Effectiveness of laparoscopic correction of niche after cesarean section

The frequency of niche after cesarean section (NACS) is 25–85% and depends on many factors, increasing with each next cesarean section, which can cause chronic abnormal uterine bleeding, pelvic pain, subfertility.The objective: to evaluate the immediate and long-term results of the developed method of laparoscopic correction of symptomatic NACS.Materials and methods. During 2022–2024, 58 patients of reproductive age were prospectively observed in the clinics of the Odesa National Medical University: 28 women (main group) with a NACS and 30 practically healthy women of the same age with a uterine scar who were examined for male factor infertility (control group). A comprehensive assessment of the uterine scar, length, depth, width of the niche, and thickness of the residual myometrium was performed using ultrasound examonation. The histological structure of the endometrium and myometrium was studied. All patients in the main group underwent laparoscopic isthmoplasty using the developed technique (two-row separate Vicryl (2.0) sutures with delayed tying of 1 row of sutures).Results. The niche was visualized by transvaginal ultrasound examination as a defect in the myometrium in the anterior uterine wall of a triangular, oval or irregular shape, with a depth of 6.3 ± 1.6 mm, the thickness of the residual myometrium was from 2 to 4 mm, on average 3.0 ± 0.3 mm. The most frequent symptoms of the NACS were menorrhagia – 35.7%, intermenstrual bleeding – 32.1%, perimenstrual spotting – 67.9%, chronic pelvic pain – 57.1%, dysmenorrhea – 64.3%, dyspareunia – 53.6%, chronic vaginal discharge – 28.6% and subfertility – 53.6% of cases. Laparoscopic isthmoplasty according to the developed technique after 3 months after surgery contributed to a significant reduction in the frequency of menorrhagia by 3.3 times (p < 0.01), intermenstrual bleeding by 3.0 times (p < 0.01), perimenstrual spotting by 3.2 times (p < 0.01), as well as chronic pelvic pain by 2.7 times (p < 0.01), dysmenorrhea by 2.2 times (p < 0.05), dyspareunia by 2.5 times (p < 0.05), chronic vaginal discharge with a stable clinical effect 6 and 12 months after surgery. The thickness of the residual myometrium after laparoscopic isthmoplasty increased from 3.0 ± 0.6 to 4.5 ± 0.4 mm after 3 months, to 5.2 ± 0.6 mm after 6 months and up to 5.9 ± 0.5 mm 12 months after laparoscopic treatment (p < 0.01).Conclusions. Laparoscopic correction of symptomatic NACS using the developed technique helps to reduce symptoms of abnormal uterine bleeding, pelvic pain, increase the thickness of the residual myometrium, and improves the pregnancy rate in patients with subfertility.