Residual Myometrial Thickness Research Articles

The association between gynecological complaints and the uterine sonographic features in women with a history of cesarean section.

The aim of this study is to investigate the association between post-cesarean sonographic uterine measures, dysmenorrhea, and bleeding disorders. This is a cross-sectional study where 500 women with a history of only one cesarean section (CS) were recruited. A transvaginal transducer, GE RIC6-12-D was used for the acquisition of volumetric datasets 18±7months postpartum. Uterine length (UL), cervical length (CL), niche length (L), niche depth (D), niche width (W), fibrosis length (FL), fibrosis depth (FD), residual myometrial thickness (RMT), endometrial thickness (EM), scar to internal os distance (SO), anterior myometrial thickness superior (sAMT) and inferior (iAMT) to the scar, and the posterior myometrial thickness opposite the scar (PMT), superior (sPMT), and inferior to it (iPMT) were measured. Logistic regression with odds ratios (OR), 95% confidence intervals (CI) and ROC curves were utilized. The proportion of patients with incident post-cesarean bleeding disorders and dysmenorrhoea was 36% (CI 32%, 40%) and 17% (CI 14%, 21%) respectively. Univariate logistic regression showed that only UL was associated with bleeding disorders [OR 1.04 (CI 1.01,10.7) p value 0.005], whereas dysmenorrhea was associated with RMT [OR 0.82 (CI 0.71,0.95) p value 0.008], SO [OR 0.91 (CI 0.86,0.98) p value 0.01], and RMT ratio [OR 0.98 (CI 0.97,0.99) p value 0.03]. Multivariate logistic regression for dysmenorrhoea including SO and RMT remains statistically significant with p values <0.05 and area under the curve of 0.66. There is an association between sonographic appearance of CS scars and dysmenorrhoea. Nevertheless, the association is weak and other biological post-cesarean characteristics should be explored as potential causes.

Isthmocele and Infertility.

Isthmocele is a gynecological condition characterized by a disruption in the uterine scar, often associated with prior cesarean sections. This anatomical anomaly can be attributed to inadequate or insufficient healing of the uterine wall following a cesarean incision. It appears that isthmocele may impact a woman's quality of life as well as her reproductive capacity. The incidence of isthmocele can range from 20% to 70% in women who have undergone a cesarean section. This review aims to sum up the current knowledge about the effect of isthmocele on fertility and the possible therapeutic strategies to achieve pregnancy. However, currently, there is not sufficiently robust evidence to indicate the need for surgical correction in all asymptomatic patients seeking fertility. In cases where surgical correction of isthmocele is deemed necessary, it is advisable to evaluate residual myometrial thickness (RMT). For patients with RMT >2.5-3 mm, hysteroscopy appears to be the technique of choice. In cases where the residual tissue is lower, recourse to laparotomic, laparoscopic, or vaginal approaches is warranted.

Effectiveness of an articulating laparoscopic needle holder for cesarean scar defect repair.

To evaluate the efficacy of an articulating laparoscopic needle holder in laparoscopic surgery for cesarean scar defect. We performed a retrospective case-control study at the Shiga University of Medical Science. Patients who underwent laparoscopic uterine scar repair were divided into an articulating laparoscopic needle holder (ArtiSential®) group and a rigid needle holder (conventional) group to compare the suture and total operative times. Uterine myometrial suturing involves a double-layer interrupted suture, including a modified Gambee suture for the first layer. We measured the residual myometrial thickness using magnetic resonance imaging preoperatively and at 3 months postoperatively. Both groups comprised 10 patients each. The time per stitch for the first and second layers was significantly shorter in the ArtiSential group than in the conventional group (median 208 s vs. 403 s, p < 0.0001 and median 17 s vs. 29 s; p < 0.0001, respectively). The total operating time was significantly shorter in the ArtiSential group (mean 188 min vs. 240 min, p = 0.0015). The postoperative residual myometrial thickness (mean 9.1 mm in the ArtiSential group and 9.6 mm in the conventional group) was significantly higher than the preoperative residual myometrial thickness (mean 1.6 mm in the ArtiSential group and 1.6 mm in the conventional group) (p < 0.0001 in both groups). An articulating needle holder is useful in laparoscopic surgery for cesarean scar defect, especially when a modified Gambee suture is required.

