Hysteroscopy-assisted Transvaginal Repair without Scar Defect Resection: A Novel Technique for the Treatment of Uterine Niche

Abstract

To describe hysteroscopy-assisted transvaginal repair technique without scar defect resection for uterine niche. Surgical video article (Supplemental Videos 1-3). Stepwise narrated video demonstration of the novel technique. A total of 15 women diagnosed as having niche in the uterus were enrolled in our study. Patients provided a signed consent and there are no conflicts of interest. Niche in the uterus is defined as an indentation in the myometrium at the uterine incision owing to healing defects [1]. Surgical treatment options for niche include hysteroscopic, laparoscopic, and vaginal surgery [2]. Compared with hysteroscopic surgery, regular vaginal surgery may effectively increase the residual myometrium thickness, reducing the risk of subsequent pregnancy [3-5]. However, regular vaginal surgery removes the original scar defect followed by suture, which can lead to a new niche after the surgery and may postpone conception because of the new uterine incision [6]. Here we describe a new technique of hysteroscopy-assisted transvaginal repair for the niche, which does not remove the original scar defect [7]. This surgery may be beneficial for those who plan conceive as soon as possible after the operation. Hysteroscopy-assisted vaginal surgery without scar defect resection was selected as ideal surgical approach. Hysteroscopy was used for abnormal structures in the niche [8,9]. Opening the peritoneum through the vaginal wall confirmed the position of the niche, and a 2-0 absorbable suture was used to interruptedly suture the upper and lower margins of the scar defect and close the niche (or reduce its size), rather than resection. Hysteroscopy was used again to assess the status of the niche after suture and confirm repair. If unsatisfactory, suture procedure was repeated to close the remaining part of the niche. Our novel technique, described and demonstrated in this video article, is an efficacious and viable approach to treat uterine niche. Chinese experts recommend at least a 1-year gap between conventional scar defect resection with suturing and conception, because of the new uterine incision [6]. In contrast, this novel procedure avoids removal of the original scar defect and the surrounding scar tissue by directly repairing the lower uterine segment. Meanwhile, hysteroscopy can treat abnormal structures in the niche and improve effectiveness. Given that the integrity of the uterine myometrium is retained, this technique may help shorten contraception time after operation. Further studies with larger sample size, longer follow-up time, and more postoperative follow-up indicators, such as fertility outcomes, are needed to comprehensively evaluate the restorative effect of this novel technique.