Repair Of Cesarean Scar Defect Research Articles

P-742 In-vitro fertilization outcomes after laparoscopic repair of cesarean scar defect

Abstract Study question Does laparoscopic repair of cesarean scar defect improve in-vitro fertilization (IVF) outcomes? Summary answer Laparoscopic (LSC) repair of cesarean scar defect (CSD) should selectively indicated to patients experiencing repetitive pregnancy failure or having an increased depth of niche What is known already Cesarean section (CS) rate has markedly from 7% in 1990 to an estimated 29% of all births by 2030. CSD, also known as isthmocele or uterine niche, has emerged as a cause of secondary infertility, frequently encountered with recurrent implantation failures and cycle cancellations because of the endometrial fluid collection both in endometrium and uterine lower segment of cesarean scar. Study design, size, duration This is a retrospective study encompassing total of 62 patients. With 50 patients undergoing expectant management, 12 undergoing LSC repair of CSD at a single IVF center from 2019 to 2023. Primary outcomes included the clinical pregnancy rate and time to pregnancy, while secondary outcomes were the depth of CSD and residual myometrial thickness. Of the 72 patients, 68 patients underwent frozen embryo transfer. Participants/materials, setting, methods Patients with secondary infertility who had experienced more than two instances of implantation failure or cycle cancellation due to endometrial fluid collection were included. Laparoscopic repair of CSD was performed by a single gynecologic oncologist in accordance with the physician’s preference and patient consent. For patients in expectant management, diagnostic hysteroscopy and endometrial fluid suction were conducted prior to embryo transfer. Main results and the role of chance The age, BMI, gravidity, parity, or the number of previous cesarean section showed no statistical differences between the expectant management and the LSC repair group. The uterine position, either anteflexion was similar across groups. (all p value >0.05). Both the clinical pregnancy rate and live birth rate did not significantly differ between the expectant management group and the LSC repair group (26.0% vs 50.0%, p = 0.149, and 32.0% vs 60.0%, p = 0.149, respectively). The mean time to pregnancy was 7.38 months in the expectant management group and 9.80 months in LSC repair group, showed no significant difference (p = 0.240). Correlation analysis revealed a significantly moderate correlation between the initial depth of CSD and the depth of CSD at embryo transfer with clinical pregnancy (r = -0.424, P = 0.001). Furthermore, our data indicated that the CSD depth at embryo transfer was significantly impacted on clinical pregnancy outcomes from the multivariate regression logistic analysis (OR = 0.522, 95% CI [0.332 – 0.823]). Limitations, reasons for caution This study is retrospectively designed and including small sample size, caution is required in interpreting the findings. Wider implications of the findings This study suggests that the depth of niche influences clinical pregnancy outcomes. Laparoscopic repair may offer a viable treatment option who have experienced multiple failed cycles and increased depth of niche. Future studies with larger population studies may further indicate the LSC repair based on the depth of CSD. Trial registration number not applicable

A Prediction Model for the Efficacy of Transvaginal Repair in Patients With Cesarean Scar Defect: An Evidence-Based Proposal for Patient Selection

To establish a prediction model to help doctors determine which patients with cesarean scar defect are more suitable for transvaginal repair. Retrospective analysis. Xinhua Hospital and Shanghai First Maternity & Infant Hospital between June 2014 and May 2021. 1015 women who underwent transvaginal repair of cesarean scar defect (CSD). All enrolled patients underwent CSD repair performed by the same gynecologist and his team. And followed up a clinic visit at 6 months to record their menstruation and measure multiple parameters of the CSD by Magnetic Resonance Imaging. CSD patients are categorized as optimal healing group when the menstruation duration is no more than 7 days, meanwhile the thickness of residual myometrium is no less than 5.39 mm after vaginal repair. The final nomogram is constructed to predict surgical outcomes based on preoperative variables. The key factors that determine optimal healing are the timing of cesarean section (elective or emergency), menstrual cycle, CSD length, width, depth, and the thickness of the lower uterine segment. With the prediction model, scores are given to each parameter according to the statistics. Total scores range from 0 to 25 points, with a cutoff point of 16.5. When a score is greater than 16.5, the transvaginal repair can achieve optimal healing. Uterine position (anteflexion or retroflexion) and preoperative thickness of residual myometrium are the key factors affecting postoperative thickness of residual myometrium. The width of the CSD and the thickness of the lower uterine segment are the key factors affecting abnormal uterine bleeding symptoms (p < 0.01). For the first time, we established a prediction model system that may predict the repair effect of CSD and can potentially be useful in future clinical trials to determine which patients are more suitable for surgery or other treatment options.

