Cesarean scar niche: An evolving concern in clinical practice

Abstract

Cesarean sections have increased worldwide and there is an increasing awareness of the adverse long-term sequelae associated with the procedure. The World Health Organization estimates that there are approximately 18.5 million women who undergo this procedure annually, with rates in the Western world increasing from 14.5% to 27.2% between the years 2000 and 2017. 1 A cesarean scar niche, first described in 1961 when a wedgeshaped defect was noted in the uterine wall of a patient who had previously had a cesarean section during hysterosalpingography, 2 is defined as the presence of a hypoechoic area and discontinuation

The presentation and management of cesarean scar defects: an updated review on an evolving diagnosis

“…When the RMT is less than 3 mm, a hysteroscopy-guided laparoscopic repair is preferred. This allows for clear visualization of the CSD through hysteroscopic illumination after reflection of the vesicouterine peritoneum, at which point the defect can be resected and repaired [38,39 ▪▪ ,40]. When the uterus is retroverted, some surgeons advocate for concurrent round ligament suspension to decrease uterine angulation and consequent tensile forces within the lower uterine segment [41].…”

“…The vaginal approach involves incision of the vaginal epithelium at the cervicovaginal junction, followed by dissection of the bladder to open the vesicovaginal space and reach the peritoneum, similar to the initial steps for a Shirodkar cerclage placement. The CSD is identified using an intrauterine probe, the defect is excised and the myometrium repaired [38,44].…”

Niche development after closure of caesarean uterotomy by conventional double‐suture or modified single‐suture technique (NICUM): A randomized trial

“…[2][3][4] A number of symptoms have been associated with niches, in particular postmenstrual spotting and pain with derived lower quality of life, dysmenorrhoea, dyspareunia and possibly subfertility. 3,[5][6][7][8][9] Also, a niche should be considered a risk factor for obstetric adverse outcomes in subsequent pregnancies, as uterine dehiscence and rupture, caesarean scar pregnancy, and abnormally invasive placenta disorders have all been associated with the presence and increasing size of a niche. 8,[10][11][12][13] Niche repair surgery may improve postmenstrual spotting but the effects on reproductive outcomes remain uncertain.…”

“…3,[5][6][7][8][9] Also, a niche should be considered a risk factor for obstetric adverse outcomes in subsequent pregnancies, as uterine dehiscence and rupture, caesarean scar pregnancy, and abnormally invasive placenta disorders have all been associated with the presence and increasing size of a niche. 8,[10][11][12][13] Niche repair surgery may improve postmenstrual spotting but the effects on reproductive outcomes remain uncertain. 14,15 Until 2019, where European niche experts published a modified Delphi procedure on uterine evaluation of niches with ultrasound, there was little consensus of how to define or quantify niches.…”

“…1 The uterotomy closure technique is speculated to be one of the important factors in the development of a CS niche. 8,10,16 Previous studies found no association between the number of uterotomy layers 17,18 or the use of locked versus non-locked stiches 17 and the risk of niches, whereas the effect of endometrium inclusion is still debated. [18][19][20] The interpretation of the evidence may be challenged by difficulties in the standardization of perioperative factors such as surgeon's expertise or inter-operator variation and by varying timing, method for evaluating the niche, and definition of outcomes.…”