The association of endometrial closure during cesarean section to the risk of developing uterine scar defect: a randomized control trial.

The surgical technique for uterine closure following cesarean section influences the healing of the cesarean scar; however, there is still no consensus on the optimal technique regarding the closure of the endometrium layer. The aim of this study was to compare the effect of closure versus non-closure of the endometrium during cesarean section on the risk to develop uterine scar defect and associated symptoms. A randomized prospective study was conducted of women undergoing first elective cesarean section at a single tertiary medical center. Exclusion criteria included previous uterine scar, preterm delivery and dysmorphic uterus. Women were randomized for endometrial layer closure versus non-closure. Six months following surgery, women were invited to the ambulatory gynecological clinic for follow-up visit. 2-D transvaginal ultrasound examination was performed to evaluate the cesarean scar characteristics. In addition, women were evaluated for symptoms that might be associated with uterine scar defect. Primary outcome was defined as the residual myometrial thickness (RMT) at the uterine cesarean scar. Data are presented as median and interquartile range. 130 women were recruited to the study, of them follow-up was achieved in 113 (86.9%). 61 (54%) vs. 52 (46%) of the women were included in the endometrial closure vs. non-closure groups, respectively. Groups were comparable for patient's demographic, clinical characteristics and follow-up time for postoperative evaluation. Median RMT was 5.3 (3.0-7.7) vs. 4.6 (3.0-6.5) mm for the endometrial closure and non-closure groups, respectively (p = 0.38). Substantially low RMT (< 2.5mm) was measured in four (6.6%) women in the endometrial closure group and three (5.8%) of the women in the non-closure group (p = 0.86). All other uterine scar sonographic measurements, as well as dysmenorrhea, pelvic pain and intermenstrual bleeding rates were comparable between the groups. Closure versus non-closure of the endometrial layer during cesarean uterine incision repair has no significant difference in cesarean scar characteristics and symptom rates at 6months follow-up.

Evaluation of Cesarean section scar using saline contrast sonohysterography in women with previous Cesarean scar pregnancy.

To evaluate Cesarean scar defects using saline contrast sonohysterography (SCSH) in women with a history of Cesarean scar pregnancy (CSP). A cohort of 38 non-pregnant women with a history of CSP treated with combined local and systemic methotrexate was investigated prospectively by SCSH. For the purpose of analysis, they were classified, according to the modified Delphi consensus criteria for CSP in early gestation, into three subgroups based on the depth of the gestational sac herniation in the midsagittal plane. Subgroup A included eight (21.1%) cases, in which the largest part of the gestational sac protruded towards the uterine cavity; Subgroup B included 20 (52.6%) cases, in which the largest part of the gestational sac was embedded in the myometrium; and Subgroup C included 10 (26.3%) cases, in which the gestational sac was located partially outside the outer contour of the cervix or uterus. SCSH revealed that all women in Subgroup C had a uterine niche. The median niche length (P = 0.006) and depth (P = 0.015) were significantly greater in Subgroup C than in Subgroups A or B. The median residual myometrial thickness (RMT) was significantly lower in Subgroup C than in Subgroups A or B (P = 0.006). Women with prior CSP who had a gestational sac protruding beyond the serosal line had a significantly greater niche length and depth, and lower RMT. This knowledge may guide individualized risk counseling. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

The effect of uterine closure technique on cesarean scar niche development after multiple cesarean deliveries.

