Hysteroscopic repair of cesarean scar isthmocele.

OBJECTIVE: To demonstrate an approach to the hysteroscopic repair of cesarean scar isthmocele and discuss its association with secondary infertility.

DESIGN: A step-by-step explanation of the procedure with surgical video footage.

SETTING: Academic medical center.

PATIENT(S): Two patients undergoing hysteroscopic repair of symptomatic cesarean scar isthmoceles. Surgical candidates for this procedure include patients with a symptomatic isthmocele and a residual myometrial thickness of at least 3 mm confirmed with pre-operative imaging.

INTERVENTION(S): Operative hysteroscopy is performed using a step-wise approach: identification of relevant anatomy; resection of the cephalad edge of fibrosis; resection of the caudad edge of fibrosis; and ablation of the isthmocele base.

MAIN OUTCOME MEASURE(S): Restoration of the contour between the uterine cavity and cervical canal.

RESULT(S): Hysteroscopic resection of cesarean scar isthmocele is successfully performed in both cases presented. Postoperatively, both patients had resolution of their symptoms.

CONCLUSION(S): The surgical approach presented in this video can result in the successful revision of a cesarean scar isthmocele. Current literature supports a role for hysteroscopic isthmoplasty in treating isthmocele-related abnormal uterine bleeding. However, more evidence is required on the safety of conceiving following hysteroscopic isthmoplasty, and its use in the setting of secondary infertility.