Surgical Management of Niche, Isthmocele or Cesarean Scar Defect

An isthmocele is a defect of the caesarean scar characterized by myometrial discontinuity, similar to a diverticulum, located on the anterior isthmus of the uterus. It was first described by Morris in 1995 and in 2003 the first laparoscopic cesarean scar defect correction was performed. An isthmocele is an iatrogenic entity created due to the worldwide increase rate of cesarean delivery. It is mostly asymptomatic, which leads to its underdiagnosis and may be left untreated. However, its presence may be associated with gynecological complaints: typically postmenstrual spotting, dysmenorrhea, chronic pelvic pain, vaginal discharge, dyspareunia and secondary infertility or obstetrical complications in subsequent pregnancies, such as: ectopic scar pregnancy, scar tissue dehiscence and abnormally adherent placenta. The easiest, most reproducible and non-invasive method of diagnosing an isthmocele is by transvaginal ultrasound. Laparoscopic treatment of isthmocele is not standardized yet, but should be individualized and offered to symptomatic patients who desire future pregnancies. The minimally invasive approach remains an excellent option in the event of medical treatment failure. In this paper we present a case of uterine isthmocele after cesarean section that was treated by laparoscopic resection and repair of the defect.