynecol. 2009;200:370, e1-370.e4.
29. Wang CJ, Huang HJ, Chao A, Lin YP, Pan YJ, Horng SG. Challenges
in the transvaginal management of abnormal uterine bleeding second-
ary to cesarean section scar defect. Eur J Obstet Gynecol Reprod Biol.
2011;154:218–222.
30. Feng YL, Li MX, Liang XQ, Li XM. Hysteroscopic treatment of
postcesarean scar defect. J Minim Invasive Gynecol. 2012;19:498–
502.
31. Li C, Guo Y, Liu Y, Cheng J, Zhang W. Hysteroscopic and laparo-
scopic management of uterine defects on previous cesarean delivery scars.
J Perinat Med. 2014;42:363–370.
32. Perez-Medina T, Sancho-Sauco J, Rios M, et al. Hysteroscopy in
pregnancy-related conditions: descriptive analysis in 273 patients. J Minim
Invasive Gynecol. 2014;21:417–425.
33. Xie H, Wu Y, Yu F, He M, Cao M, Yao S. A comparison of vaginal
surgery and operative hysteroscopy for the treatment of cesarean-
induced isthmocele: a retrospective review. Gynecol Obstet Invest.
2014;77:78–83.
34. Raimondo G, Grifone G, Raimondo D, Seracchioli R, Scambia G,
Masciullo V. Hysteroscopic treatment of symptomatic cesarean-
induced isthmocele: a prospective study. J Minim Invasive Gynecol.
2015;22:297–301.
35. Tanimura S, Funamoto H, Hosono T, et al. New diagnostic criteria and
operative strategy for cesarean scar syndrome: endoscopic repair for sec-
ondary infertility caused by cesarean scar defect. J Obstet Gynaecol Res.
2015;41:1363–1369.
Journal of Minimally Invasive Gynecology, Vol 25, No 1, January 2018
36. Donnez O, Jadoul P, Squifflet J, Donnez J. Laparoscopic repair of wide
and deep uterine scar dehiscence after cesarean section. Fertil Steril.
2008;89:974–980.
37. Klemm P, Koehler C, Mangler M, Schneider U, Schneider A. Lapa-
roscopic and vaginal repair of uterine scar dehiscence following cesarean
section as detected by ultrasound. J Perinat Med. 2005;33:324–331.
38. Yalcinkaya TM, Akar ME, Kammire LD, Johnston-MacAnanny EB,
Mertz HL. Robotic-assisted laparoscopic repair of symptomatic cesar-
ean scar defect: a report of two cases. J Reprod Med. 2011;56:265–
270.
39. Jeremy B, Bonneau C, Guillo E, et al. [Uterine ishtmique transmural
hernia: results of its repair on symptoms and fertility]. Gynecol Obstet
Fertil. 2013;41:588–596.
40. Marotta ML, Donnez J, Squifflet J, Jadoul P, Darii N, Donnez O. Lapa-
roscopic repair of post-cesarean section uterine scar defects diagnosed
in nonpregnant women. J Minim Invasive Gynecol. 2013;20:386–391.
41. Nirgianakis K, Oehler R, Mueller M. The Rendez-vous technique for
treatment of caesarean scar defects: a novel combined endoscopic ap-
proach. Surg Endosc. 2016;30:770–771.
42. Zhang Y. A comparative study of transvaginal repair and laparoscopic
repair in the management of patients with previous cesarean scar defect.
J Minim Invasive Gynecol. 2016;23:535–541.
43. Liu S, Ly W, Li W. Laparoscopic repair with hysteroscopy of cesare-
an scar diverticulum. J Obstet Gynaecol Res. 2016;42:1719–1723.
44. Akdemir A, Sahin C, Ari SA, Ergenoglu M, Ulukus M, Karadadas N.
Determination of isthmocele using a Foley catheter during laparo-
scopic repair of cesarean scar defect. J Minim Invasive Gynecol.
2017;25:21–22.
45. Donnez O, Donnez J, Orellana R, Dolmans MM. Gynecological and
obstetrical outcomes after laparoscopic repair of a cesarean scar defect
in a series of 38 women. Fertil Steril. 2017;107:289, e2-296.e2.
46. Luo L, Niu G, Wang Q, Xie HZ, Yao SZ. Vaginal repair of cesarean
section scar diverticula. J Minim Invasive Gynecol. 2012;19:454–
458.
47. Chen Y, Chang Y, Yao S. Transvaginal management of cesarean scar
section diverticulum: a novel surgical treatment. Med Sci Monit.
2014;20:1395–1399.
48. Zhou J, Yao M, Wang H, Tan W, Chen P, Wang X. Vaginal repair of
Cesarean section scar diverticula that resulted in improved postopera-
tive menstruation. J Minim Invasive Gynecol. 2016;23:969–978.
49. Schepker N, Garcia-Rocha GJ, von Versen-Hoynck F, Hillemanns P,
Schippert C. Clinical diagnosis and therapy of uterine scar defects after
caesarean section in non-pregnant women. Arch Gynecol Obstet.
2015;291:1417–1423.
50. Pomorski M, Fuchs T, Rosner-Tenerowicz A, Zimmer M. Sonographic
evaluation of surgical repair of uterine cesarean scar defects. J Clin Ul-
trasound. 2017;45:455–460.
51. Api M, Boza A, Gorgen H, Api O. Should Cesarean scar defect be treated
laparoscopically? A case report and review of the literature. J Minim
Invasive Gynecol. 2015;22:1145–1152.
52. Bujold E, Jastrow N, Simoneau J, Brunet S, Gauthier RJ. Prediction
of complete uterine rupture by sonographic evaluation of the lower uterine
segment. Am J Obstet Gynecol. 2009;201:320, e1-320.e6.