To use saline infusion sonohysterography (SIS) to evaluate the effect of uterine closure technique on niche formation after multiple cesarean deliveries (CDs). Patients with at least one prior CD were evaluated for niche via SIS. Subgroups of any number repeat CD (>1 prior), lower-order CD (<4 prior), and higher-order CD (≥4 prior) were analyzed, stratifying by hysterotomy closure technique at last cesarean preceding imaging; techniques included Technique A (endometrium-free double-layer closure) and Technique B (single- or double-layer routine endo-myometrial closure). Niche defects were quantified (depth, length, width, and residual myometrial thickness). The primary outcome was clinically significant niche, defined as depth >2 mm. Statistical analysis was performed using chi-square, ANOVA, t-test, Kruskal-Wallis, and multiple logistic regression, with p-values of <0.05 were statistically significant. A total of 172 post-cesarean SIS studies were reviewed: 105 after repeat CDs, 131 after lower-order CDs, and 41 after higher-order CDs. Technique A was associated with a shorter interval to imaging and more double-layer closures. Technique B was associated with more clinically significant niches across all subgroups, and these niches were significantly longer and deeper when present. Multiple logistic regression demonstrated a 5.6, 8.1, and 11-fold increased adjusted odds of clinically significant niche following Technique B closure in the repeat CD (p<0.01), lower-order CD (p<0.001), and higher-order CD (p=0.04) groups, respectively. While multiple CDs are known to increase risk for niche defects and their sequelae, hysterotomy closure technique may help to reduce niche development and severity.

Scope and Suction: Hysteroscopic-Guided Suction Evacuation of Cesarean Scar Pregnancy—A Safe and Efficacious Treatment for Selected Patients

(Abstracted from Gynecol Minim Invasive Ther 2023;12:72–76) A continual rise of cesarean rates indicates a need to further study the possible development of lower uterine niches or cesarean scar defects, which can be described by adjacent myometrial thickness and residual myometrial thickness (RMT). Pregnancy complications such as placenta accreta spectrum disorders and uterine rupture are associated with RMTs of &lt;2.2 mm.

Hidden in plain sight: role of residual myometrial thickness to predict outcome of Cesarean scar pregnancy.

Ultrasound in Obstetrics & GynecologyAccepted Articles Opinion Hidden in plain sight: role of residual myometrial thickness to predict outcome of Cesarean scar pregnancy I. E. Timor-Tritsch, Corresponding Author I. E. Timor-Tritsch [email protected] orcid.org/0000-0001-9774-3107 Department of Obstetrics and Gynecology, New York University, New York, NY, USACorrespondence to: Prof. I. E. Timor-Tritsch, Department of Obstetrics and Gynecology, New York University, New York, NY, USA, E-mail: [email protected]Search for more papers by this authorA. Monteagudo, A. Monteagudo Icahn School of Medicine, Carnegie Maternal–Fetal Associate's, NY, USASearch for more papers by this authorG. Calỉ, G. Calỉ Department of Obstetrics and Gynecology, Maternal–Fetal Medicine Unit, Azienda Ospedaliera Villa Sofia-Cervello, Palermo, Italy Maternal–Fetal Unit, Candela Clinic, Palermo, ItalySearch for more papers by this authorA. Kaelin Agten, A. Kaelin Agten orcid.org/0000-0002-3344-0315 Liverpool Women's Hospital NHS Foundation Trust, Liverpool, UKSearch for more papers by this authorJ. M. Palacios Jaraquemada, J. M. Palacios Jaraquemada Department of Obstetrics and Gynecology, CEMIC University Hospital, Buenos Aires, ArgentinaSearch for more papers by this authorF. D'Antonio, F. D'Antonio orcid.org/0000-0002-7546-8025 Center for Fetal Care and High-Risk Pregnancy, University of Chieti, Chieti, ItalySearch for more papers by this author I. E. Timor-Tritsch, Corresponding Author I. E. Timor-Tritsch [email protected] orcid.org/0000-0001-9774-3107 Department of Obstetrics and Gynecology, New York University, New York, NY, USACorrespondence to: Prof. I. E. Timor-Tritsch, Department of Obstetrics and Gynecology, New York University, New York, NY, USA, E-mail: [email protected]Search for more papers by this authorA. Monteagudo, A. Monteagudo Icahn School of Medicine, Carnegie Maternal–Fetal Associate's, NY, USASearch for more papers by this authorG. Calỉ, G. Calỉ Department of Obstetrics and Gynecology, Maternal–Fetal Medicine Unit, Azienda Ospedaliera Villa Sofia-Cervello, Palermo, Italy Maternal–Fetal Unit, Candela Clinic, Palermo, ItalySearch for more papers by this authorA. Kaelin Agten, A. Kaelin Agten orcid.org/0000-0002-3344-0315 Liverpool Women's Hospital NHS Foundation Trust, Liverpool, UKSearch for more papers by this authorJ. M. Palacios Jaraquemada, J. M. Palacios Jaraquemada Department of Obstetrics and Gynecology, CEMIC University Hospital, Buenos Aires, ArgentinaSearch for more papers by this authorF. D'Antonio, F. D'Antonio orcid.org/0000-0002-7546-8025 Center for Fetal Care and High-Risk Pregnancy, University of Chieti, Chieti, ItalySearch for more papers by this author First published: 09 May 2023 https://doi.org/10.1002/uog.26246 This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1002/uog.26246. AboutPDF ToolsExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Accepted ArticlesAccepted, unedited articles published online and citable. The final edited and typeset version of record will appear in the future. RelatedInformation

