Robotic or laparoscopic treatment of cesarean scar defects or cesarean scar pregnancies with a uterine sound guidance

ObjectiveTo evaluate the feasibility and effectiveness of robotic/laparoscopic repair of cesarean scar defects or cesarean scar pregnancies with a uterine sound.Materials and methodsAll consecutive women with cesarean scar defects or cesarean scar pregnancies who underwent robotic/laparoscopic repair with a bent uterine sound guidance were reviewed. Subjective changes in symptoms and objective changes in the depth and width of cesarean scar defects after surgery were reviewed.ResultsA total of 20 women underwent robotic (n = 3) or conventional laparoscopic (n = 17) repair of cesarean scar defects, which included postmenstrual vaginal bleeding associated with cesarean scar defects (n = 15), cesarean scar pregnancies (n = 3), accumulated pus in the cesarean scar defect (n = 1) and an incomplete abortion incarcerated in the cesarean scar defect (n = 1). Bladder perforation occurred in one woman during robotic adhesiolysis. All women with cesarean scar defects (n = 15) reported an improvement in postmenstrual vaginal bleeding after surgery. Follow-up sonography showed a decrease in the depth and width of the cesarean scar defect and an increase in the residual myometrial thickness.ConclusionRobotic or laparoscopic repair with a uterine sound guidance seems to be a feasible and effective method in the treatment of cesarean scar defect or cesarean scar pregnancy.     

Association between hysteroscopic findings of previous cesarean delivery scar defects and abnormal uterine bleeding

ObjectiveThe aim of the present study was to describe various hysteroscopic findings of previous cesarean delivery scar defects (PCDS), and evaluate the relationship between these findings and abnormal uterine bleeding.Materials and methodsThis was a retrospective study including patients with abnormal uterine bleeding after a cesarean section. Transvaginal ultrasound and hysteroscopy were used to detect the origin of the symptoms, and the gynecological symptoms and hysteroscopic findings were recorded. Relationships between the hysteroscopic findings and abnormal uterine bleeding were evaluated.ResultsNinety-six (82.8%) patients presented with intermenstrual bleeding. The most common findings of scar defects on hysteroscopy were increased local vascularization (74.1%) and oozing spots (47.4%). Increased local vascularization on the defect was significantly related to intermenstrual bleeding (p = 0.048).ConclusionThis study categorized different findings of PCDS under hysteroscopy. Increased local vascularization on the scar defect was significantly related to intermenstrual bleeding.     

Type 2 Cesarean Scar Pregnancy Successfully Treated via Hysteroscopy-Assisted Laparoscopy

Study ObjectiveTo evaluate the efficacy of hysteroscopy-assisted laparoscopy as a treatment strategy for type 2 cesarean scar pregnancy at gestational age >8 weeks.DesignRetrospective case series (Canadian Task Force classification II-3).SettingA tertiary hospital.PatientsEight women with type 2 cesarean scar pregnancy at a gestational age >8 weeks.InterventionsAll patients underwent hysteroscopy-assisted laparoscopic resection and isthmus repair of cesarean scar pregnancy.Measurements and Main ResultsAll patients underwent removal of the cesarean scar pregnancy and complete repair of the uterine scar defect. The median operative time was 123.0 minutes (range, 100–168 minutes), median blood loss was 65.0 mL (range, 20–100 mL), and median length of hospital stay was 9.1 days (range, 8–12 days). There were no adverse reactions. The mean time to serum β-human chorionic gonadotropin (β-HCG) resolution was 22.9 days (range, 14–30 days), and menstruation resumed after 9 to 15 days with serum β-HCG returning to nondetectable levels. There was no recurrence of cesarean scar pregnancy at long-term follow-up.ConclusionHysteroscopy-assisted laparoscopy may be an effective treatment for patients with type 2 cesarean scar pregnancy at gestational age >8 weeks.     

