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Mancuso AC, Maetzold E, Kowalski JT, Voorhis BJV. Surgical repair of a cesarean scar defect using a vaginal approach. Fertil Steril. In press
) succinctly summarizes much of the aforementioned literature yet lacks specific commentary on appropriate management and counseling that would be beneficial for physicians. This was most notable in counseling patients concerning their diagnosis, treatment options given symptomology, and the limited data surrounding surgical outcomes (2Vitale S.G. Ludwin A. Vilos G.A. Török P. Tesarik J. Vitagliano A. et al.From hysteroscopy to laparoendoscopic surgery: what is the best surgical approach for symptomatic isthmocele? A systematic review and meta-analysis.). As AUB is truly the only symptom that can be definitively linked to CSD, individuals who experience other symptoms should not undergo surgery (2Vitale S.G. Ludwin A. Vilos G.A. Török P. Tesarik J. Vitagliano A. et al.From hysteroscopy to laparoendoscopic surgery: what is the best surgical approach for symptomatic isthmocele? A systematic review and meta-analysis.). The investigators mention at the end of the video that candidates for surgery should be those whose symptoms could be “reasonably explained by the defect” (5Mancuso AC, Maetzold E, Kowalski JT, Voorhis BJV. Surgical repair of a cesarean scar defect using a vaginal approach. Fertil Steril. In press
). However, at this time, all surgery is considered experimental and has not been shown to improve fertility outcomes (2Vitale S.G. Ludwin A. Vilos G.A. Török P. Tesarik J. Vitagliano A. et al.From hysteroscopy to laparoendoscopic surgery: what is the best surgical approach for symptomatic isthmocele? A systematic review and meta-analysis.). It is important to note that in the management section, only repair of CSD was reviewed, although they mention discussing hormonal treatment with their patients. Other options always should be explored, including definitive treatment through hysterectomy and suppressive hormonal therapy in patients who are not surgical candidates or wish to avoid surgery.The surgical video comprehensively covers the steps required for vaginal repair of a CSD and includes some details on patient counseling and postoperative imaging (5Mancuso AC, Maetzold E, Kowalski JT, Voorhis BJV. Surgical repair of a cesarean scar defect using a vaginal approach. Fertil Steril. In press
). In their video, they localized the defect with hysteroscopy and a uterine sound, and commented that hysteroscopy could likely be eliminated because of palpation of the defect. In addition, we would state that preoperative imaging with transvaginal ultrasound or magnetic resonance imaging could help with localization of the lesion without the additive procedure. Their method of excising the abnormality, ensuring patency of the canal, and repair of the defect was reviewed carefully while still being a concise video that could be reviewed easily preoperatively. In addition, we believe that the use of hysteroscopy at the end could be eliminated, as palpation of the defect would likely be sufficient to ensure adequate closure. However, complete elimination of the defect is unlikely, as a small defect was still noted in their patient even with the use of the hysteroscope.The investigators stated they had similar success through the vaginal approach in other patients, even those who decided to pursue fertility (5Mancuso AC, Maetzold E, Kowalski JT, Voorhis BJV. Surgical repair of a cesarean scar defect using a vaginal approach. Fertil Steril. In press
). We would caution, however, that patient selection is vital in this decision process. As this defect has been identified only more recently, no surgical procedure has been determined to be superior. Several systematic reviews and a meta-analysis show that the success ranges for treatment of associated AUB vary greatly. Hysteroscopic repair has seen between 59%–100% improvement in AUB, vaginal (89%–93.5%), laparoscopic (86%–94.7%), and medical therapy (90.9%) (1Emerging manifestations of cesarean scar defect in reproductive-aged women., 2Vitale S.G. Ludwin A. Vilos G.A. Török P. Tesarik J. Vitagliano A. et al.From hysteroscopy to laparoendoscopic surgery: what is the best surgical approach for symptomatic isthmocele? A systematic review and meta-analysis., 3Setubal A. Alves J. Osório F. Guerra A. Fernandes R. Albornoz J. et al.Treatment for uterine isthmocele, a pouchlike defect at the site of a cesarean section scar.). No information was available for laparotomies. Likewise, complication rates in addition were similar, with complications occurring in 2.18% with vaginal, 0.76% with hysteroscopic, 1.70% with laparoscopic, and none with laparotomy repair (2Vitale S.G. Ludwin A. Vilos G.A. Török P. Tesarik J. Vitagliano A. et al.From hysteroscopy to laparoendoscopic surgery: what is the best surgical approach for symptomatic isthmocele? A systematic review and meta-analysis.). These studies had a wide range of patients and lacked uniformity. In addition, the criteria for which procedure to use is lacking, with recent recommendations suggesting a myometrial thickness of at least 2.5–3 mm for a hysteroscopic approach, but no other guidelines for the other approaches (2Vitale S.G. Ludwin A. Vilos G.A. Török P. Tesarik J. Vitagliano A. et al.From hysteroscopy to laparoendoscopic surgery: what is the best surgical approach for symptomatic isthmocele? A systematic review and meta-analysis.). However, the quality and quantity of the evidence was low; thus, the decision to undergo surgical repair/treatment of AUB should be individualized, taking into consideration defect location, surgeon comfort, and with frank disclosure of the limited data between surgical approaches.This detailed surgical video brings to light that the vaginal approach is a viable option for treatment of CSD in many women who have bothersome AUB after comprehensive counseling. The body of literature for treatment options for CSD is woefully lacking; thus, leading to recommendations based largely on expert opinion. The investigators mentioned at the end of the video that they had other patients treated successfully by this approach, as well as several that had pursued fertility. This would add greatly to the body of literature to help determine best candidates for vaginal surgery and patient factors that increase success. However, until more data have been collected, the vaginal approach for treatment for CSD should still be considered experimental for patients with a thin myometrial interface, as no one approach has been shown to be optimal.
ReferencesEmerging manifestations of cesarean scar defect in reproductive-aged women.
J Minim Invasive Gynecol. 23: 893-902Vitale S.G. Ludwin A. Vilos G.A. Török P. Tesarik J. Vitagliano A. et al.From hysteroscopy to laparoendoscopic surgery: what is the best surgical approach for symptomatic isthmocele? A systematic review and meta-analysis.
Arch Gynecol Obstet. 301: 33-52Setubal A. Alves J. Osório F. Guerra A. Fernandes R. Albornoz J. et al.Treatment for uterine isthmocele, a pouchlike defect at the site of a cesarean section scar.
J Minim Invasive Gynecol. 25: 38-46Antila-Långsjö R.M. Mäenpää J.U. Huhtala H.S. Tomás E.I. Staff S.M.Cesarean scar defect: a prospective study on risk factors.
Am J Obstet Gynecol. 219: 458.e1-458.e8Mancuso AC, Maetzold E, Kowalski JT, Voorhis BJV. Surgical repair of a cesarean scar defect using a vaginal approach. Fertil Steril. In press
Article InfoPublication HistoryPublished online: July 04, 2021
Publication stageIn Press Corrected ProofFootnotesYou can discuss this article with its authors and other readers at https://www.fertstertdialog.com/posts/33166
IdentificationDOI: https://doi.org/10.1016/j.fertnstert.2021.06.006
Copyright©2021 Published by Elsevier Inc. on behalf of the American Society for Reproductive Medicine
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