Cesarean Scar Defects: Hysteroscopic Treatment of Isthmocele in Menstrual Disorders and Infertility

  • Carlo Tantini
  • Gersia Araújo Viana
  • Giampietro Gubbini


Surgical deliveries may lead, as a consequence, the formation of cesarean scar defects (CSD), also called isthmocele. This pathology can cause symptoms, such as abnormal uterine bleeding, pelvic pain and infertility. Surgical correction should be performed using hsiteroscopic procedure for its efficacy and low invasiveness.The increasing incidence of surgical deliveries has resulted in a greater number of cesarean scar defects (CSD). This disorder is also known as isthmocele and is responsible for symptoms like post-menstrual abnormal uterine bleeding (PAUB), infertility, chronic pelvic pain, and possible obstetric complications in subsequent pregnancies. Diagnostic investigation for this disorder should be carried out by transvaginal ultrasound and hysteroscopy (imaging methods that allow identification of the defect and guide the surgical program). Surgical treatment is effective. Of the developed techniques, the hysteroscopic technique is the most used because of its low invasiveness and satisfactory results. Currently, mini resectoscopy (of 16-Fr diameter) is the most suitable technique because it is technically simpler and safer. This study includes 412 patients with a cesarean delivery history and confirmed diagnosis of isthmocele treated surgically by vaginal resectoscope. Results showed a correction of anatomical defects in 100 % of cases, with persistent symptoms in only 9 % of patients. While there is not a broad awareness of the correct indication for caesarean sections amongst gynecologists, the diagnosis and treatment of isthmocele will continue to feature in modern gynecological practice.


Cesarean scar defects Isthmocele Hysteroscopy Mini-resectoscope Post-menstrual abnormal uterine bleeding Infertility 


  1. 1.
    Zizza A, Tinelli A, Malvasi A, Barbone E, Stark M, De Donno A, et al. Caesarean section in the world: a new ecological approach. J Prev Med Hyg. 2011;52(4):161–73.PubMedGoogle Scholar
  2. 2.
    Betran AP, Torloni MR, Zhang J, Ye J, Mikolajczyk R, Deneux-Tharaux C, et al. What is the optimal rate of caesarean section at population level? A systematic review of ecologic studies. Reprod Health. 2015;12:57.PubMedPubMedCentralCrossRefGoogle Scholar
  3. 3.
    Betrán AP, Ye J, Moller AB, Zhang J, Gülmezoglu AM, Torloni MR. The increasing trend in caesarean section rates: global, regional and national estimates: 1990-2014. PLoS One. 2016;11(2):e0148343.PubMedPubMedCentralCrossRefGoogle Scholar
  4. 4.
    Hellerstein S, Feldman S, Duan T. China’s 50% caesarean delivery rate: is it too high? BJOG. 2015;122(2):160–4.PubMedCrossRefGoogle Scholar
  5. 5.
    Prefumo F, Ferrazzi E, Di Tommaso M, Severi FM, Locatelli A, Chirico G, et al. Neonatal morbidity after cesarean section before labor at 34(+0) to 38(+6) weeks: a cohort study. J Matern Fetal Neonatal Med. 2016;29(8):1334–8.PubMedCrossRefGoogle Scholar
  6. 6.
    De Luca R, Boulvain M, Irion O, Berner M, Pfister RE. Incidence of arly neonatal mortality and morbidity after late-preterm and term cesarean delivery. Pediatrics. 2009;123(6):e1064–71.PubMedCrossRefGoogle Scholar
  7. 7.
    Farchi S, Di Lallo D, Franco F, Polo A, Lucchini R, Calzolari F, et al. Neonatal respiratory morbidity and mode of delivery in a population-based study of low-risk pregnancies. Acta Obstet Gynecol Scand. 2009;88(6):729–32.PubMedCrossRefGoogle Scholar
  8. 8.
    Many A, Helpman L, Vilnai Y, Kupferminc MJ, Lessing JB, Dollberg S. Neonatal respiratory morbidity after elective cesarean section. J Matern Fetal Neonatal Med. 2006;19(2):75–8.PubMedCrossRefGoogle Scholar
  9. 9.
    O’Neill SM, Kearney PM, Kenny LC, Henriksen TB, Lutomski JE, Greene RA, et al. Caesarean delivery and subsequent pregnancy interval: a systematic review and meta-analysis. BMC Pregnancy Childbirth. 2013;13:165.PubMedPubMedCentralCrossRefGoogle Scholar
  10. 10.