Robotic CSP Resection and Hysterotomy Repair

Study ObjectiveTo demonstrate a technique for the robot-assisted laparoscopic surgical management of cesarean section scar ectopic pregnancy (CSP) and hysterotomy repair.DesignStep-by-step presentation of the procedure using video.SettingCSP is a rare form of ectopic pregnancy. The incidence of CSP has been increasing with rising cesarean deliveries and is estimated to range from 1 of 1800 to 1 of 2500 of all pregnancies. Various management of CSP have been used such as systemic or local methotrexate, surgical resection, and uterine artery chemoembolization. Exogenic or deep CSP occurs when the gestational sac is deeply embedded in the scar and the surrounding myometrium and grows toward the bladder. Surgical resection of this type of CSP seemed reasonable, which could shorten hospitalization and follow-up time and reduce the failure rate of treatment. For its magnification of the 3-dimensional laparoscope, flexibility endo-wrist, and stabilization of instruments within the surgical field, robot-assisted laparoscopic resection can be performed to manage this type of complex procedure.InterventionsIn this video, we describe our technique for robot-assisted laparoscopic management of a CSP and a hysterotomy repair. We present the case of a 34-year-old gravida 2 para 1 woman with the finding of a 7-week pregnancy embedded in the cesarean section scar. The patient had undergone 1 previous uncomplicated cesarean section at term. On presentation, her β-human chorionic gonadotropin level was 9212 IU/L. In this case, the gestational sac was deeply embedded in the scar and the surrounding myometrium and was growing toward the bladder. A decision was made to proceed with surgical treatment in the form of a robot-assisted laparoscopic resection of the ectopic pregnancy and the hysterotomy repair. The surgery was uneventful, and the patient was discharged home within 48 hours of her procedure. No residual scar defect was visible on follow-up ultrasonography 1 month after surgery. Forty days after surgery, the patient had resumed normal menstruation and was followed up for 3 years with regular menstruation and no abnormal uterine bleeding.ConclusionRobot-assisted laparoscopic excision of CSP and hysterotomy repair is an effective procedure for the management of this increasingly more common condition. The use of a cervix dilator and robot-assisted laparoscopic suturing can prevent hemorrhage and peripheral tissue damage and allow for the safe removal of the ectopic pregnancy with multilayer repair of the uterine defect.     

Four Surgical Strategies for the Treatment of Cesarean Scar Defect: A Systematic Review and Network Meta-analysis

ObjectiveThis network meta-analysis compared treatment via laparoscopy, hysteroscopy (HP), combined laparoscopy with HP (LH), and vaginal repair (VR) for reducing intermittent abnormal uterine bleeding and cesarean scar defect (CSD) diverticulum depth in patients with CSD.Data SourcesElectronic databases (PubMed, EMBASE, The Cochrane Central Register of Controlled Trials, MEDLINE, ClinicalTrials.gov, Chinese Biomedical Literature Database, and China National Knowledge Integrated) were searched for articles published through June 13, 2018.Methods of Study SelectionThe search included randomized controlled trials (RCTs) and observational studies of surgical treatment for CSD. Standardized mean difference (SMD) and 95% confidence intervals (CIs) were reported. RCTs were evaluated by the Cochrane risk-of-bias tool, observational studies by Risk of Bias in Nonrandomized Studies of Intervention, and overall evidence quality by grade. Data were analyzed by STATA (version 15.0; StataCorp, College Station, TX) and R software for windows (version 3.5.0; R Core Team, 2018).Tabulation, Integration, and ResultsTen studies (n = 858; 4 RCTs and 6 observational studies) were included. Patients who underwent uterine diverticulum resection by LH had a shorter duration of abnormal uterine bleeding than those by HP (SMD = 1.36, 95% CI, 0.37–2.36; p = .007) and VR (SMD = 1.58, 95% CI, 0.97–2.19; p <.0001). LH reduced the CSD diverticulum depth more than VR (SMD = 1.57, 95% CI, 0.54–2.61; p = .003). There was no significant difference in efficacy among the surgical procedures.ConclusionLH reduced intermittent abnormal uterine bleeding and scar depth more than the other surgical interventions. Larger clinical trials are warranted to verify this analysis.     

