Hysterectomy in the Setting of Complex Uterine Isthmocele

INTRODUCTION: A uterine isthmocele is a pouch-like defect at a prior cesarean scar, also called a niche or cesarean scar defect. Estimates of the incidence of an isthmocele range from 20% to 80% among those with a prior cesarean delivery, with approximately 1/3 of patients becoming asymptomatic. An isthmocele may cause abnormal uterine bleeding, pelvic pain or dysmenorrhea, or secondary infertility. In pregnancy, an isthmocele may lead to cesarean-scar ectopic pregnancy, abnormal placentation, or uterine rupture. OBJECTIVE: In this video, we present a clinical case of a large, symptomatic uterine isthmocele. We demonstrate surgical techniques to facilitate laparoscopic hysterectomy in the setting of a complex isthmocele. METHODS: Our submission is a surgical video. RESULTS: Our patient is a 48-year-old G2P2 who initially presented to the emergency department with acute-onset left lower quadrant pain, nausea, and vomiting. Her past history was notable for two prior cesarean deliveries, tubal ligation, and an endometrial ablation. She initially went to the OR with general OB/GYN urgently due to concern for possible ovarian torsion. In the OR, she was noted to have normal-appearing bilateral ovaries and a bulge extending from the uterus into the left broad ligament. The patient was ultimately referred to minimally invasive gynecologic surgery and underwent a scheduled total laparoscopic hysterectomy, bilateral salpingectomy, cystoscopy with insertion and removal of ureteral stents. During the operation, the retroperitoneum was entered, a ureterolysis was performed, and the uterine artery was ligated at its origin. Ultimately, the case was successfully completed with minimal blood loss, and the patient was discharged home on the day of surgery. CONCLUSIONS: In conclusion, uterine isthmocele is a common yet under-recognized clinical entity. While often asymptomatic, they may present acutely with pain, abnormal uterine bleeding, or complicate future pregnancy. Here, we present a case of a patient with acute-onset pelvic pain and large uterine isthmocele, who ultimately underwent hysterectomy with a minimally invasive approach. For patients with complex uterine isthmoceles, knowledge of retroperitoneal anatomy and use of avascular surgical spaces is critical to the success of the operation. Surgeons should consider cytoscopic stent placement to aid in ureterolysis as well as ligation of the uterine artery at its origin to reduce blood loss.