Reproductive outcomes following abdominal repair for cesarean scar defect in women who desire subsequent pregnancies: A single-center retrospective study

ObjectiveTo clarify the reproductive outcomes of women who underwent abdominal repair surgery for cesarean scar defect (CSD). Study designThis is a retrospective observational study performed in a tertiary center. We retrospectively reviewed 20 women who underwent abdominal repair between 2007 and 2021. The indication for the repair was a minimal residual myometrial thickness (RMT) of ≦3.0 mm. We investigated surgical complications, changes in minimal RMT before and three-months after the repair, and reproductive outcomes. ResultsThe median age at the time of repair was 36 years (27–40), with a median body mass index of 21.0 (17.7–28.7) and a median of 1 prior cesarean section (1–5). Twelve women reported secondary infertility, while eight women were concerned about the potential risk of uterine rupture in future pregnancies due to thin RMT. Additionally, one woman had a co-existing vesicouterine fistula, two had abscess and hematoma formation at the precedent cesarean section, and three showed remarkable dehiscence of the defect. The median minimal RMT significantly increased to 5.05 mm (range; 2.5–14.2 mm) after the repair. Seven women had a total of eight live births, with a median duration from the repair to a live-birth pregnancy of 11.5 months (range; 4–20 months). No surgical complications occurred during the repair, and there were no instances of uterine rupture in subsequent pregnancies. However, one woman who became pregnant with twins following double blastocyst transfer required a cesarean section at 25 weeks of pregnancy due to bulging towards the bladder side of the repaired CSD. ConclusionAbdominal repair for CSD is feasible in women with thin RMT who experience secondary infertility. Twin pregnancies can promote thinning of the CSD repair site, potentially increasing the risk of uterine rupture.

Reproductive outcomes after laparoscopic resection of symptomatic niches in uterine cesarean scars: Long-term follow-up on the prospective LAPNICHE study.

After incomplete healing of the uterine cesarean section scar, a niche can be observed; 24% of the women develop large niches with a residual myometrial thickness <3 mm. In these cases a laparoscopic resection is possible. The effect of this new treatment on fertility outcome is not known yet. This paper describes reproductive outcomes 2 years after a laparoscopic niche resection and compares women with or without secondary infertility at baseline. A prospective cohort study was performed, with consecutive inclusion of women between 2011 and 2019. Women with a niche in the uterine cesarean scar, with a residual myometrial thickness of <3 mm and with a desire to become pregnant, were scheduled to undergo a laparoscopic niche resection because of one or more of the following problems (1) postmenstrual spotting; (2) midcycle intrauterine fluid accumulation diagnosed during the fertility workup or (3) difficulties with a previous embryo transfer and preferring a surgical therapy. The study is registered in the ISRCTN register (ref. no. ISRCTN02271575) on April 23, 2013. There were 133 (62%) women included with a desire to become pregnant, 88 with secondary infertility. In all, 83 had an ongoing pregnancy at the 2-year follow-up. The ongoing pregnancy rate in patients with previous fertility problems was 60.2% compared with 66.7% in patients without infertility (odds ratio [OR] 0.68, 95% confidence interval [CI] 0.32-1.7). The OR for live births was 0.57 (95% CI 0.02-1.2). Overall, 8.3% of the pregnancies resulted in miscarriages by the 2-year follow-up. The reproductive outcomes in women with and without previous fertility problems undergoing resection of a large niche are very promising and quite comparable in both groups. These results suggest, but do not prove, a beneficial effect of this therapy for these indications. The results support the design of future randomized controlled trials to evaluate the effect of niche resection vs expectant management to assess its additional value in women with or without fertility problems who desire pregnancy.