Hernie transmurale isthmique de l’utérus : résultats de l’isthmorraphie sur la symptomatologie et la fertilité

ObjectiveTo study the effect of the surgical repair (isthmorraphy) of the large scar dehiscence after cesarean on symptoms and fertility for women who desire pregnancy.Patients and methodsIn this retrospective study, 14 symptomatic patients, who desire a new pregnancy underwent a surgical repair by laparotomy, laparoscopic or vaginal technique. Five women experienced failure of Assistance Reproductive Technique (IVF or ICSI) for idiopathic secondary infertility. The dehiscent scars were evaluated by ultrasound, hysterography, hysteroscopy and magnetic resonance imaging.OutcomeSymptoms improvement was found in 92% of case. Ten pregnancy (71%) was obtained after surgical repair, 6 spontaneous and 4 after Assistance Reproductive Technique. Among the 5 women initially followed in the reproductive unit, 4 became pregnant, 3 after IVF or ICSI and 1 spontaneous. No operative complication occurred. The subsequent pregnancy was unremarkable with no uterine rupture.DiscussionLarge scar defect after cesarean can take shape of a complete absent of the anterior wall of the uterus. No incident has been proved in this condition. There is a lack of data concerning these isthmocele. The experience of hysteroscopic repair cannot be applied to these real large diverticule of the scar cesarean. The results of this study suggest a link between the isthmocele and reversible symptoms after surgery. The first results concerning the subsequent fertility after surgical repair seem interestingConclusionWhen a large scare defect (isthmocele) is found in symptomatic woman (pelvic pain, bleeding uterine, infertility), a surgical repair can be proposed, especially for woman who desire a new pregnancy     

Surgical treatment and follow-up of women with intermenstrual bleeding due to cesarean section scar defect

STUDY OBJECTIVE: Previous cesarean delivery scar (PCDS) defect has been described as a cause of intermenstrual bleeding in women with no other uterine pathology except for a pouch on the anterior uterine segment at the site of the cesarean scar. The objective of this study was to assess the effectiveness of hysteroscopic surgery to correct this anatomic defect and eliminate the bleeding disturbance in a group of women with this symptom. DESIGN: Retrospective study (Canadian Task Force classification XX). SETTING: Private hospital, department of obstetrics and gynecology. PATIENTS: Twenty-four women, age 29-41 years, who reported intermenstrual bleeding, especially postmenstrual spotting, with no other gynecologic pathology except for the presence of a PCDS defect. Diagnosis was established with transvaginal ultrasound, when a fluid-filled, triangular defect was seen in the anterior uterine isthmus, in relation to the cesarean section scar. INTERVENTION: Hysteroscopic resection of fibrotic tissue that overhangs underneath the triangular pouch, facilitating blood drainage through the cervix and fulguration of endometrial glands and/or dilated blood vessels. MEASUREMENTS AND MAIN RESULTS: The mean number of previous cesarean-section deliveries was 2.75. Postoperative follow-up was 24 months in 21 patients and at least 14 months in the other 3 patients. Eleven of these patients with the desire to become pregnant were unable to conceive after trying for a period of at least 2 years before hysteroscopy. Infertility work-up in the 11 patients revealed 9 with unknown infertility, 1 with male infertility, and 1 with failed tubal reversal surgery. Nine of them became pregnant between 14- and 24-months of follow-up. Eighty-four percent of patients (20/24) remained asymptomatic (without bleeding disturbances) after surgery. CONCLUSION: Previous cesarean delivery scar defect may be the cause of intermenstrual bleeding, and it is possible that it also may impair fertility, but it can be successfully treated by hysteroscopic surgery.     

Channel-like 360° Isthmocele Treatment with a 16F Mini-Resectoscope: A Step-by-step Technique

