ISTMOCEL (isthmocele) or niche surgery
Damage at the Caesarean Section Surgery Site
An isthmus is the separation and damage to the uterus at the incision made to remove the baby during a caesarean section. Most of the time, patients do not show any signs or symptoms and may be detected by chance on ultrasound; however, if they do, symptoms may include intermittent abnormal bleeding, pain and even inability to conceive a child.
Sometimes brown bleeding or discharge after the end of menstruation can severely impair the patient’s quality of life; this constant bleeding or discharge can alter the vaginal flora and lead to chronic cervicovaginal infection.
The worldwide prevalence of isthmus is parallel to cesarean delivery rates.
Patients with no signs or symptoms usually do not require treatment; in case of symptoms, treatment should be planned and individualized according to the patient’s complaints and expectations.
Transvaginal ultrasonography is usually sufficient for diagnosis and sonohysterography may rarely be required.
Surgical treatment of isthmocele should be recommended for symptomatic women.
We never recommend removal of the uterus (hysterectomy) for isthmocele. It is necessary to preserve the uterus and possibly treat asymptomatic women who are planning a future pregnancy.
Patients who are planning a pregnancy, even if they have no symptoms, should be treated, because if the gestational sac (more precisely the placenta, the mate of the child) implants in this damaged area, the risk of scar pregnancy increases greatly. If the scar pregnancy progresses to placental adhesion anomaly (i.e. placenta increata, placenta percreata, placenta percreata), it becomes more difficult to treat.
CAUTION: Depending on the extent and depth of the damage to the isthmus, if the next gestational sac and the placenta itself implant in the isthmus, cesarean scar pregnancy and placenta percreata may be inevitable in later gestational weeks.
Laparoscopy is the most ideal approach fortreatment; hysteroscopy can also be performed. The options should be explained and discussed in detail according to the patient’s complaints and expectations.