Diagnosis and management of isthmocele (Cesarean scar defect): a SWOT analysis.

The purpose of this State-of-the-Art Review was to provide a strategic analysis, in terms of strengths, weaknesses, opportunities and threats (SWOT analysis), of the current evidence regarding the management of uterine isthmocele (Cesarean scar defect). Strengths include the fact that isthmocele can be diagnosed on two-dimensional transvaginal ultrasound, and that surgical repair may restore natural fertility potential and prevent secondary infertility, as well as reduce the risk of miscarriage and other obstetric complications. However, there is a lack of high-quality evidence regarding the best diagnostic method and criteria, as well as the potential benefits of surgical repair with respect to fertility. There is a need for experienced surgeons skilled in the various isthmocele repair techniques. Isthmocele repair does not prevent the need for Cesarean delivery in subsequent pregnancies. There is increasing awareness regarding the accuracy of transvaginal ultrasound in diagnosing isthmocele. This may lead to surgical correction and prevention of obstetric and perinatal complications in subsequent pregnancies, including Cesarean scar pregnancy. Regarding threats, the existence of different surgical techniques means that there is a risk of selecting an inadequate approach if the type of isthmocele and the patient's characteristics are not considered. There is a risk of overtreatment when asymptomatic defects are repaired surgically. Finally, there is an absence of cost-effectiveness analyses to justify routine repair. Thus, while there are many data suggesting that isthmocele has an adverse effect on both natural fertility and the outcome of assisted reproduction techniques, high-quality evidence to support surgical isthmocele repair in all asymptomatic patients desiring future fertility are lacking. There is increasing agreement to recommend hysteroscopic repair of isthmocele as a first-line approach as long as the residual myometrial thickness is at least 2.5-3.0 mm. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

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.

Cesarean scar disorder: Management and repair.

Cesarean scar disorder (CSD) is an entity recently defined as uterine niche with at least one primary or 2 secondary symptoms. CSDs can be visualized by hysterosalpingography, transvaginal sonography, saline infusion sonohysterography, hysteroscopy, and magnetic resonance imaging, but diagnosis should be performed by exams able to measure the residual myometrial thickness (RMT). Although there is a limited number of studies evaluating fertility and reproductive outcomes after different types of surgery, the following consideration should be kept in mind. Asymptomatic women should not be operated with the hope of improving obstetrical outcomes. It is reasonable to consider hormone therapy for CSDs as a symptomatic treatment in women who no longer wish to conceive and have no contraindications. In case of failure of or contraindications to medical treatment, surgery should be offered according to the severity of symptoms, including infertility, the desire or otherwise to preserve the uterus, the size of the CSD, and RMT measurement. Hysteroscopy is considered to be more of a resection than a repair, so women who desire pregnancy should be excluded from this technique in case of RMT <3mm. In this instance, repair is essential and can only be achieved by a laparoscopic or vaginal approach. The benefit of laparoscopic approach seems to persist after subsequent CS. Women with CSDs need to be given complete information, including available literature, before any treatment decision is made.