Study ObjectiveTo show the technique of hysteroscopic channel-like 360° repair of a cesarean scar defect performed with a Gubbini 16F miniresectoscope (GUBBINI system; Tontarra Medizintechnik, Tuttlingen, Germany).DesignA step-by-step demonstration of the surgical technique using slides, pictures, and a video (an instructive video [Video 1]).SettingA university hospital (Bologna University Hospital, Sant'Orsola-Malpighi Polyclinic, Bologna, Italy).PatientsA 35-year-old woman with a history of a previous cesarean section complaining of pelvic pain and postmenstrual spotting.InterventionsWith the vaginoscopic approach, the isthmocele was localized; a high-frequency 90° angled circular loop electrode and pure cutting current of 100 W were used to resect the fibrotic tissue of the proximal (step 1) and distal (step 2) part of the niche. We performed resection not only of the fibrotic tissue underneath the niche but also of the inflamed tissue placed around the niche and on the opposite site (the so-called channel-like 360° endocervical ablation). A high-frequency angled ball electrode was used to obtain focused coagulation of all residual inflamed tissue still present on the niche surface and on the cervical canal walls (step 3); the aim of this step is to facilitate the re-epithelialization of the cervical canal walls by the paraphysiological endocervical epithelium. The procedure was ended by controlling any bleeding of the endocervical vessels by reducing the inflow and pressure of the distending medium and by focused electrocauterization with a ball electrode (step 4).Measurements and Main ResultsThe operative time was 14 minutes. The small diameter of a 16F resectoscope and the use of a miniaturized loop without cervical dilation allow the operative procedures to be performed without cervical dilation and without anatomic distortion of the defect, reducing the risk of complications. The small diameter of the sheaths also makes the surgical gesture faster with an easier and faster approach to the niche compared with isthmocele hysteroscopic standard surgery.ConclusionThe presence of a uterine scar defect is usually asymptomatic or refers to postmenstrual spotting with dark red or brown discharge, dysmenorrhea, dyspareunia, chronic pelvic pain, infertility, or a dull sensation after menstruation. Several factors may play a role in isthmocele development such as a low uterine incision, a deficient suturing technique of the uterine incision, and patient-related factors that impair wound healing or increase inflammation or adhesion formation. Different techniques were used as reconstructive therapies of the cesarean scar defect including laparoscopic or robot-assisted laparoscopic excision, vaginal repair, or hysteroscopic treatment. All of these procedures remove or ablate the niche fibrotic tissue with the aim of relieving symptoms. Asymptomatic cases should not be treated. According to the most recent literature, hysteroscopic repair of a cesarean scar represents an effective and safe surgical option in cases of a symptomatic isthmocele. The persistence of symptoms has been reported in up to 18% of cases, so adequate counseling should be performed before the procedure.     

儿童感音神经性耳聋20例内耳多层螺旋 CT特征及应用分析

目的    探讨儿童感音神经性耳聋（SNHL）内耳多层螺旋CT（MSCT）特点及其对诊断的价值。方法    选取2008年1月至2010年12月中国医科大学附属盛京医院经脑干听觉诱发电位（BAER）诊断儿童SNHL患儿65例,均行内耳MSCT扫描,然后行冠状面多平面重建（MPR）。结果    20例（33只耳,45例次）存在内耳畸形,其中12只耳多种畸形并存,包括耳蜗畸形伴内耳道畸形5只耳;耳蜗畸形伴前庭导水管扩大3只耳;前庭畸形伴内耳道畸形2只耳;半规管畸形伴前庭导水管扩大1只耳;内耳道畸形伴前庭导水管扩大1只耳。45例次畸形中耳蜗畸形10例次［包括Michel型1例次、共同腔畸形2例次、耳蜗未发育1例次、耳蜗发育不全1例次、不完全分隔Ⅰ型2例次、不完全分隔Ⅱ型（Mondini畸形）3例次］、前庭畸形7例次、半规管畸形5例次、内耳道畸形8例次、前庭导水管扩大15例次。结论    根据MSCT检查结果显示多数SNHL患儿存在内耳畸形。内耳横断面MSCT扫描和冠状面MPR可对儿童先天性SNHL内耳畸形进行全面评估,从而为进一步指导治疗及预后提供有力依据。     

Surgical Management of Cesarean Scar Defect: The Hysteroscopic-Assisted Robotic Single-Site Technique

