This document discusses cesarean scar defects and various treatment methods. It describes three studies conducted on this topic. The first study found that 22% of women with a previous cesarean section had a scar defect, which were associated with symptoms like abnormal bleeding and pain. Defects higher in the uterus were more symptomatic. The second study evaluated vaginal ligation of the uterine artery to treat bleeding from scar defects, finding it effective with few complications. The third study assessed transvaginal repair of scar defects in 22 infertile women, finding it addressed symptoms and improved scar dimensions.

2. Cesarean Scar Defects
2014 2

3. Other nomenclature
Niche
Isthmocele
Uterine diverticulum
Uterine pouch
2014

4. 2014
CS Scar defect
(Niche or isthmocele)

5. Hysterectomy Specimens isthmocele
2014

6. 2014
Hysterectomy Specimens

7. 2014
endometrium
{Intact myom
Niche
Remaining myom >
C…..=remaining myometrium…D=Intact myometrium
Measurement of the Niche

8. Residual myometrium
measurement
2014
R .Myometrium

9. Biodevin1961
2014
<Isthmocele

10. 2014
niche
Transabdominal sonography in 1982
(Burge et al., 1982)

11. With transvaginal ultrasound in 1990
(Chen et al., 1990)
2014

12. 3D
2014 3D isthmocele ,in one woman in this study

13. 3D one woman in this study two CS scars ARE seen
1 2
Endocervical canal
2
2C S Scar defects one is high,other
is
low
3D 2014

14. 3D with zooming in
2014

15. Hysteroscopy and MRI
2014
isthmocele

16. Niche By MRI
Residual myometrium
2014

17. 2014
Mouth of the Niche (Hysteroscopy)

18. Sound in ut
Niche as seen by Lap
2014
Old blood
Adenomyosis

19. 2014
semicircular triangular
Droplet
Inclusion cyst
Various Shapes of Niche

20. Gynecologic impact of isthmocel
*Asymptomatic in most of the cases
*Abnormal uterine bleeding
*Pelvic pain
*Dyspareunia
*Dysmenorrhea
*Infertility
*Scar ectopic pregnancy
2014

21. Gynecologic impact of isthmocele
* Misdiagnosis as fibroid or bladder mass, adenomyosis .
* Difficulties during IUCD insertion, hystroscopy,D&C.
* There are some reported cases of c s scar infection
with abscess formation

22. Infertility
C S scar defect is proposed to be a cause of infertility
in some cases(31% in our study), (Al.sheemy 2012),by
the following mechanisms:
1- Distortion of the uterine cavity(endometrial line).
2- Myofibrils incoordination.
3- Interfere with sperm ascending motility.
4- Interfere with implantation.

23. 2014
Distortion of end line

24. Pathophysiology
A histopathological study of hysterectomy
specimens with Cesarean section scars proposed
three possible mechanisms underlying the patho-genesis
of these symptoms.
2014 ,Al.Sheemy &Samia Eid, MSc . thesis

25. Lymphocytic Infiltration
2014 Al.Sheemy@Samia Eid MSc thesis

26. Scar Adenomyosis
2014 Al.Sheemy@Samia Eid MSc thesis

27. Firstly, menorrhagia and abnormnal uterine
bleeding may be explained by presence of a
congested endometrial fold and small polyps in the
scar recess
2014
Pathophysiology
2014 ,Al.Sheemy &Samia Eid, MSc .
thesis

28. Secondly , Chronic pelvic pain and
dyspareunia may be explained by lymphocytic
infiltration and distortion of the lower uterine
segment
2014
Pathophysiology
2014 ,Al.Sheemy &Samia Eid, MSc .
thesis

29. Thirdly , iatrogenic adenomyosis confined to
the scar could account for dysmenorrhea. .
2014
Pathophysiology
2014 Al.Sheemy@Samia Eid MSc
thesis