Near-infrared and hysteroscopy-guided robotic excision of uterine isthmocele with laser fiber: a novel high-precision technique

To describe a novel high-precision technique for robotic excision of uterine isthmocele, employing a carbon dioxide laser fiber, under hysteroscopic guidance, and near-infrared guidance. Video article. A 36-year-old multipara with three prior cesarean sections presented to our infertility clinic with secondary infertility. The patient had been trying to conceive for 6 months without success. The patient underwent a hystero-salpingo contrast sonography which identified a large cesarean scar defect with a 1.4 mm residual myometrial thickness (RMT). The patient was counseled on surgical management with robotic approach due to RMT < 3 mm precluding her from hysteroscopic resection and the potential risk for a cesarean scar ectopic or abnormal placentation if she were to become pregnant in the future. She elected to undergo excision and repair and informed consent was obtained from the patient. The robot was docked for traditional gynecologic robotic surgery. The uterus was injected with 5 units of vasopressin. We used a carbon dioxide laser fiber (Lumenis® FIberLase) at a power of 5 watts as the sole energy source for dissection. The bladder was dissected off the uterus to identify the general area of the isthmocele. At that point, diagnostic hysteroscopy was performed using a 30-degree 5 mm hysteroscope (Karl Storz®) to identify and enter the isthmocele. Near-infrared vision (da Vinci Firefly®, Intuitive USA) was activated to precisely outline the extent of the isthmocele, which was not visible with simple transillumination from the hysteroscope. We proceeded with laser excision in infrared/grey scale using the laser at a power of 20 watts removing the entire area that was highlighted by the Firefly®. After full excision of the isthmocele, the hysteroscope was removed and was eventually replaced by a uterine manipulator (ConMed VCare DX®). The hysterotomy was closed with a two layer closure: 4 mattress sutures of 2-0 Vicryl (Ethicon®) followed by a running 2-0 PDS Stratafix (Ethicon®). The peritoneal layer was closed over these two layers with 2-0 PDS Stratafix (Ethicon®) in a running fashion. The uterine manipulator was removed and a 14 French Malecot catheter (Bard®) was placed in the uterine cavity to allow the healing to proceed with minimal risk of cervical stenosis. The bladder was backfilled to ensure integrity of the bladder wall. Interceed adhesion barrier (Gynecare®) was then placed over the area of the repair and the procedure was concluded. The patient included in this video gave consent for publication of the video and posting of the video online including social media, the journal website, scientific literature websites (such as PubMed, ScienceDirect, Scopus, etc.) and other applicable sites. Completion of excision and repair of cesarean scar defect without surgical complications. Robotic excision and repair of a sizable uterine isthmocele with carbon dioxide laser fiber and da Vinci Firefly® was completed successfully without any surgical complications. Diagnostic hysteroscopy was used to positively identify the isthmocele and provide transillumination. However, the thickness of the cervical myometrium only allows the hysteroscopic light to shine through the thinnest portion of myometrium at the apex of the isthmocele, while the near-infrared vision allowed by the da Vinci Firefly® technology was used to precisely identify the borders of the defect. The carbon dioxide laser was used to completely remove the defect while avoiding damage to delicate reproductive tissue and over-excision. No complications were identified during the postoperative visit. MRI three months after the surgery revealed a RMT of 10 mm at the location of excision compared to the initial RMT of 1.4 mm. Currently, there is no gold-standard technique for surgical management of isthmocele. This is the first description of the combined use of hysteroscopy, near-infrared vision and laser fiber for the robotic excision of isthmocele. This specific setup proves to be a useful technical improvement. The use of near-infrared vision combined with precise hysteroscopic targeting allows much clearer definition of the isthmocele borders, and the flexible laser fiber allows millimetric excision in the absence of appreciable lateral thermal spread. Further investigation is warranted to identify a gold standard surgical technique for patients with CSD.