    Evers EC, McDermott KC, Blomquist JL, Handa VL. Mode of delivery and subsequent fertility. Hum Reprod. 2014;29(11):2569–74.PubMedPubMedCentralCrossRefGoogle Scholar
  11. 11.
    Stewart KS, Evans TW. Recurrent bleeding from the lower segment scar—a late complication of Caesarean section. Br J Obstet Gynaecol. 1975;82(8):682–6.PubMedCrossRefGoogle Scholar
  12. 12.
    Morris H. Surgical pathology of the lower uterine segment caesarean sectionscar: is the scar a source of clinical symptoms? Int J Gynecol Pathol. 1995;14(1):16–20.PubMedCrossRefGoogle Scholar
  13. 13.
    Gubbini G, Casadio P, Marra E. Resectoscopic correction of the “isthmocele” in women with postmenstrual abnormal uterine bleeding and secondary infertility. J Minim Invasive Gynecol. 2008;15(2):172–5.PubMedCrossRefGoogle Scholar
  14. 14.
    Chang Y, Tsai EM, Long CY, Lee CL, Kay N. Resectoscopic treatment combined with sonohysterographic evaluation of women with postmenstrual bleeding as a result of previous cesarean delivery scar defects. Am J Obstet Gynecol. 2009;200(4):370.e1–4.CrossRefGoogle Scholar
  15. 15.
    Borges LM, Scapinelli A, de Baptista Depes D, Lippi UG, Coelho Lopes RG. Findings in patients with postmenstrual spotting with prior cesarean section. J Minim Invasive Gynecol. 2010;17(3):361–4.PubMedCrossRefGoogle Scholar
  16. 16.
    Lin YH, Hwang JL, Seow KM. Endometrial ablation as a treatment for postmenstrual bleeding due to cesarean scar defect. Int J Gynaecol Obstet. 2010;111(1):88–9.PubMedCrossRefGoogle Scholar
  17. 17.
    Gubbini G, Centini G, Nascetti D, Marra E, Moncini I, Bruni L, et al. Surgical hysteroscopic treatment of cesarean-induced isthmocele in restoring fertility: prospective study. J Minim Invasive Gynecol. 2011;18(2):234–7.PubMedCrossRefGoogle Scholar
  18. 18.
    Florio P, Gubbini G, Marra E, Dores D, Nascetti D, Bruni L, et al. A retrospective case-control study comparing hysteroscopic resection versus hormonal modulation in treating menstrual disorders due to isthmocele. Gynecol Endocrinol. 2011;27(6):434–8.PubMedCrossRefGoogle Scholar
  19. 19.
    Uppal T, Lanzarone V, Mongelli M. Sonographically detected caesarean section scar defects and menstrual irregularity. J Obstet Gynaecol. 2011;31(5):413–6.PubMedCrossRefGoogle Scholar
  20. 20.
    Shih CL, Chang YY, Ho M, Lin WC, Wang AM, Lin WC. Hysteroscopic transcervical resection. A straightforward method corrects bleeding related to cesarean section scar defects. Am J Obstet Gynecol. 2011;204(3):278.e1–2.CrossRefGoogle Scholar
  21. 21.
    Wang CJ, Huang HJ, Chao A, Lin YP, Pan YJ, Horng SG. Challenges in the transvaginal management of abnormal uterine bleeding secondary to cesarean section scar defect. Eur J Obstet Gynecol Reprod Biol. 2011;154(2):218–22.PubMedCrossRefGoogle Scholar
  22. 22.
    Bij de Vaate AJ, van der Voet LF, Naji O, Witmer M, Veersema S, Brölmann HA, et al. Prevalence, potential risk factors for development and symptoms related to the presence of uterine niches following Cesarean section: systematic review. Ultrasound Obstet Gynecol. 2014;43(4):372–82.CrossRefGoogle Scholar
  23. 23.
    Heller DS. Pathologic basis for abnormal uterine bleeding with organic uterine pathologies. Menopause. 2011;18(4):412–5.PubMedCrossRefGoogle Scholar
  24. 24.
    Rayburn WF, Schwartz WJ 3rd. Refinements in performing a cesarean delivery. Obstet Gynecol Surv. 1996;51(7):445–51.PubMedCrossRefGoogle Scholar
  25. 25.