30. Treatment of patients with symptomatic niche.
 There is no definite guideline for treatment till now
 Oral hormonal contraceptive pills can be used for
short term treatment for patients with CS defect and
suffering from PAUB ,but most authors reported that
oral contraceptives and progestin therapy failed to
eliminate the problem . (Klinim et al 2005)

31. Treatment of patients with symptomatic niche.
* Resectoscopic repair of the defect as a therapy was
tried in small series with variable results, 40% of this
group still retained the symptoms in
(Wang et al series 2011).
* Hysteroscopic treatment depends on electro cautery of
dilated blood vessels, endometrial like tissues ,with
removal of fibrotic scar and debris in the roof of the
pouch as it is impossible to take stitches by
hysteroscope.(Gubbin et al 2010).

32. Treatment of patients with symptomatic niche.
LaparoscopicTreatment
Donnez et al 2007 described only 3 cases of
laparoscopic repair .
Mauricio et al 2012,described one case of
laparoscopic robotic repair of niche.
However, the studied cases are limited in number ,
and need a special skill with much expense, in well
occupied centers.

33. Vaginal Repair
* Trial for transvaginal repair is started only recently,
aiming to providing a more simple method for repair
* There are only one trial for using laparoscopic guided
vaginal repair of niche in 5 cases.(Klemin et al 2005)
*Also there is one trial for vaginal repair is recently
described in 2012 by Lulu et al in 42 cases with
symptomatic relief and anatomical correction in 92%
of cases ,with nigh pregnancy rate

34. Laparoscopic Repair
Abdominal Repair of niche
Donnez et al 2012

35. 2014
Laparoscopic repair
Moricio 2012

36. In 2 011 we started to undergoes a series of studies in our
department .
The first was
To study the prevalence of C S scar defects and, its patterns
in relation to symptoms, {MSc thesis published in 2012}
The second was
To evaluate the novel operation of transvaginal uterine artery
ligation in treatment of associated menorrhagia. Published In
2013.17 Ain Shams inter confer and M D thesis.
The third is
What we discuss now which is transvaginal repair of CSSD
in 2014 under publication.
2014

37. The aims of the first study was to describe the
incidence of various clinical symptoms in
patients with cesarean section scar to determine
the association between the pattern of the scar
and clinical symptoms in women with previous
history of CS
Al.sheemy&Alsaawy
{M D thesis a approved 2012)
2014
First study

38.  A cross sectional randomized study conducted in
Ultrasound Unit of Obstetrics and Gynecology
Dep. at Al Azhar University hospital ( Domiat ).
 100 non-pregnant women were recruited for this
study from outpatient clinic who attended for
transvaginal ultrasound examination.
2014

39. frequency of scar defect in studied cases, it was reported in 22
cases out of 100 cases (22.0%).
Intact
Defect
22%
78%
2014

40. Relation between scar defect cases and
clinical symptoms
Clinical symptoms Number of cases %
Abnormal uterine
bleeding
9 40%
Dysmenorrhea 5 22%
Chronic pelvic pain 4 18%
Infertility 7 31%
2014

41. High scar is usually symptomatic
2014
High niche

42. Niche Height Ratio ab.
a = distance between fundus of uterus and the defect.
b = distance between fundus of uterus and the internal os .
Intact scar Scar defect
Mean height ratio 0.8 0.61
The mean height ratio in cases with intact scar was 0.8 and in symptomatic
cases with scar defect was 0.61 that means high defects are associated with
more clinical symptoms.
2014

43. Results in short
 Scar defects were reported in a high
frequency among women with higher rate of
parity, who had higher number of previous CS
more common with RVF uterus.
 Women with scar defects had higher
abnormal uterine bleeding, dysmenorrhea
and chronic pelvic pain. infertility in 30%.
 The most frequent clinical symptom related
to the scar defect is postmenstrual spotting.
2014

44. Recommendation of the first study
Screening for all women with CS scar is
mandatory to correlate the scar pattern with the
clinical presentation as abnormal uterine
bleeding pelvic pain dysmenorrhea infertility
and dyspareunia.
2014

