The effect of laparoscopic resection of large niches in the uterine caesarean scar on symptoms, ultrasound findings and quality of life: a prospective cohort study

Abstract

ObjectiveTo evaluate the effectiveness of a laparoscopic niche resection on niche‐related symptoms and/or fertility‐related problems, ultrasound findings and quality of life.DesignProspective cohort study.SettingUniversity hospital.PopulationWomen with a large niche (residual myometrium <3 mm) and complaints of either postmenstrual spotting, dysmenorrhoea, intrauterine fluid accumulation and/or difficulties with embryo transfer due to distorted anatomy.MethodsWomen filled out questionnaires and a validated menstrual score chart at baseline and 6 months after the laparoscopic niche resection. At baseline and between 3 and 6 months follow up niches were evaluated by transvaginal ultrasound.Main outcome measuresThe primary outcome was reduction of the main problem 6 months after the intervention. Secondary outcomes were complications, menstrual characteristics, dysmenorrhoea, niche measurements, intrauterine fluid, surgical outcomes, satisfaction and quality of life.ResultsIn all, 101 women underwent a laparoscopic niche resection. In 80 women (79.2%) the main problem was improved or resolved. Postmenstrual spotting was significantly reduced by 7 days at 6 months follow up compared with baseline. Dysmenorrhoea and discomfort related to spotting was also significantly reduced. The residual myometrium was increased significantly at follow up. The intrauterine fluid was resolved in 86.9% of the women with intrauterine fluid at baseline; 83.3% of women were (very) satisfied. The physical component of quality of life increased, the mental component did not change.ConclusionsA laparoscopic niche resection reduced postmenstrual spotting, discomfort due to spotting, dysmenorrhoea and the presence of intrauterine fluid in the majority of women and increased the residual myometrium.Tweetable abstractLaparoscopic niche resection reduces niche‐related problems and enlarges the residual myometrium.

Gynaecological morbidity associated with caesarean niche: increasing awareness, prevention and management

“…Significant improvements were reported in number of days of postmenstrual spotting (4 versus 7 days; P = 0.04) and in postmenstrual spotting‐associated pain ( P = 0.02) . In a similar interventional study of symptomatic women undergoing laparoscopic niche resection of large caesarean niches, defined as RMT <3 mm, repair resulted in an almost 80% improvement in the symptoms of postmenstrual spotting, dysmenorrhoea and pelvic pain …”

“…Different terms have since been used to describe the same phenomenon, including caesarean scar defect, isthmocele, post‐caesarean section scar defect (PCSD), caesarean niche, and caesarean delivery scar pouch . Caesarean niche is commonly identified on ultrasound as a hypoechoic area seen in the anterior lower segment, representing a defect in the myometrium as a result of poor healing of the uterine scar created at hysterotomy.…”

“…In 2018, Vervoort et al. published the results of the largest consecutive cohort of laparoscopic niche resection in 101 symptomatic women with RMT <3 mm . Niche resection was performed under hysteroscopic guidance (Figure ).…”

Isthmocele: From Risk Factors to Management

“…35,45,51,64,[68][69][70][71][72][73][74][75][76][77][78][79] Laparoscopy is a technique that has to be preferred especially if the residual myometrial thickness is < 3 mm. 78 A skilled laparoscopic surgeon can use conventional laparoscopy or robotic-assisted surgery to correct the isthmocele. 25 After the defect is identified, it is cut open and the isthmocele and the surrounding fibrotic tissue are trimmed carefully and removed from the edges of the defect to access the healthy myometrium.…”

“…In fact, Api et al 79 analyzed the myometrial thickness, finding a mean value of 2 mm (0.7-6.2 mm) before the laparoscopy and of 9.8 mm (2.5-13.1 mm) after the surgery. Vervoort et al 78 published the first large prospective cohort study that evaluated the effect of laparoscopic isthmocele resection on symptoms, on fertility, and on ultrasound findings, evaluating 101 women. In this study, Vervoort et al 78 showed that the laparoscopic approach reduces postmenstrual spotting and its correlated discomfort, reduces dysmenorrhea, and enlarges the residual myometrial thickness 6 months after the intervention.…”