Efficacy of isthmocele repair via the vaginal approach

Abstract

Objective. To evaluate the efficacy of vaginal metroplasty in patients with isthmocele. Patients and methods. This prospective comparative study included 76 patients with a cesarean scar defect. Two patient groups were identified. In group 1 (n = 46), vaginal metroplasty using an original surgical technique was performed. In group 2 (n = 30), patients underwent laparoscopic metroplasty. In all cases, clinical and anamnestic characteristics, as well as the condition of the uterine scar, were assessed before surgery and after 3 months. The assessment included ultrasound findings, changes in clinical symptoms, surgery duration, volume of blood loss, pain characteristics within the first 6 hours after surgery, complications, and reproductive outcomes. Results. The main complaints among patients with a niche included menstrual cycle disorders characterized by prolonged postmenstrual spotting (68.2%), heavy and frequent regular menstrual bleeding (menorrhagia/polymenorrhea) (48.4%), dysmenorrhea (11%), and secondary infertility (33.5%). A total of 66.1% of women had a history of emergency cesarean section (CS), while a history of two or more cesarean deliveries was documented in 22.3% of patients. Following laparoscopic metroplasty, clinical symptoms associated with the niche resolved in 90.5% of cases, and the mean minimum residual myometrial thickness increased significantly to 4.9 (1.3) mm (p < 0.001). Vaginal repair of CS scar demonstrated comparable outcomes, with symptom regression observed in 98% of cases and a mean residual myometrial thickness of 5.1 (1.4) mm (p < 0.001). The mean duration of laparoscopic surgery was 74 minutes, whereas vaginal metroplasty lasted 36 minutes, which is more than two times shorter and is attributable to the simplified technique for niche repair. In all cases of vaginal metroplasty, spinal anesthesia was used, while laparoscopic procedures were performed under endotracheal anesthesia. Patients undergoing vaginal metroplasty also experienced less severe postoperative pain (VAS score 2–3). Conclusion. Vaginal metroplasty demonstrated high efficacy and certain advantages over the laparoscopic approach and may be considered a preferred surgical option in settings with limited technological resources, provided that the surgeon possesses adequate expertise. Key words: vaginal metroplasty, isthmocele, cesarean section, laparoscopy, uterine scar defect, reproductive health