Vaginal Repair of Cesarean Scar Defect under Hysteroscopic Guidance.

Vaginal Repair of Cesarean Scar Defect under Hysteroscopic Guidance.

Uterine dehiscence: a laparoscopic uterine repair in early pregnancy

To review the existing literature on uterine cesarean scar defect repair in pregnancy and describe an approach to minimally invasive surgical repair in early pregnancy to facilitate a term live birth. A case study and literature review, followed by a demonstration of the procedure with surgical video and concurrent ultrasound footage. Academic medical center. This video is a case presentation of a 35-year-old, gravida 2, para 1 woman with a previous cesarean section. She presented at 10 weeks and 3 days gestational age with complete uterine dehiscence at the site of her previous cesarean section scar, which was diagnosed by ultrasound. Surgical video and medical images have been extracted from this patient's chart after consent was obtained. Ultrasound-guided laparoscopic repair of cesarean scar defect at 11 weeks and 3 days of gestation. The video showed a large 2.6-cm uterine scar defect in early pregnancy confirmed using ultrasound and magnetic resonance imaging. This diagnosis was confirmed by direct visualization at the time of surgery. This video demonstrates our surgical approach as follows: careful uterine manipulation and identification of the defect with laparoscopy and concurrent transvaginal ultrasound; reflection of the bladder using an ultrasound-guided approach to confirm the borders of the defect; and repair with a running 2-layer closure under transvaginal ultrasound guidance. Through ultrasound-guided laparoscopic repair, we were able to demonstrate a restoration of approximately 8 mm of myometrial thickness across the cesarean scar defect on antenatal follow-up. The patient had a term live birth via cesarean section. With an increased number of cesarean sections and improved quality of ultrasound imaging, an increase in the incidental findings of cesarean scar defects has been observed. The risk of spontaneous prelabor uterine rupture remains unknown. There is a literature gap in this area regarding the appropriate standard of care. This video demonstrates that ultrasound-guided laparoscopic repair was possible, safe, and effective in our patient. However, further studies are required to establish the safety and efficacy of this approach.

Hysteroscopic removal, with or without laparoscopic assistance, of first-trimester cesarean scar pregnancy

To demonstrate the implementation and potential benefits of hysteroscopic removal, with or without concomitant laparoscopic assistance, of first-trimester cesarean scar pregnancies (CSPs). Patients with prior cesarean deliveries may have scar formation at the muscular wall of the uterine isthmus, resulting in a cesarean scar defect (CSD), also known as an isthmocele or diverticulum. When implantation of a trophoblast occurs at the CSD, a CSP develops, and with progression onto higher gestational age, it carries risks for serious complications, such as placenta previa spectrum, life-threatening bleeding, uterine rupture, and cesarean hysterectomy. Therefore, early termination is often recommended. Given that the chorionic frondosum only penetrates the decidual basalis layer during the first trimester and does not invade the distal myometrial segment until early second trimester, operative hysteroscopy can be a reliable and efficient treatment modality for early intervention. This narrated video features the systematic approach and surgical management for patients with first-trimester CSPs. Academic tertiary hospital. Three multiparous women between 34 and 38 years of age diagnosed with CSPs within the first trimester. Initial assessment with transvaginal ultrasonography and color Doppler flow identifies the site of implantation and measures the residual myometrial thickness (RMT), which are important parameters for classifying the CSPs into type I or type II. Type I CSPs often present at an earlier gestational age, have a thicker RMT, and grow toward the uterine cavity, while type II CSPs are frequently noted at a higher gestational age, have a thinner RMT, demonstrate obvious scar dehiscence, and often invade toward the bladder. The patients received either operative hysteroscopy alone or with concomitant laparoscopic assistance and repair of CSD dehiscence. For all hysteroscopic operations, misoprostol (200 μg) was given 4 hours before the procedure while oxytocin (20 U in 1000 mL isotonic solution, intravenous infusion) was infused immediately after removal of the placental tissue. For laparoscopic excision and repair of the dehiscent scar, local injection of 5 mL terlipressin acetate (1 mg) was added before the initiation of laparoscopic CSD excision. Appraisal of the parameters used for preoperative assessment, the efficacy of the surgical procedures, and the intention to minimize the associated risks and morbid sequalae were evaluated. Most of the type I CSPs or type II CSPs with gestational age <8 weeks and RMT >3 mm can be successfully treated with operative hysteroscopy alone. In contrast to blind dilatation and curettage, operative hysteroscopy offers direct visualization to ensure complete removal of the chorionic villi, which can occasionally be buried deep within the concavity of the CSD. It is worth noting that gently sweeping the decidua basalis from the myometrium with the loop resectoscope is more than enough to separate the chorionic villi within and completely displace the placental tissues without causing massive hemorrhage. For type II CSPs in late first-trimesters showing distended CSDs and diminished RMT, laparoscopy can be established before the hysteroscopic procedure for better surveillance and to prevent inadvertent myometrial perforation. Then, hysteroscopic removal of CSP can further induce uterine contractions to help reduce blood loss during subsequent laparoscopic repair of CSD. Accurate diagnosis and timely management of CSPs during the first trimester are crucial for preventing significant morbidities associated with advanced gestational age. Operative hysteroscopy offers the benefit of direct visualization for competent detachment of the decidua basalis of the CSP from the steep concavity of the CSD. Furthermore, the employment of laparoscopy for type II CSPs helps avoid inadvertent complications related to the thin RMT and allows concomitant repair of the extensive dehiscence.