Study ObjectiveTo educate surgeons on the advantages of robotic techniques in hysteroscopic-assisted single-site resection of cesarean scar defect.DesignA step-by-step video presentation detailing the complete surgical procedure.SettingUniversity Hospital, Baylor College of Medicine, Houston, Texas.PatientsThe first patient was a 34-year-old G2P2002 who complained of dysmenorrhea and menorrhagia, with an expressed desire for a single-site cesarean scar defect correction. Her surgical history included 2 cesarean deliveries, in 2012 and 2014. The second patient was a 34-year-old G4P3013 who complained of dysmenorrhea and a persistent mucus vaginal discharge, with an expressed desire for a cesarean scar defect correction in anticipation of conception. Her surgical history was notable for 3 previous cesarean deliveries. Neither patient's ultrasound report showed adenomyosis or any other pathologies.InterventionsIn both patients, hysteroscopic-assisted robotic single-site resection of the cesarean scar defect was performed, using a monopolar hook, wristed needle drivers, cold scissors, and a diagnostic vs operative hysteroscope. Entry was made through the umbilicus with a 15-mm incision and carried down through the subcutaneous tissue until the fascia was grasped and entered using Mayo scissors. The abdomen was inspected. The bladder was carefully disected off of the lower uterine segment and then backfilled to aid identification of the correct plane for dissection. Once the bladder was adequatetly dissected off of the uterus, the suspected defect could be identified. The monopolar hook was used to incise the defect, and the tip of the hysteroscope was placed through the defect to fully delineate it. The edges were trimed with cold scissors (Endoshears) in the first surgery and the monopolar hook in the second surgery. The uterine defect was closed with 2 layers of countinuous running V-Loc suture. The peritonium was closed with an additional V-Loc suture in a running fashion. Finally, hysteroscopy was performed. The closure was noted to be watertight, verifying successful repair of the defect. In the second case, an intercede was placed over the defect to help prevent future adhesive disease. In addition, after consulting with experts in cesarean scar repair, an energy device was recommended, and thus the monopolar hook over cold scissors was used for the second case due to its superior cutting effect. In both cases, the pelvis was inspected, and hemostasis was observed throughout.Measurements and Main ResultsThe 2 cases had similar outcomes, with successful repair of the cesarean scar defect and resolution of the patient's symptoms. The thickness of the residual myometrium in cesarean scar defect was 2.8 mm in the first case and 2.3 mm in the second case. This video is exempt from Institutional Review Board review.In the first case, the surgery was completed in 90 minutes with only 15 mL of blood loss. The patient was discharged home on the day of surgery and denied any postoperative complications at her follow-up appointment.In the second case, the surgery was completed in 85 minutes with only 10 mL of blood loss. The patient was discharged home on the day of surgery. At her follow-up appointment, she had a positive pregnacy test and denied any postoperative complications. When contacted at a later date, she revealed that she was 15 weeks pregant.ConclusionHysteroscopic-assisted single site resection of a cesarean scar defect is a feasible method for the resection of cesarean scar defect. Use of the robot makes the difficult surgical techniques required for this operation easier and more accessible.     

剖宫产后子宫瘢痕憩室形成因素的研究进展

剖宫产后子宫瘢痕憩室(cesarean scar diverticula,CSD)是继发于剖宫产的一种妇科疾病,指剖宫产术后子宫切口肌层愈合不良,在子宫峡部出现突向浆膜层,并与宫腔相通的一个囊状缺陷,导致异常子宫出血、慢性盆腔痛、瘢痕妊娠、胎盘植入,甚至再次妊娠子宫破裂等严重并发症.目前CSD形成因素尚未完全阐明,可能...     

Obstetric and Gynecologic Outcomes after the Transvaginal Repair of Cesarean Scar Defect in a Series of 183 Women

