Clinical success rate of extensive hysteroscopic cesarean scar defect (CSD) excision and correlation to histological findings

Abstract Study Objective CSD (cesarean scar defect) is often associated with post menstrual bleeding, infertility and pain. Hysteroscopic CSD repair was described in the past, mainly as excision of the proximal edge of the defect to allow continuous blood flow during menstruation. In this study we aimed to evaluate the efficacy of extensive hysteroscopic cesarean scar niche excision in symptomatic patients. Design Patients were followed for a minimum of 1 year following hysteroscopic CSD excision. Clinical information obtained included detailed obstetric history, preoperative and postoperative menstruation pattern. Patients Symptomatic patients who were treated with hysteroscopic CSD excision. Patients were considered eligible for the procedure in case myometrial thickness of 2mm or more was observed on sonohysterography (SHG) Setting Tertiary referral center Interventions Extensive CSD excision was performed using a cutting loop and pure cutting current. The proximal and distal edges of the defect were resected. This was followed by resection of tissue at the base of the niche, until underling muscular tissue was evident. Tissue sampled from the base of the cesarean scar defect was collected for histologic examination. Measurements and main results Between 2011 and 2016, a total of 95 patients underwent extensive hysteroscopic niche excision, 67 were included in the study while the remaining were lost to follow-up. Patient's mean age at procedure was 38±5.5. Twenty-nine patients (43%) had an history of high order repeat cesarean surgeries. Sixty-six patients (98.5%) presented with post menstrual bleeding, 26 with secondary infertility (38.8%) and 2 with pelvic pain (2.9%). Following hysteroscopic niche excision, 63.4% of patients reported significant improvement or resolution of post menstrual bleeding. A statistically significant reduction in number of bleeding days per cycle (15.5±4.8 vs. 9.8±4.7, P Conclusion Extensive hysteroscopic surgical excision of cesarean scar niche should be considered in symptomatic patients suffering from irregular menstrual bleeding. The quality of the excision at the apex of the niche could be associated with a higher success rate. The role of niche excision to overcome secondary infertility should be further evaluated.