Novel laparoscopic surgery for the repair of cesarean scar defect without processing scar resection

BackgroundCesarean scar defect (CSD), especially CSD with residual myometrium less than 3 mm is reported to be the highest risk agent associated with uterine rupture for subsequent pregnancy. Currently, laparoscopic resection and suture was the mainstay therapy method for CSD with a residual myometrium less than 3 mm in women with a desire to conceive. Besides, the women have CSD related symptoms, especially postmenstrual bleeding, should be recommended for CSD treatment. This study is to investigate the efficiency of this novel laparoscopic surgery for the repair of cesarean scar defect (CSD) without scar resection for residual myometrium thickening.MethodThis retrospective clinical study enrolled 76 women diagnosed with CSD who had a residual myometrium thickness less than 3 mm and also had a desire to conceive, had undergone laparoscopic surgery for the repair of CSD in the time period March 2016 to March 2018. Two study cohorts were created among the 76 patients: 40 patients had undergone the novel laparoscopic repair of CSD without processing scar resection (Group A), whereas 36 patients had undergone the traditional laparoscopic resection and suture of CSD (Group B).ResultsResidual myometrium thickening occurred among all the 76 patients and the average residual myometrium thickness was increased to almost 6 mm, presenting no between-group difference. In Group A, all the CSD-related postmenstrual bleeding was resolved or improved, but one patient in Group B has no obvious change to postmenstrual bleeding. After CSD repair, 20 patients got pregnant naturally in Group A, and there was no cesarean scar pregnancy and uterine rupture. While, there were 9 cases of natural pregnancy in Group B. No uterine rupture occurred among these 9 pregnant women of Group B, but 1 case of pregnancy was terminated due to cesarean scar pregnancy.ConclusionLaparoscopic repair without processing scar resection seems to be a feasible, safe and simple operative approach for CSD treatment, which can thicken residual myometrium and improve postmenstrual bleeding.

Laparoscopic Repair of a Large Cesarean Scar Defect after a Prior T-Incision

Study Objective The objective of this video is to demonstrate the feasibility of the laparoscopic repair of a cesarean scar defect after a prior T-incision. Design N/A. Setting Urban, academic tertiary care hospital. Patients or Participants Case report of single patient. Interventions Laparoscopic repair large cesarean scar defect. Measurements and Main Results N/A. Conclusion Laparoscopic cesarean scar defect repair after a prior T-incision is feasible. The objective of this video is to demonstrate the feasibility of the laparoscopic repair of a cesarean scar defect after a prior T-incision. N/A. Urban, academic tertiary care hospital. Case report of single patient. Laparoscopic repair large cesarean scar defect. N/A. Laparoscopic cesarean scar defect repair after a prior T-incision is feasible.