    Hofmeyr GJ, Mathai M, Shah A, Novikova N. Techniques for caesarean section. Cochrane Database Syst Rev. 2008;1:CD004662.Google Scholar
  26. 26.
    Stark M. Clinical evidence that suturing the peritoneum after laparotomy is unnecessary for healing. World J Surg. 1993;17(3):419.PubMedCrossRefGoogle Scholar
  27. 27.
    Fabres C, Aviles G, De La Jara C, Escalona J, Muñoz JF, Mackenna A, et al. The cesarean delivery scar pouch: clinical implications and diagnostic correlation between transvaginal sonography and hysteroscopy. J Ultrasound Med. 2003;22(7):695–700.PubMedCrossRefGoogle Scholar
  28. 28.
    Yazicioglu F, Gökdogan A, Kelekci S, Aygün M, Savan K. Incomplete healing of the uterine incision after caesarean section: is it preventable? Eur J Obstet Gynecol Reprod Biol. 2006;124(1):32–6.PubMedCrossRefGoogle Scholar
  29. 29.
    Hayakawa H, Itakura A, Mitsui T, Okada M, Suzuki M, Tamakoshi K, et al. Methods for myometrium closure and other factors impacting effects on cesarean section scars of the uterine segment detected by the ultrasonography. Acta Obstet Gynecol Scand. 2006;85(4):429–34.PubMedCrossRefGoogle Scholar
  30. 30.
    Wang CB, Chiu WW, Lee CY, Sun YL, Lin YH, Tseng CJ. Cesarean scar defect: correlation between Cesarean section number, defect size, clinical symptoms and uterine position. Ultrasound Obstet Gynecol. 2009;34(1):85–9.PubMedCrossRefGoogle Scholar
  31. 31.
    Osser OV, Jokubkiene L, Valentin L. Cesarean section scar defects: agrément between transvaginal sonographic findings with and without saline contrast enhancement. Ultrasound Obstet Gynecol. 2010;35(1):75–83.PubMedCrossRefGoogle Scholar
  32. 32.
    Donnez O, Jadoul P, Squifflet J, Donnez J. Laparoscopic repair of wide and deep uterine scar dehiscence after cesarean section. Fertil Steril. 2008;89(4):974–80.PubMedCrossRefGoogle Scholar
  33. 33.
    Fernandez E, Fernandez C, Fabres C, Alam VV. Hysteroscopic correction of cesarean section scars in women with abnormal uterine bleeding. J Am Assoc Gynecol Laparosc. 1996;3(4, Supplement):S13.PubMedGoogle Scholar
  34. 34.
    Kawakami S, Togashi K, Sagoh T, Kimura I, Noguchi M, Takakura K, et al. Uterine deformity caused by surgery during pregnancy. J Comput Assist Tomogr. 1994;18(2):272–4.PubMedCrossRefGoogle Scholar
  35. 35.
    Reis FM, Cobellis L, Luisi S, Driul L, Florio P, Faletti A, et al. Paracrine/autocrine control of female reproduction. Gynecol Endocrinol. 2000;14(6):464–75.PubMedCrossRefGoogle Scholar
  36. 36.
    Guzeloglu-Kayisli O, Kayisli UA, Taylor HS. The role of growth factors and cytokines during implantation: endocrine and paracrine interactions. Semin Reprod Med. 2009;27(1):62–79.PubMedPubMedCentralCrossRefGoogle Scholar
  37. 37.
    Poidevin LO, bockner VY. A hysterographic study of uteri after caesarean section. J Obstet Gynaecol Br Emp. 1958;65(2):278–83.PubMedCrossRefGoogle Scholar
  38. 38.
    Bockner V. Hysterography and ruptured uterus. J Obstet Gynecol Br Emp. 1960;67:838–9.CrossRefGoogle Scholar
  39. 39.
    Fabres C, Alam V, Balmaceda J, Zegers-Hochschild F, Mackenna A, Fernandez E. Comparison of ultrasonography and hysteroscopy in the diagnosis of intrauterine lesions in infertile women. J Am Assoc Gynecol Laparosc. 1998;5(4):375–8.PubMedCrossRefGoogle Scholar
  40. 40.
