Ukrainian Journal of Perinatology and Pediatrics. 2025.4(104): 90-97. doi: 10.15574/PP.2025.4(104).9097
Chayka K. V., Karlova O. O., Chayka V. V.
Shupyk National Healthcare University of Ukraine, Kyiv

For citation: Chayka KV, Karlova OO, Chayka VV. (2025). Assessment and surgical management strategy for isthmocele following cesarean section. Ukrainian Journal of Perinatology and Pediatrics. 4(104): 90-97. doi: 10.15574/PP.2025.4(104).9097.
Article received: Sep 18, 2025. Accepted for publication: Nov 27, 2025.

In modern gynecology, isthmocele (cesarean scar defect – CSD) has evolved from an "incidental finding" to a clinically significant pathology requiring a clear diagnostic and therapeutic algorithm. Literature data from 2019-2024 highlight a direct correlation between Cesarean section techniques, specifically low uterine incision and suturing methods, and defect formation. Key clinical challenges include abnormal uterine bleeding in up to 85% of cases, secondary infertility, and chronic pelvic pain.
Aim – to develop a stratification algorithm for the surgical treatment of isthmocele based on ultrasound criteria for residual myometrial thickness (RMT) and the patient's clinical presentation.
A comprehensive examination for patients with CSD has been developed. It was found that ultrasonography is the primary diagnostic tool for determining the morphological parameters of the niche. RMT was identified as the key indicator. It was demonstrated that clinical symptomatology correlates with the dimensions of the defect: abnormal uterine bleeding was observed in the majority of patients (37-85%), while infertility and pelvic pain were identified in 11-39% and 18-33% of cases, respectively. A differentiated management approach has been proposed: conservative observation is recommended for patients with an asymptomatic defect, regardless of the niche size. In cases of severe symptoms and large defects, surgical correction is indicated. The feasibility of laparoscopic metroplasty was determined for cases where the RMT exceeded 3 mm. This approach allowed not only for the elimination of the niche but also for the reinforcement of the uterine wall, significantly reducing the risk of complications compared to isolated hysteroscopic resection.
Conclusions. Successful treatment of isthmocele depends on the standardization of ultrasound criteria and a multidisciplinary approach. Stratifying patients based on RMT measurements allows for the selection of an optimal strategy – ranging from a "wait-and-watch" approach to minimally invasive laparoscopic correction. Implementing laparoscopic access when the myometrial thickness is >3 mm is a pathogenetically sound method that ensures the restoration of anatomical integrity and improves reproductive outcomes.
The authors declare that there is no conflict of interest.
Keywords: cesarean section, isthmocele, uterine scar defect, residual myometrial thickness (RMT), hysteroscopy, laparoscopic metroplasty, ultrasound diagnostics.

REFERENCES

1. ACOG. (2023). Vaginal Birth After Cesarean Delivery. ACOG Practice Bulletin No. 205. Obstetrics & Gynecology. (Reaffirmed).

2. Alalfy M, El-Gazar A, Elsherbini M et al. (2024). Role of 3D transvaginal ultrasound in the assessment of cesarean section scar niche and its relation to abnormal uterine bleeding. BMC Women's Health. 24: 58. doi: 10.1186/s12905-024-02911-w.

3. Antila-Långsjö RM, Mäenpää JU, Huhtala HS, Tomás EI, Staff SM. Cesarean scar defect: a prospective study on risk factors. Am J Obstet Gynecol. 2018;219(5):458.e1-458.e8. https://doi.org/10.1016/j.ajog.2018.09.004; PMid:30240650

4. Betran AP, Ye J, Moller AB, Souza JP, Zhang J. (2021, Jun). Trends and projections of caesarean section rates: global and regional estimates. BMJ Glob Health. 6(6): e005671. https://doi.org/10.1136/bmjgh-2021-005671; PMid:34130991 PMCid:PMC8208001

5. Biaoshti G et al. (2024). Laparoscopic vs Hysteroscopic Repair of Cesarean Scar Defect: A Systematic Review and Meta-analysis. Journal of Gynecology Surgery. 40(3): 189-198.