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.

115 Total laparoscopic hysterectomy for management of large cesarean scar defect causing secondary amenorrhea: A case report

We present the clinical course of a multiparous woman diagnosed with a large cesarean scar defect (CSD)who underwent hysterectomy. We also review the diagnosis of isthmocele, our surgical management, and the unexpected pathology findings of epithelioid trophoblastic tumor (ETT). A 42-year-old female with history of four prior cesarean sections presented 18 months postpartum with secondary amenorrhea. She was diagnosed with a large lower uterine segment isthmocele on transvaginal ultrasonography. The patient had completed childbearing and opted for surgical management via hysterectomy. She underwent total laparoscopic hysterectomy. Surgery was notable for significant adhesions from the lower uterine segment to the bladder, requiring dissection via an inferior and lateral approach after ligation of the uterine vessels. Pathologic examination revealed an epithelioid trophoblastic neoplasm. The tumor was described as 2.5 cm x 1 cm, confined to the uterus, and diffusely infiltrating the lower uterine segment without invasion into the surrounding tissue. Negative margins were identified. The patient underwent consultation with Gynecology Oncology who recommended surveillance with serial beta-human chorionic gonadotropin and imaging. The clinical presentation and diagnosis of CSD have been thoroughly described. Patients commonly present with postmenstrual spotting, and diagnosis can be made via transvaginal ultrasound. In women who have completed childbearing, hysterectomy is a reasonable treatment option. Many approaches to repair of CSD have been proposed, however approach to hysterectomy in patients with large isthmoceles has not been well documented. Moreover, while desmoid tumors have been described as an extremely rare finding within a CSD, we could only find a single case report in which an ETT was found in someone with a CSD. We reviewed the literature surrounding CSDs in the context of our patient’s clinical course. We concluded that: 1) high suspicion of CSD is warranted in a patient with unexplained amenorrhea and prior cesareans; 2) during hysterectomy, performing adhesiolysis by starting at the vesicocervical tissue and progressing superiorly may be helpful in the case of significant adhesive disease; and 3) is possible that ETT is related to CSD but further research is needed to examine this relationship.View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT)

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

To analyze retrospectively the effect of hysteroscopy combined with transvaginal repair on the cesarean section diverticulum (CSD) and explore the clinical significance of this procedure. Retrospective study. University-affiliated hospital and a gynecology hospital. A 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. In this study, we reported a surgical method for repairing uterine scar through uterine therapy and explored its clinical efficacy and pregnancy outcome. The 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. The 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.

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.

Single-port laparoscopy-assisted vaginal repair of a cesarean scar defect: a single-center retrospective study.

The incidence of uterine cesarean scar defect (niche) is high, and some patients require surgery. Single-port laparoscopy can reduce post-operative pain, and provide better cosmetic effects. This study was performed to evaluate the safety and superiority of single-port laparoscopy-assisted vaginal repair of uterine cesarean scar defect (niche) in women after cesarean section. This study included 74 patients who were diagnosed with uterine cesarean niche at the Shanghai First Maternity and Infant Hospital from January 2013 to June 2015. Thirty-seven patients underwent single-port laparoscopy-assisted vaginal surgery as the case group, and the remaining patients underwent vaginal repair surgery as the control group. We collected data from the inpatient and follow-up medical records. The clinical characteristics of these two groups were compared. The odds ratios and 95% confidential intervals were calculated for each variable by univariate and multivariate analyses. Patients who underwent single-port laparoscopy-assisted vaginal repair had a significantly longer operation time (2.3 [2.0-2.7] vs. 2.0 [1.6-2.3] h, P = 0.015), shorter gas passage time (1.2 [1.0-1.5] vs. 1.7 [1.0-2.0] days, P = 0.012), shorter hospital stay (3.1 [3.0-4.0] vs. 4.5 [4.0-6.0] days, P = 0.019), and fewer complications (0 vs. 4 cases). Univariate analysis showed that depth of the niche (P = 0.021) the mild adhesiolysis score (P = 0.035) and moderate adhesiolysis score (P = 0.013) were associated with the bladder injury. Multivariate analysis showed that the moderate adhesiolysis score (P = 0.029; 95% confidence interval, 1.318-3.526) was the strongest independent predictor of bladder injury. This study confirmed the safety and superiority of single-port laparoscopy-assisted vaginal repair of uterine cesarean scars.