Study ObjectiveTo analyze retrospectively the effect of hysteroscopy combined with transvaginal repair on the cesarean section diverticulum (CSD) and explore the clinical significance of this procedure.DesignRetrospective study.SettingUniversity-affiliated hospital and a gynecology hospital.PatientsA total of 183 patients with scar diverticulum after cesarean section were recruited from the Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan and Shenzhen In Vitro Fertilization Gynecological Hospital.InterventionsIn this study, we reported a surgical method for repairing uterine scar through uterine therapy and explored its clinical efficacy and pregnancy outcome.Measurements and Main ResultsThe time of operation, volume of bleeding, and duration of hospitalization were recorded. The size of the scar diverticulum and the remaining myometrium were examined by B-mode ultrasonography before and after the operation. The length of the menstrual cycle and pelvic pain were recorded during follow-up to check the recovery of patients after surgery. The pregnancy of patients with pregnancy needs was recorded to check the pregnancy outcome. All 183 patients successfully completed the repair of the transvaginal uterus scar diverticulum with the help of a hysteroscopy examination. The mean (± standard deviation) operation time was 58.61 ± 18.56 minutes. The mean blood loss was 36.97 ± 22.32 mL. The mean hospital stay was 6.08 ± 1.89 days. In 57.14% of patients, the CSD completely disappeared, whereas the volume of CSD shrank by at least 50% in 88.95% of patients. The mean menstrual period of patients after surgery was 7.72 ± 2.68 days, which was significantly shorter than that recorded preoperatively (13.45 ± 3.69 days) (t = 19.62, p = .00). The pelvic pain disappeared in 81.08% of the patients. The mean postoperative thickness of the remaining muscular layer was 5.30 ± 1.27-mm, which was significantly higher than the preoperative value of 2.25 ± 0.92-mm (t = 28.21, p = .00). The mean postoperative thickness of the remaining muscular layer of patients with improved menstrual cycle was 5.40 ± 1.27-mm, which was significantly higher than the thickness of 4.88 ± 1.11-mm in patients without improved menstrual cycle (t = 2.31, p = .025). A total of 124 patients attempted to become pregnant, 83 of whom were successful. The pregnancy rate was as high as 66.95%, which included 2 scar pregnancies, 4 ectopic pregnancies, and 87 intrauterine pregnancies. No uterine rupture occurred.ConclusionThe transvaginal repair of the uterine diverticulum improved the symptoms and probability of a successful pregnancy effectively. This process is a surgical procedure to increase the thickness of the residual uterine muscle wall effectively.     

High-grade endometrial stromal sarcoma in cesarean section scar isthmocele - case report

ObjectiveCesarean section scar defect isthmocele, the pouchlike defect in the anterior uterine wall of the prior cesarean site. No previous report of malignant neoplasm in the isthmocele have been published. We reported a case of High-grade endometrial stromal sarcoma in isthmocele.Case reportA 45-year-old patient with gravida 4, parity 2, two previous cesarean section presents of recurrent heavy vaginal bleeding. Curettage and hormone therapy were unsuccessful. She underwent hysteroscopic isthmoplasty. The pathology revealed high-grade sarcoma. Patient was referred to a tertiary medical center and she underwent total hysterectomy with bilateral salpingo-oophorectomy, aortic & pelvic LNs dissection. The final diagnosis was High-grade endometrial stromal sarcoma (HG-ESS) stage IA (pT1a N0) involving isthmocele.ConclusionThe presence of this rare tumor in the isthmocele is very interested. We stress the necessity for a high degree of suspicion to diagnose the malignancy in perimenopausal women with isthmocele and persisted abnormal uterine bleeding.     

Laparoscopic Repair of Post-Cesarean Section Uterine Scar Defects Diagnosed in Nonpregnant Women

Herein we describe laparoscopic repair of uterine scar defects after cesarean section and pregnancy outcomes in a series of 13 patients. Defects and the residual anterior uterine wall were evaluated using ultrasound and magnetic resonance imaging (MRI). Patients' clinical symptoms were recorded. Pregnancy outcomes were investigated after laparoscopic surgical repair. Intervention included laparoscopic repair of the defect, including excision of fibrotic tissue and laparoscopic closure of the anterior uterine wall. The defect was completely corrected using this technique in all 13 patients. Four patients became pregnant spontaneously, 3 delivered via cesarean section between 38 and 39 weeks, and 1 is currently pregnant. Evaluation of uterine scar defects after cesarean section can be performed using ultrasound and MRI, and the defect can be repaired via laparoscopy, with reproducible postoperative anatomic and functional outcomes.     

Planned conservative management of placenta accreta – experience of a regional general hospital

Abstract

Objective: There are only a few series treating ≥10 cases of accreta conservatively, all from university teaching hospitals, with reported success rate of 60–85%. We reported the first series of accreta managed by planned uterine conservation in the setting of non-university district general hospital.

Methods: Women with placenta previa overlying previous cesarean scar who desired uterine conservation were included. For cases with accreta confirmed during cesarean delivery, placenta was purposefully left behind, followed immediately by uterine artery embolization. Cases were followed in our special postnatal clinic. Charts were reviewed to retrieve clinical details.