45. The aim of second study was to evaluate a
new operation of vaginal uterine artery
ligation in treatment of abnormal bleeding
related to the scar and this is presented in 17
Ain shams conference 2013
2014
(ALSHEEMYconf
2013.17 AinShams
The second study

46. 0250/1145/13

47. Review
There is only 2 previous trial for VBUAL but in
treating fibroid rather than menorrhagia related to
cs scar/ in Nigeria 2010 by Akinola the other in
small series by Pelosi 2006.
However ,there is one trial to use it to control
postpartum hemorrhage in 2002
By Gundula etal
2014 52

48. Idea of Vaginal ligation of the uterine artery is to
ligate the artery in continuity close to the cervix,
the cervical tissues are included in the suture so the
edges of the CS scar defect is included in the
sutures laterally. Ligation Of the uterine artery has
its own benefit of controlling menorrhagia
2014
Idea of Vaginal ligation of
the uterine artery
Alsheemy &Samia E 2014 MD thesis

49. 2014

50. Site of vaginal ligation
of U A
<

51. Results Of Sonographic And Color Doppler
Study During The First Year Of Operation.
Item
N
Studied
Decrease in the mean uterine volume. 18 cases 35.5 %
Mean niche diameters. 8 cases 70.1%
Peak systolic velocity in intra myometrial arteries 18 cases 32 cm/s
Pregnancy in infertile group 12 cases 75%
* R I : Resistance Index.
Results
56

52. suture in place
lt side
Why the niche treated with
Vag
U A ligation
05/15/13 A1SHEEMY 57

53. Why the defect diameters improved
after vaginal ligation ?
The decrease in the niche diameter after VBUAL can
be attributed to approximation of the lateral flaps of
the old incision during suturing the arteries as the
cervix and isthmus are included in the ligature.

54. Results
Complications
• No specia1 complications occurred except a small
59
non progressing vault hematoma in 3 cases
• Excessive operative bleeding in 2casase which
rapidly stopped after ligation.

55. 2014
After 3 month after VBUAL

56. Scar Dimension Before and 3 m
Scar
Dimension
After Operation
Before
Operation
After
Operation
%
Mean width
±SD (mm) 7.2±2.2 2.3±7.7 70.2%
Mean depth ±
SD (mm)
7.4±3.2 1.8±1.4 78.6%
2014

57. • Less time consuming.
• No abdominal scar.
• Simple to learn
• Can be performed during diagnostic D&C for
abnormal uterine bleeding as an office procedure .
• Low complication
• more safe and less coasty 62

58. Recommendation of the Second Study
• The study recommend VBUAL in case of
refractory menorrhagia it can be performed
during diagnostic D&C .
• VBUAL seems to be more indicated when no
uterine lesion is found or small fibroids are
starting in young women infertile, and in CS
scar related abnormal bleeding.
2014 A!lsheemy 63

59. The third study is to assess the neo vaginal repair
of the scar defect ,without ligating the uterine
arteries except in cases which presented with
bleeding.
2014
The third study

60. 22 infertile cases were included in the study with at
least one c s the last one was at least 3 ys ago
Inclusion criteria
All with symptomatic c s scar defect
All were infertile, with associated symptoms in form of
bleeding………………. 11 case(group1)
Pelvic pain……………..11 cases.(group2)
The dimension of c s scar should be 5mm at base and 6
mm in length or more.
2014

61. The cases selected among cases attending the
El-Sheemy Clinic for period March 2012 to April
2014.
In February 2013,Our Department in AL-Azhar
university hosp started a new series in a wider scale
0250/1145/13 66

62. 2014
The endometrial surface is not
included , it only refreshed
One cm
Curette thiss urface

63. Idea of Transvaginal Repair operation
1.Curette the endometrial surface of the niche to
remove necrotic tissues and bring a fresh raw area , to
avoid suturing the endometrial side a step that avoided
to decrease a theoretical possibility of local ischemia or
adhesions.
2.The healthy residual myometrium is not incised.
3.Only one cm is the depth of the needle during
stitching 2014
the defect.