Clinical outcomes of hysteroscopy-assisted transvaginal repair of cesarean scar defect.

This study was conducted to evaluate comparative clinical outcomes of hysteroscopy-assisted transvaginal repair in the treatment of cesarean scar defect (CSD) in patients desirous of conceiving again. We retrospectively enrolled 63 patients with CSD who were treated at Beijing Hospital between January 2014 and January 2016. Patients were divided into the hysteroscopic electrocauterization group (electrocauterization group, n = 28) and hysteroscopy-assisted transvaginal repair group (transvaginal group, n = 35). Perioperative parameters including operation time, intraoperative blood loss, time to passage of flatus, hospitalization duration, duration of postoperative vaginal bleeding, pre- and postoperative myometrial thickness, rate of full-term births and surgical complications were compared between the two groups. At the 6-month follow-up, myometrial thickness was significantly greater in the transvaginal group (9.8 ± 1.0 mm) compared to the electrocauterization group (3.3 ± 0.7 mm, P < 0.05). One patient in the transvaginal group required intraoperative conversion to laparotomy because of surgical complications. The transvaginal group had a significantly higher rate of full-term live birth compared to the electrocauterization group (92% vs 46%, P < 0.05). There were no significant between-group differences in the other pre-, intra-, and postoperative parameters. The maximum postoperative diameter of the CSD in the transvaginal and electrocauterization groups was 1.6 ± 0.8 and 17 ± 2.0 mm, respectively. Compared to hysteroscopic electrocauterization, hysteroscopy-assisted transvaginal repair of CSD was associated with better clinical outcomes and higher rate of full-term live births.

2960 An Overview of Uterine Scar Defects Post Cesarean Section

Study Objective Using a patient's obstetrical history, symptomatology, and radiologic findings of cesarean scar defects (CSD) to establish criteria to triage patients who require surgical repair. Additionally, to outline surgical technique for successful Robotic-assisted laparoscopic repair of CSDs. Design Comprehensive overview of diagnosis, radiological findings and repair of CSD. Setting Two large tertiary care academic medical centers. Patients or Participants Patients with previous cesarean section who are referred for possible surgical intervention for CSD. Interventions Robotic-assisted laparoscopic approach after proper multidisciplinary planning with Radiologist, Maternal fetal medicine specialist, and minimally-invasive gynecologic surgeon. Measurements and Main Results Cesarean scar defects are readily visible on ultrasound evaluation, and is a finding in many patients following cesarean section. Currently, there are no accepted guidelines to aid in the decision for when surgical management is required. The study will combine obstetrical history, symptomatology, and, most importantly, radiologic findings to aid clinicians in designing a treatment plan. Radiologic findings include degree of myometrial thinning and presence/width of the serosal dehiscence. If surgical intervention is necessary, outline the steps to robotic assisted laparoscopic repair of CSD. Included in this analysis are radiographic images of defects and video of surgical repairs. Conclusion There are numerous reports of the minimally invasive repair of CSD; however, it remains unknown in the obstetrical literature when interventions are required. Patients with minimal myometrial thinning and without evidence of serosal dehiscence may not require repair of the defect. More evidence is needed to observe obstetrical outcomes with or without repair.