Results: Among 15 cases of placenta previa overlying cesarean scar opting for conservative management, 12 (80%) were confirmed to be accreta intra-operatively. They had 20–100% of the adherent placentae retained (median 90%) and their uterus preserved. Postpartum, abnormal vaginal bleeding and/or infection led to unscheduled readmission in 67% (8/12), all managed conservatively. Sonographic resolution of placenta took 2–13 months (median 6.6), and was later than menstrual return in 11 cases.

Conclusions: Successful planned conservative management of placenta accreta is feasible in the setting of district general hospital with facilities for interventional radiology.     

剖宫产后子宫瘢痕憩室治疗方式的研究进展

子宫瘢痕憩室（cesarean scar diverticula,CSD）近年发病率增高,主要由剖宫产术后的子宫切口愈合不良引起,是剖宫产手术的主要远期并发症,可引起育龄期女性异常子宫出血、经期延长、慢性盆腔痛和不孕等。目前临床上CSD治疗方式众多,口服避孕药、左炔诺孕酮宫内节育器及中药等保守药物治疗可在一定程度上改善患者经期延长的症状,宫腔镜、腹腔镜、经阴道修复、宫腹腔镜联合和宫腔镜辅助经阴道修复等手术治疗是目前CSD的主要治疗方式,术后能改善患者症状,降低CSD合并继发性不孕及瘢痕妊娠的发生率,但目前仍缺乏统一的术式选择标准,手术方式的选择、手术治疗的效果也存在争议,有待进一步研究。综述了CSD治疗方式选择、具体手术方法、不同治疗方式之间的疗效区别等内容。     

Laparoscopic Excision of Cesarean Scar Pregnancy with Scar Revision

ObjectiveTo demonstrate our technique for robot-assisted laparoscopic ectopic pregnancy excision and concomitant scar revision.DesignWe present a stepwise narrated demonstration of our primary laparoscopic technique.SettingAlthough cesarean scar pregnancy is rare, it leads to life-threatening complications and often emergent hysterectomy [1,2]. Because of its rarity, there is a scarcity of centers with high-volume experience with its treatment, and no standardized diagnostic or management guidelines are yet available [3,4]. Recent evidence suggests that primary surgical management may be superior to medical or radiologic management as the latter methods carry a high reintervention rate [5]. An additional consideration in selecting a treatment method is a patient's plans for future fertility, as cesarean scar defects are associated with secondary infertility. Evidence shows that repair of cesarean scar defects decreases the likelihood of future recurrence and secondary infertility, thus it may be pertinent to select a management strategy that allows for the accomplishment of both ectopic pregnancy removal and defect revision. We present our primary laparoscopic approach to ectopic pregnancy excision and revision of the cesarean scar defect using techniques rooted in evidence and robust experience.InterventionsRobot-assisted laparoscopic excision of a cesarean scar ectopic pregnancy with concomitant scar revision demonstrating key strategies to minimize blood loss and preserve future fertility.(1) A laparoscopic approach allows for concomitant ectopic pregnancy removal followed by cesarean scar revision.(2) Generous use of dilute vasopressin and purposeful application of electrosurgical energy provides hemostasis without the use of more invasive measures such as vascular clips or uterine artery balloons.(3) A multilayer closure is associated with a lower risk of wedge defect formation and uterine rupture.(4) Diagnostic hysteroscopy is a useful tool for identifying the location of the scar defect, assessing for an adequate repair, and identifying potential additional uterine pathology.ConclusionPrimary laparoscopic management is not only the most effective method with the lowest complication rates but is an approach that allows for simultaneous repair and revision of the cesarean scar defect. We demonstrate easily adaptable techniques for maintaining hemostasis, minimizing injury to normal myometrium, and creating multilayer closures that lead to successful revisions with minimal impact to subsequent fertility.     