O-108 C-section scar defect: Hysteroscopic vs laparoscopic repair

Abstract Objective: To present a systematic review of the literature on the hysteroscopic and laparoscopic repair of cesarean scar niche and offer an evidence-based approach to the treatment of cesarean scar niche. Data sources: A thorough search of the PubMed/Medline, Embase, and Cochrane databases was performed. (PROSPERO registration number CRD42020190668). Methods of study selection: Studies from the last 20 years that addressed cesarean scar niche repair were collected. Both authors screened for study eligibility and extracted data. All prospective and retrospective studies of more than ten women were included. Tabulation and integration: The initial search identified 666 articles [PRISMA flow chart]. We excluded duplicates, case reports, reviews, video articles, and technique articles. We also excluded studies describing only laparotomy or vaginal repair as these were not of the scope of this review. A total of 31 articles met the inclusion criteria, 21 for hysteroscopic resection and 13 for laparoscopic or combined repair (4 articles tested both modalities and appear in both tables). Results: For abnormal uterine bleeding (AUB), hysteroscopic remodeling relieved symptoms in 60%-100% of cases and laparoscopy in 78%-94%. Secondary infertility was not evaluated in all studies. We found that after hysteroscopic and laparoscopic treatment, 46%-100% and 37.5%-90% of those who wished to conceive became pregnant following the procedure, respectively. Pain and dysmenorrhea seem to be uncommon. All studies that tested improvement of pain had less than ten women. However, it would appear that between 66% and 100% of women who complain of pain or dysmenorrhea will note a marked improvement to full resolution. Conclusion: cesarean scar niche or cesarean scar defect is usually asymptomatic. For symptomatic women, a repair is a valid option. For those with RMT (Residual Myometrial thickness) &amp;gt;2-3 mm, hysteroscopic remodeling is the modality of choice with an improvement in AUB, secondary infertility, and pain. For women with a RMT &amp;lt;2-3 mm, laparoscopic repair with simultaneous hysteroscopic guidance shows similar results. Since available data is limited, no cutoff for the correct choice between hysteroscopy or laparoscopy can be concluded. We recommend 2.5 mm as the cutoff value based on common practice and expert opinion, although no significance between hysteroscopic and laparoscopic treatment was shown.

Laparoscopic niche repair: A small retrospective multicenter study

ObjectiveThe aim of this study was to evaluate laparoscopic niche repair as a safe and therapeutical option for patients with a residual myometrial thickness (RMT)≤3mm. Study designThis was a retrospective multicenter study of all patients undergoing a laparoscopic niche repair from January 1, 2016 through March 1, 2021. Patient data were obtained from the electronic medical record or provided by the performing surgeon. ResultsA total of 13 patients were included in this study. Median follow-up was 5months. One peroperative complication and no postoperative complications or long-term morbidity were withheld. Median RMT increased from 1.5±1mm to 5.2±1.7mm (mean±SD). Among the patients, 69.2% experienced symptom resolvement. Nine patients had a subsequent successful pregnancy. ConclusionThe laparoscopic niche repair is a safe minimal invasive option for symptomatic patients, able to offer symptom relief. The role for repair in asymptomatic subfertility remains up for debate.

Tek kat ve çift kat onarımın rezidüel miyometriyal kalınlık, istmosel oluşumu ve jinekolojik bozukluklar üzerine etkisi: Prospektif Randomize Kontrollü Bir Çalışma.

Abstract:&#x0D; Physicians are making great efforts to decrease the long-term complications of the cesarean section such as placental adherent syndromes, uterine scar pregnancies, uterine rupture, abnormal menstrual bleeding, or isthmocele. There is a controversy about the closure technique of the cesarean incision. The purpose of that study was to compare the impact of single layer versus double-layer closure of the hysterotomy incision on the residual myometrial thickness, isthmocele, menstrual disorders, dysmenorrhea, and dyspareunia.&#x0D; Material and Method&#x0D; A prospective randomized cohort study has been performed in a tertiary center named Bursa Yuksek İhtisas Training Research Hospital between July – October 2021. Patients were randomly assigned to each procedure (1:1) to the Single Layer Locked Continuous group and Double-layer Continuous un-locked group as uterine closure technique. Patients were examined via transvaginal ultrasound to evaluate the isthmocele occurrence, residual myometrium thickness, and inquired about menstrual properties, dysmenorrhea, and dyspareunia. Patients were also divided into groups via underwent first cesarean and more than one cesarean. &#x0D; Results:&#x0D; The numbers of the women whose hysterotomy incision was closed by single-layer locked continuous( SLLC) technique and double-layer un-locked continuous(DLUC) technique 68 and 71 respectively. There was no statistically significant difference in terms of demographic variables, obstetric history, post-operative complications, neonatal outcomes. The comparison of these groups revealed that there was no significant difference in terms of post-menstrual bleeding, heavy menstrual bleeding, post-coital bleeding, dysmenorrhea, dyspareunia. The incisional residual myometrial thickness was higher in the DLUC group with a p-value of 0,007. Six patients in SLLC and 5 patients in the DLUC group have detected isthmocele (p: 0,941). &#x0D; Patients have also been categorized as women who undergone their first cesarean section (SLLC n: 33 versus DLUC, n:33) and more than one cesarean section (SLLC n: 35 versus DLUC, n:38). Comparing the patients in these subgroups also did not differ significantly in terms of isthmocele occurrence, menstrual disorders, or residual myometrial thickness. &#x0D; Conclusion:&#x0D; No significant difference had occurred in terms of isthmocele incidence, or menstrual disorders comparing the single layer versus double-layer closure. However, women whose hysterotomy insicions were closed with double-layer un-locked continuous technique have a thicker resudial myometrium than single layer closure group especially women who underwent repeated cesarean.