Outcome of laparosopic repair of cesarean scar defect

Outcome of laparosopic repair of cesarean scar defect

Comparison of transvaginal repair versus laparoscopic repair of lower‐segment cesarean scar defects

To evaluate transvaginal repair versus laparoscopic repair of cesarean scardefects (CSDs). A retrospective cohort study was conducted among 67 symptomatic women with CSDs who attended a tertiary hospital in Beijing, China, between July 1, 2013, and March 31, 2017. The participants underwent either transvaginal repair (n=31) or laparoscopic repair (n=36). Medical costs, perioperative outcomes, and surgical outcomes were compared. No statistically significant between-group differences were found at baseline. The mean thickness of the residual myometrium increased from 1.71±0.67mm before surgery to 4.41±2.09mm after surgery in the transvaginal repair group (P<0.001), and from 1.81±0.93 to 4.68±1.96mm in the laparoscopic repair group (P<0.001). The duration of menses after surgery was less than 10days in both the transvaginal repair group (n=30, 96.3%) and the laparoscopic repair group (n=30, 83.9%; P=0.113). Operative time and medical costs were both lower in the transvaginal repair group than in the laparoscopic repair group (P<0.001). Conception rates for the two groups were similar among women who desired fertility. Transvaginal repair of CSD was associated with reduced operative times and medical costs when compared with laparoscopic repair.

Single-incision laparoscopic repair of a cesarean scar defect

To evaluate the feasibility of laparoscopic single-incision repair for a cesarean scar defect (CSD). Step-by-step explanation of surgery using an instructive video, with Institutional Review Board approval. University Hospital, Shandong Province, People's Republic of China. A 36-year-old G2P1011 woman presented with postmenstrual spotting and pelvic pain that was resistant to medical management. Transvaginal ultrasound revealed a CSD measuring 1.08 × 0.71cm with a residual myometrial thickness of 1.5mm. She desired to preserve fertility and had cosmetic concerns related to surgery. We performed single-incision laparoscopic CSD repair. After abdominal entry, the overlying peritoneum and bladder adhesion were dissected using a monopolar hook, cold scissors, and a grasper. Diagnostic hysteroscopy was performed to identify CSD boundaries. Cold scissors were used to resect the scar tissue, avoiding the use of thermal energy to prevent injury that would impair wound healing. Closure was performed using 2/0 Ethibond suture (Ethicon); the first layer was a running full-thickness vertical suture, and the second layer was a horizontal mattress suture to reduce incisional tension. Single-incision intracorporeal knot tying was successfully accomplished by forming a triangle with the straight laparoscopic forceps and the articulated instrument. Successful repair of CSD via single-incision laparoscopic surgery. Operative time was 50minutes; blood loss was 50mL. At the postoperative visit, the umbilical wound had properly healed with excellent cosmetic results. Abdominal ultrasound demonstrated that the CSD had disappeared. Cyclic menses resumed without postmenstrual spotting or pelvic pain. Our case suggests that single-incision laparoscopic repair is a feasible approach to treat CSD that can provide excellent cosmetic results. Additional studies should investigate the clinical utility of single-incision laparoscopic CSD repair in a larger sample to compare the outcomes with the vaginal and hysteroscopic approaches.

Role of hysteroscopic repair of cesarean scar defect in women with secondary infertility

Role of hysteroscopic repair of cesarean scar defect in women with secondary infertility

A new method using a Foley Catheter to locate the diverticulum in laparoscopic repair of uterine cesarean scar defects

Objective(s)To introduce a new method using a Foley catheter to locate the diverticulum in laparoscopic repair of uterine cesarean scar defect (CSD), and to evaluate the gynecological outcomes and prognosis of this new procedure. Study designTwelve patients with abnormal uterine bleeding or future fertility requirements opted for the laparoscopic repair of CSD. Then we present a series of photographic images before and after placement of the Foley catheter, and their clinical data to evaluate this new surgical technique. ResultsAll operations were completed successfully, and a CSD in the posterior lower uterine segment was first reported in our study. In each case, photographic images confirmed that the location, size and boundary of the CSD, and its relationship with the surrounding organs, were clearly marked after placement of the Foley catheter. Mean operation time was 88.2 min and mean blood loss was 25.4 ml; no complications were observed. Of the 12 patients, 8 cases experienced abnormal uterine bleeding. Following laparoscopic repair, 75% of our cases achieved complete remission while 25% showed significant improvement. ConclusionLaparoscopic repair represents an effective approach for symptomatic women with CSD. The additional use of a Foley catheter is strongly recommended for identifying and locating the diverticulum, and marking its boundary in the laparoscopic repair of uterine CSD.