Resectoscopic correction of the "isthmocele" in women with postmenstrual abnormal uterine bleeding and secondary infertility

STUDY OBJECTIVE: The obstetric complications that a cesarean delivery may produce have been known and studied for a long time. In the last few years, new correlations with some gynecologic disturbances also emerged, such as postmenstrual abnormal uterine bleeding (PAUB), and with some cases of secondary infertility. This is due to the presence of a diverticulum on the anterior wall of the uterine isthmus or of the cervical canal at the site of a previous cesarean delivery scar. The aim of our study was to assess the effectiveness of a hysteroscopic surgical technique to correct this anatomic defect and therefore eliminate the symptoms. DESIGN: A prospective study (Canadian Task Force classification III). SETTING: Private clinic and university hospital. PATIENTS: Twenty-six patients who previously had 1 or more cesarean deliveries, were evaluated from 2001 to 2005 for postmenstrual uterine bleeding and secondary infertility in 9 patients. All patients had a "niche" (which we defined as "isthmocele") principally on the isthmus-superior third of cervical canal (18/26), but on the lower cervical tract too (8/26). All of them underwent resectoscopic correction of the "isthmocele." INTERVENTIONS: Hysteroscopic resection of the edges and the bottom of the defect until the complete removal of the fibrotic scar tissue showing the muscular tissue below, using a cutting loop and pure cutting current. Aimed electrocoagulation of the bottom of the pouch with a roller-ball to avoid the in situ production of blood. MEASUREMENTS AND MAIN RESULTS: The anatomic defect in 100% of patients treated (26/26) was repaired, thus solving the symptom. Seven of 9 patients with secondary infertility became pregnant. CONCLUSIONS: The "isthmocele" represents a possible consequence of one or more cesarean deliveries and may be symptomatic in some women. It is a defect that can be easily diagnosed by hysteroscopy and successfully treated by resectoscopic technique.     

Cesarean Scar Defects: An Underrecognized Cause of Abnormal Uterine Bleeding and Other Gynecologic Complications

The gynecologic sequelae due to deficient uterine scar healing after cesarean section are only recently being identified and described. These include conditions such as abnormal bleeding, pelvic pain, infertility, and cesarean scar ectopic pregnancy, as well as a potentially higher risk of complications and difficulties during gynecologic procedures such as uterine evacuation, hysterectomy, endometrial ablation, and insertion of an intrauterine device. The proposed mechanism of abnormal uterine bleeding is a pouch or “isthmocele” in the lower uterine segment that causes delayed menstrual bleeding. The prevalence of symptomatic or clinically relevant cesarean scar defects (CSDs) ranges from 19.4% to 88%. Possible risk factors for CSD include number of cesarean sections, uterine position, labor before cesarean section, and surgical technique used to close the uterine incision. There are no accepted guidelines for the diagnostic criteria of CSD. We propose that a CSD be defined on transvaginal ultrasound or saline infusion sonohysterography as a triangular hypoechoic defect in the myometrium at the site of the previous hysterotomy. We also propose a classification system to aid in standardized classification for future research. Surgical techniques for repair of CSD include laparoscopic excision, resectoscopic treatment, vaginal revision, and endometrial ablation.     

Surgical hysteroscopic treatment of cesarean-induced isthmocele in restoring fertility: prospective study

The reproductive outcome in 41 consecutive patients with cesarean-induced isthmocele and secondary infertility was evaluated prospectively. Patients included menopausal women (mean [SD; 95% CI] age, 35 [4.1; 29-42] years), with fertility duration of 3 to 8 (4.6 [28]) years with isthmocele, postmenstrual abnormal uterine bleeding, and suprapubic pelvic pain. Transvaginal ultrasound and office hysteroscopy were used to diagnosis isthmocele. Complete fertility tests were performed to exclude other causes of infertility in both female and male participants. Operative hysteroscopy was performed to correct the cesarean scar defect, and histologic findings were evaluated. Correction of isthmocele via operative hysteroscopy was successful in all cases evaluated. Patients became pregnant spontaneously between 12 and 24 months after isthmoplasty. Thirty-seven of the 41 patients (90.2%) delivered via cesarean section, and 4 (9.8%) had a spontaneous abortion in the first trimester. Isthmoplasty resulted in resolution of postmenstrual abnormal uterine bleeding and suprapubic pelvic pain in all patients. Thus, it was concluded that surgical treatment of cesarean-induced isthmocele using a minimally-invasive approach (operative hysteroscopy) restores fertility and resolves symptoms in women with a cesarean section scar and secondary infertility.