64. Anatomicallythe isthmus is the 4
mm above the I Os
2014

65. Traction of cx downwards, the supravaginal cx
Felt through the covering vaginal wall.
0250/1145/13 A1sheemy/-/-/-/-eid 70

66. D&C
D&C is performed as usual .but,
with curetting of the floor of the
niche near the isthmus to create a
row surface which we think that it
help in the healing of the
defect
2014

67. The bladder
is separated
from the cx
and reflected
upward for 3
cm
05/15/13 A1SHEEMY72
5/15/2013
2014

68. Traction, of, cx, to,
opposite
Side, to, feel, the,
supravaginal, cx
2014 05/15/13 A1SHEEMY 73

69. 2014
niche
isthmus

70. 2014

71. Push bladder up
Encircle
T V l of UA in cases
with AU B
The vessels twice
02W50/1145e/1d3nesday, May 15, 2013 76

72. suture in place
Rt side
2014 05/15/13 A1SHEEMY 77

73. 2014

74. 2014
1

75. 2014
2

76. 2014
3

77. 2014
4

78. 2014
5

79. 2014
6

80. 2014
7

81. Cystoscopy
Was then done
Only in the first
5case to be sure
that
The ureters
Are intact
2014
05/15/13 86

82. Cystoscopy
In case of vaginal uterine artery ligation cystoscopy
is performed at end of operation with ureteric
catheterization in the first10 cases to detect any
ureteric in jury a step which is not needed after
the first 5cases, as we gained the experience of
entering the correct plain.

83. cystoscopy
Ureteric catheter shows intact
Ureter after the VBUAL operation
88

84. Serial post operative follow up every 2 months
then applied for 3 years to record the response to
the operation as regard bleeding cycles regularity
degree of pain with vaginal sonogaphy CD
,pregnancy rate with its outcome and uterine
volume measurement.
89

85. After 2 hours of
vaginal repair TAS

86. 2014
Before Repair
One woman with niche with 2 small
interstitial fibroid before v. repair

87. One hour after vaginal repair
The same patient
after v. repair

88. 2014
2 weeks after vaginal
repair

89. 2014
2 week after vaginal repair
Endometrial
side
B
CX

90. After 6 months of vaginal repair
2014
05/15/13

91. Results of V repair
• Bleeding Control: All cases show decrease in the
amount and duration However 6 cases reported a
heavy menses for only 2 months.
• Pain control: Most of the women complaining of
pelvic pain before the operation recoded an
improvement(8 out of12)
• There is anatomical and symptomatic correction
of the problem.

92. Results of V repair
 16 cases became pregnant out of 22 cases (72.7%)
 2 cases aborted ,the other completed an unremarkable
pregnancy.
 All the 14 cases were delivered by CS at 37W during
operation the scar is not thin and even difficult to
differentiate from surrounding myometrium ,no
myoma or bulky uterus were present in cases
presented with uterine pathology.

93. Conclusion
We agree with Marotta et al 2013 that if the
residual myometrium is 3mm or less
hystroscopic repair should be avoided
although of the limited number studied this
v repair provides a simple alternative to both
hystroscopic and laparoscopic repair
2014

94. Results
• The operative time without
cystoscopy was 22 minutes.
• The mean hospital stay time was
3hours.
2014
05/15/13 99

95. Early pregnancy 3 months after v repair
2014

96. 2014
Pregnancy after vaginal repair

97. 2014
Pregnancy after vaginal repair

98. After 3 years of follow up most of the
patients are still satisfied with the
operation results especially as regard the
bleeding control, pain improvement and
pregnancy outcome

99. • VBUAL and Vaginal repair are simple safe,
minimally invasive and not time consuming uterine
preservative operations.
• Clinical and sonographic results of both are
promising specially as regard patient satisfaction.
• Our primary results indicate that unremarkable
pregnancy can occur with good pregnancy outcome .
104
Conclusion of three studies

100. Acknowledgment
2014
All staff members in department
,my family members ..
dr.reffat45@gmail.com

101. For your attention