Endometriosis and Isthmocele: Common or Rare?

Abstract

Higher cesarean section rates and better ultrasound diagnostics have led to a more frequent diagnosis of isthmocele, a cesarean scar defect. Sometimes, endometriosis is found in the isthmocele, but simultaneous extrauterine endometriosis and endometriosis in the isthmocele have not yet been reported. Additionally, the surgical technique to repair the isthmocele is the subject of ongoing controversy. The aim of this study is to analyze a possible correlation between uterine scar (isthmocele) endometriosis and extrauterine endometriosis and to investigate the outcome of laparoscopic isthmocele resection in the rendezvous technique. In this single-center retrospective study, we included 83 women of reproductive age with symptomatic isthmocele undergoing laparoscopic isthmocele repair in rendezvous technique from 2004 to 2020 at the University of Bern. We collected data on patient and surgical characteristics as well as on postoperative outcomes (symptoms, further pregnancy, and pregnancy outcomes) retrospectively. We analyzed and compared these data for patients with and without endometriosis. Endometriosis was diagnosed during surgery in 22 out of 83 operated patients (26.5%). Diagnosis of isthmocele endometriosis (n = 9, 11%) was significantly higher in patients with extrauterine endometriosis (n = 6, p = 0.004). While the duration of surgery was significantly longer for patients with endometriosis (p = 0.006), the groups did not differ with regard to blood loss or complications. In addition, both groups showed similar indications for isthmocele repair (infertility, abnormal uterine bleeding, or dysmenorrhea). Surgery significantly improved abnormal uterine bleeding (χ2 p < 0.001), dysmenorrhea (χ2, p = 0.03), and infertility (χ2, p < 0.001). Regardless of the presence of endometriosis, 25 of 40 (63%) infertile patients became pregnant after surgery. In one out of eight pregnancies, however, we observed scar complications during pregnancy such as uterine scar pregnancy (n = 3), uterine scar dehiscence (n = 3), and placenta previa (n = 1). Endometriosis is a non-negligible intraoperative finding in patients with symptomatic isthmocele. The laparoscopic approach in the rendezvous technique is safe and effective. Therefore, this method should be recommended, especially in women with secondary infertility, and preoperatively simultaneous endometriosis resection should be discussed with the patient. In follow-up, postoperative pregnancies have to be monitored with care.

Isthmocele and Infertility

“…This dissemination of endometrial cells could be facilitated by the surgical trauma and inflammation associated with the cesarean procedure [23]. This weakening may create an environment that can promote the implantation and proliferation of extrauterine endometriotic tissue [24]. Understanding the mechanisms underlying this connection necessitates further research and is of critical importance for the appropriate management and effective treatment of this complex clinical condition.…”

“…The presence of mucus or scar tissue within the isthmocele can further alter the uterine environment, making it more challenging for sperm to survive and move effectively. These factors collectively diminish the chances of conception for a couple seeking to conceive, especially if the isthmocele is substantial and remains untreated [24,81].…”

Prevalence, definition, and etiology of cesarean scar defect and treatment of cesarean scar disorder: A narrative review

“…41 Isolated or combined symptoms are expressed as niche-related symptoms or symptomatic isthmoceles. 48,49 Morris advocated calling these symptoms cesarean scar syndrome. 50 Since the term describing this condition was not unified, a task force was established to avoid confusion under these conditions.…”

“…Isolated or combined symptoms are expressed as niche‐related symptoms or symptomatic isthmoceles 48,49 . Morris advocated calling these symptoms cesarean scar syndrome 50 .…”

“…Dysmenorrhea and chronic pelvic pain are symptoms of CSDi experienced by women with endometriosis. Gulz et al 49 showed that endometriosis was diagnosed during laparoscopic surgery in 22 of 83 patients (27%). In contrast, our recent report demonstrated that endometriosis was detected in 51 (70%) patients with CSDi, although majority of patients were not at a severe stage of endometriosis 62 .…”