Finding the Niche: A Niche Strategy for Intraoperative MRI-Guided Uterine Isthmocele Repair

INTRODUCTION: A uterine niche, or isthmocele, is a defect in the uterine wall at the site of prior hysterotomy. It is estimated to occur in over 50% of women following cesarean delivery. While many niches can be asymptomatic, they can also lead to abnormal bleeding, infertility, and pelvic pain. Surgical repair can be challenging due to distorted anatomy, particularly in cases of extensive adhesions. Precise intraoperative localization of the defect and surrounding adhesions is critical to optimize outcomes and minimize complications. OBJECTIVE: To demonstrate the integration of intraoperative magnetic resonance imaging (MRI) in the identification and repair of a uterine niche, and in facilitating safe and effective adhesiolysis in the setting of complex pelvic anatomy. METHODS: This video presents a case of a laparoscopic uterine niche repair enhanced by intraoperative MRI. The patient had a history of prior cesarean delivery, with significant adhesions tethering the uterus to the anterior abdominal wall. Intraoperative MRI was used to clearly delineate uterus, the niche, and surrounding adhesions in real time. This imaging guided both the adhesiolysis and niche excision, allowing for safe mobilization of the uterus and excision of the niche. RESULTS: Intraoperative MRI enabled accurate identification of the uterine niche and the extent of anterior wall adhesions. Image-guided dissection facilitated complete and safe adhesiolysis, exposure of the defect, and successful repair. CONCLUSIONS: Uterine isthmocele can be a common finding among women with a history of cesarean delivery and can present with a range of symptoms. Preoperative imaging with MRI can assist with diagnosis as well as surgical planning and identification of adhesive disease. Intraoperative use of MRI images is a valuable adjunct in the surgical management of complex uterine niches, allowing for precise localization, excision, and repair. MRI has the ability to delineate anatomical relationships and offers a novel approach for challenging cases.