Abstract
Higher cesarean section rates and better ultrasound diagnostics have led to a more frequent diagnosis of isthmocele, a cesarean scar defect. Sometimes, endometriosis is found in the isthmocele, but simultaneous extrauterine endometriosis and endometriosis in the isthmocele have not yet been reported. Additionally, the surgical technique to repair the isthmocele is the subject of ongoing controversy. The aim of this study is to analyze a possible correlation between uterine scar (isthmocele) endometriosis and extrauterine endometriosis and to investigate the outcome of laparoscopic isthmocele resection in the rendezvous technique. In this single-center retrospective study, we included 83 women of reproductive age with symptomatic isthmocele undergoing laparoscopic isthmocele repair in rendezvous technique from 2004 to 2020 at the University of Bern. We collected data on patient and surgical characteristics as well as on postoperative outcomes (symptoms, further pregnancy, and pregnancy outcomes) retrospectively. We analyzed and compared these data for patients with and without endometriosis. Endometriosis was diagnosed during surgery in 22 out of 83 operated patients (26.5%). Diagnosis of isthmocele endometriosis (n = 9, 11%) was significantly higher in patients with extrauterine endometriosis (n = 6, p = 0.004). While the duration of surgery was significantly longer for patients with endometriosis (p = 0.006), the groups did not differ with regard to blood loss or complications. In addition, both groups showed similar indications for isthmocele repair (infertility, abnormal uterine bleeding, or dysmenorrhea). Surgery significantly improved abnormal uterine bleeding (χ2 p < 0.001), dysmenorrhea (χ2, p = 0.03), and infertility (χ2, p < 0.001). Regardless of the presence of endometriosis, 25 of 40 (63%) infertile patients became pregnant after surgery. In one out of eight pregnancies, however, we observed scar complications during pregnancy such as uterine scar pregnancy (n = 3), uterine scar dehiscence (n = 3), and placenta previa (n = 1). Endometriosis is a non-negligible intraoperative finding in patients with symptomatic isthmocele. The laparoscopic approach in the rendezvous technique is safe and effective. Therefore, this method should be recommended, especially in women with secondary infertility, and preoperatively simultaneous endometriosis resection should be discussed with the patient. In follow-up, postoperative pregnancies have to be monitored with care.
Highlights
Isthmocele, called “uterine scar defect”, “pouch”, or “niche”, is a common longterm consequence of cesarean section, which can severely impact the quality of life
Several studies report the existence of endometriosis in the isthmocele, but the presence of coexisting extrauterine endometriosis has not yet been reported [8–11]
We investigate the data of patients with a symptomatic isthmocele who were treated at the SEF (Stiftung Endometriose Forschung) certified endometriosis center of Bern University Hospital between April 2004 and March 2020
Summary
Isthmocele, called “uterine scar defect”, “pouch”, or “niche”, is a common longterm consequence of cesarean section, which can severely impact the quality of life. The prevalence of isthmocele ranges from 24% to 88% [1,2]. The pathogenesis and risk factors are not yet fully understood. Repeated cesarean section and several preoperative, intraoperative, and individual factors play a role [1,3–6]. Isthmocele and endometriosis show similar symptoms: infertility, bleeding disorders, and pain. It is known that isthmocele is a consequence of cesarean section. Several studies report the existence of endometriosis in the isthmocele ( called uterine scar endometriosis), but the presence of coexisting extrauterine endometriosis has not yet been reported [8–11]
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