6. Bij de Vaate AJ, van der Voet LF, Naji O, Witmer M, Veersema S, Brölmann HA et al. (2014, Apr). Prevalence, potential risk factors for development and symptoms related to the presence of uterine niches following Cesarean section: systematic review. Ultrasound Obstet Gynecol. 43(4): 372-82. https://doi.org/10.1002/uog.13199; PMid:23996650

7. Calzolari S, Sisti G, Pavone D et al. (2025). Isthmocele: Hysteroscopic resection or laparoscopic repair? Journal of Clinical Medicine. 14(2): 315.

8. Clark SL, Koonings PP, Phelan JP. (1985). Placenta previa/accreta and prior cesarean section. Obstetrics & Gynecology. 66(1): 89-92.

9. Donnez O. (2020, Apr). Cesarean scar defects: management of an iatrogenic pathology whose prevalence has dramatically increased. Fertil Steril. 113(4): 704-716. https://doi.org/10.1016/j.fertnstert.2020.01.037; PMid:32228874

10. He Y, Liu S, Tu X et al. (2024). Comparison of Different Surgical Treatments for Isthmocele: A Network Meta-analysis. Journal of Minimally Invasive Gynecology. 31(2): 112-124.

11. Jordans IPM, de Leeuw RA, Stegwee SI, Amso NN, Barri-Soldevila PN, van den Bosch T et al. (2019, Jan). Sonographic examination of uterine niches: is there a common language? Ultrasound Obstet Gynecol. 53(1): 107-115. https://doi.org/10.1002/uog.19049; PMid:29536581 PMCid:PMC6590297

12. Kremer TG, Ghiorzi IB, Dibi RP. (2023). Association between cesarean section scar aseptic necrosis and isthmocele. Journal of Minimally Invasive Gynecology. 30(11): S102.

13. Naji O, Abdallah Y, Bij de Vaate AJ et al. (2022). Standardized approach to longitudinal ultrasound assessment of cesarean section scar: a consensus statement. Ultrasound in Obstetrics & Gynecology. 59(5): 690-698.

14. Shashikant L, Shrestha A. (2025). Impact of isthmocele on fertility outcomes and the role of surgical repair: A systematic review. International Journal of Gynecology & Obstetrics. 168(1): 45-53.

15. Silver RM, Landon MB, Rouse DJ et al. (2006). Maternal morbidity associated with multiple repeat cesarean deliveries. Obstetrics & Gynecology. 107(6): 1226-1232. https://doi.org/10.1097/01.AOG.0000219750.79480.84; PMid:16738145

16. Stegwee SI, van der Voet LF, Ben AJ, de Leeuw RA, van de Ven PM, Duijnhoven RG et al. (2021, Apr). Effect of single- versus double-layer uterine closure during caesarean section on postmenstrual spotting (2Close): multicentre, double-blind, randomised controlled superiority trial. BJOG. 128(5): 866-878. Epub 2020 Oct 25. https://doi.org/10.1111/1471-0528.16472; PMid:32892392 PMCid:PMC7983985

17. Tanimura S, Funamoto H, Hosono T, Shitano Y, Nakashima M et al. (2015). New diagnostic criteria and operative strategy for cesarean scar syndrome: Endoscopic repair for secondary infertility caused by cesarean scar defect. Journal of Obstetrics and Gynaecology Research. 41(9): 1363-1369. https://doi.org/10.1111/jog.12738; PMid:26111547

18. Vervoort AJ, Uittenbogaard LB, Hehenkamp WJ, Brölmann HA, Mol BW, Huirne JA. (2015, Dec). Why do niches develop in Caesarean uterine scars? Hypotheses on the aetiology of niche development. Hum Reprod. 30(12): 2695-702. Epub 2015 Sep 25. https://doi.org/10.1093/humrep/dev240; PMid:26409016 PMCid:PMC4643529

19. Vitale SG, Ludwin A, Vilos GA et al. (2024). From diagnosis to treatment of cesarean scar defects: a comprehensive review of the European Society for Gynaecological Endoscopy (ESGE). Facts, Views & Vision in ObGyn. 16(2): 141-155.

20. Xie H, Wu Y, Fu X et al. (2023). The effect of niche on the outcomes of in vitro fertilization and embryo transfer. Frontiers in Endocrinology. 14: 1124456.