Niche development after closure of caesarean uterotomy by conventional double‐suture or modified single‐suture technique (NICUM): A randomized trial

AbstractIntroductionThe aim of the study was to compare two different techniques for closure of the caesarean uterotomy on the occurrence of a caesarean scar niche.MethodsThe study was a randomized controlled trial performed in a tertiary hospital with inclusion of singleton pregnant women with a scheduled, first caesarean section. We randomized participants to two different uterotomy closure techniques; (1) Conventional double‐suture using a running suture involving the myometrium followed by a running superficial suture or (2) modified single‐suture technique with running alternating deep‐superficial stitches. The primary outcome was the proportion of caesarean scar niches &gt;2 mm deep at 6 months' follow‐up using transvaginal hysterosalinography. Secondary outcomes included residual myometrial thickness and scar niche measurements. Analyses were by intention‐to‐treat.ResultsWe randomized 230 women; 115 in each intervention group. The follow‐up rate was &gt;70% in both groups. Caesarean scar niches &gt;2 mm deep occurred in 42/81 women (52%) after double‐suture versus 35/81 women (43%) after single‐suture closure (risk difference [RD] 8.6% (95% confidence interval [CI] −6.9; 24.2)). Women in the single‐suture group had more additional stitches to the uterotomy closure. The niche was deeper after double‐suture than after single‐suture (RD 0.52 mm (95% CI 0.01–1.02). There were no other differences in ultrasonograpic or maternal clinical secondary outcomes between the two groups.ConclusionWe hypothesized a decreased occurrence of caesarean scar niches using a single‐suture technique as compared to double‐suture closure but did not observe a difference in niche occurrence between the two techniques.

Does suture material affect cesarean section scar healing?

Background: Sutures are an essential part of any major surgery which serve to hold opposing tissues together and accelerate the healing process, resulting in decreased scarring of the affected areas. In the past, gold, silver, iron, and steel wires, dried animal gut, silk, and plant fibers (e.g., linen, cotton) have been used as suture materials. Obstetricians commonly use synthetic absorbent sutures for uterine closure during CS. This study aim to evaluate the effects of different synthetic absorbable suture materials on cesarean scar defect formation.Methods: After excluding patients who did not meet inclusion criteria and those who declined to participate, the patients were randomly divided in to 2 groups: - study group І: - 35 patients and study group II: - 35 patientsPatients were subjected to the following: Ultrasound evaluation Ultrasound was done to ensure viability, determine the gestational age, the position of the placenta, the presenting part, the amniotic fluid and the estimated fetal weight using convex transducer of (Samsung Medison H60, Korea & 50/60 HZ).Results: Regarding demographic data of the studied patients, Age, gestational age and BMI there were no significant difference between both groups. Regarding time of operation and type of anesthesia there were no significant difference between both groups. There was no significant difference in the preoperative, post-operative and delta Hb concentration between both groups. Regarding post-operative pain, there was no significant difference between both groups. Regarding post-operative hospital stay was no significant difference between both groups. Regarding myometrial thickness, total and residual myometrial thickness was significantly thicker in group II compared to group I.Conclusions: Our results showed that monofilament sutures reduced pathological inflammation during wound healing without increasing costs, operation time, or intraoperative complication rates; resulting in improved uterine scar recovery; and potentially reduced CSD. These findings suggest that gynecological sequelae due to CSD and serious obstetric complications that may occur in subsequent pregnancies can be reduced.