    Ofili-Yebovi D, Ben-Nagi J, Sawyer E, Yazbek J, Lee C, Gonzalez J, et al. Deficient lower-segment Cesarean section scars: prevalence and risk factors. Ultrasound Obstet Gynecol. 2008;31(1):72–7.PubMedCrossRefGoogle Scholar
  41. 41.
    Florio P, Filippeschi M, Moncini I, Marra E, Franchini M, Gubbini G. Hysteroscopic treatment of the cesarean-induced isthmocele in restoring infertility. Curr Opin Obstet Gynecol. 2012;24(3):180–6.PubMedCrossRefGoogle Scholar
  42. 42.
    Li C, Tang S, Gao X, Lin W, Han D, Zhai J, et al. Efficacy of combined laparoscopic and hysteroscopic repair of post-cesarean section uterine diverticulum: a retrospective analysis. Biomed Res Int. 2016;2016:1765624.PubMedPubMedCentralGoogle Scholar
  43. 43.
    Schepker N, Garcia-Rocha GJ, von Versen-Höynck F, Hillemanns P, Schippert C. Clinical diagnosis and therapy of uterine scar defects after caesarean section in non-pregnant women. Arch Gynecol Obstet. 2015;291(6):1417–23.PubMedCrossRefGoogle Scholar
  44. 44.
    Klemm P, Koehler C, Mangler M, Schneider U, Schneider A. Laparoscopic and vaginal repair of uterine scar dehiscence following cesarean section as detected by ultrasound. J Perinat Med. 2005;33(4):324–31.PubMedCrossRefGoogle Scholar
  45. 45.
    Luo L, Niu G, Wang Q, Xie HZ, Yao SZ. Vaginal repair of cesarean section scar diverticula. J Minim Invasive Gynecol. 2012;19(4):454–8.PubMedCrossRefGoogle Scholar
  46. 46.
    Marotta ML, Donnez J, Squifflet J, Jadoul P, Darii N, Donnez O. Laparoscopic repair of post-cesarean section uterine scar defects diagnosed in nonpregnant women. J Minim Invasive Gynecol. 2013;20(3):386–91.PubMedCrossRefGoogle Scholar
  47. 47.
    Dealberti D, Riboni F, Cosma S, Pisani C, Montella F, Saitta S, et al. Feasibility and acceptability of office-based polypectomy with a 16F mini-resectoscope: a multicenter clinical study. J Minim Invasive Gynecol. 2016;23(3):418–24.PubMedCrossRefGoogle Scholar
  48. 48.
    Bettocchi S, Nappi L, Ceci O, Selvaggi L. Office hysteroscopy. Obstet Gynecol Clin N Am. 2004;31(3):641–54.CrossRefGoogle Scholar
  49. 49.
    Papalampros P, Gambadauro P, Papadopoulos N, Polyzos D, Chapman L, Magos A. The mini-resectoscope: a new instrument for office hysteroscopic surgery. Acta Obstet Gynecol Scand. 2009;88(2):227–30.PubMedCrossRefGoogle Scholar
  50. 50.
    Li C, Guo Y, Liu Y, Cheng J, Zhang W. Hysteroscopic and laparoscopic management of uterine defects on previous cesarean delivery scars. J Perinat Med. 2014;42(3):363–70.PubMedCrossRefGoogle Scholar
  51. 51.
    Ricciardi R, Lanzone A, Tagliaferri V, Di Florio C, Ricciardi L, Selvaggi L, et al. Using a 16-French resectoscope as an alternative device in the treatment of uterine lesions: a randomized controlled trial. Obstet Gynecol. 2012;120(1):160–5.PubMedCrossRefGoogle Scholar
  52. 52.
    Gupta J, Kai J, Middleton L, Pattison H, Gray R, Daniels J, ECLIPSE Trial Collaborative Group. Levonorgestrel intrauterine system versus medical therapy for menorrhagia. N Engl J Med. 2013;368(2):128–37.PubMedCrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Carlo Tantini
    • 1
    • 2
  • Gersia Araújo Viana
    • 2
  • Giampietro Gubbini
    • 3
  1. 1.Centro de Pesquisa e Assistência em Reprodução Humana (CEPARH)SalvadorBrazil
  2. 2.CENAFERT/INSEMINA, Centro de Medicina ReprodutivaSalvadorBrazil
  3. 3.Clinica Madre Fortunata TonioloBolognaItaly

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