Impact of purse-string uterine suture on scar healing after a cesarean delivery: a randomized controlled trial

Uterine closure technique can affect scar healing, potentially resulting in unfavorable gynecologic and life-threatening obstetrical outcomes. Double-layer continuous unlocked suture has been demonstrated to promote optimal residual myometrial thickness. Recently, the purse-string uterine suture technique has emerged as a viable method to enhance the healing of scars. However, the current lack of randomized trials assessing the relevance of this technique warrants further investigation. This study aimed to evaluate the impact of purse-string uterine sutures on scar healing after cesarean delivery when compared with double-layer continuous unlocked suture. This was a randomized controlled trial; 126 patients with singleton pregnancies undergoing primary cesarean delivery were enrolled in 2 groups. The primary outcome was the mean residual myometrial thickness measured by saline infusion sonography 6 months after surgery by 2 sonographers blinded to uterine closure techniques. Operative time, calculated blood loss, total number of needed threads, and perioperative scar width were used for the perioperative analysis. Healing ratio and cesarean scar defect measurements were used for the 6-month analysis. There was no significant difference in terms of residual myometrial thickness (9.38±2.3 vs 8.4±3.9 mm; P=.187), blood loss (540 [146-982] vs 495 [241-903] mL; P=.815), or operative time (6.2 [5.2-7] vs 6 [5.3-7] minutes; P=.977). Achievement of purse-string uterine suture required significantly fewer threads (1 [1-1] vs 2 [1-2]; P<.001) and fewer hemostatic complementary sutures (1 [1-1] vs 1 [1-2]; P=.013). Scar width was significantly lower with purse-string uterine sutures (50 [40.5-50.5] vs 70 [60-70.5] mm; P<.0001). Purse-string uterine sutures allowed a higher healing ratio (1 [0.9-1] vs 0.84 [0.59-1]; P=.003) and significantly fewer cesarean scar defects (12% vs 35%; P=.018) compared with double-layer continuous unlocked suture. Despite resulting in no difference in residual myometrial thickness, purse-string uterine closure seems to be associated with better uterine scar healing on the basis of a higher healing ratio, and a lower rate of cesarean scar defects compared with double-layer continuous unlocked suture.

The association between uterine scar defect (niche) and the presence of symptoms

Research questionIs there association between the presence of a uterine niche and the presence of symptoms? DesignThis cross-sectional study was conducted at a single tertiary medical centre. All women who underwent Caesarean section from January 2017 to June 2020 were invited to the gynaecological clinics, and requested to complete a questionnaire regarding symptoms related to the presence of a niche (heavy menstrual bleeding, intermenstrual spotting, pelvic pain, infertility). Transvaginal two-dimensional ultrasonography was performed to assess the uterus and uterine scar characteristics. The primary outcome was defined as the presence of a uterine niche, evaluated by length, depth, residual myometrial thickness (RMT) and ratio between the residual myometrial thickness (RMT) and adjacent myometrial thickness (AMT). ResultsOf 524 women who were eligible and scheduled for evaluation, 282 (54%) completed the follow-up; 173 (61.3%) were symptomatic and 109 (38.6%) asymptomatic. Niche measurements, including RMT/AMT ratio, were comparable between the groups. In a sub-analysis of each symptom, heavy menstrual bleeding and intermenstrual spotting were associated with reduced RMT (P = 0.02 and P = 0.04, respectively) compared with women with normal menstrual bleeding. An RMT less than 2.5 mm was significantly more prevalent in women reporting heavy menstrual bleeding (11 [25.6%] versus 27 [11.3%]; P = 0.01] and new infertility (7 [16.3%] versus 6 [2.5%]; P = 0.001]. In logistic regression analysis, infertility was the only symptom associated with an RMT less than 2.5 mm (B = 1.9; P = 0.002). ConclusionsA reduced RMT was found to be associated with heavy menstrual bleeding and intermenstrual spotting, while values below 2.5 mm were also associated with infertility.