Isthmocele Endometriosis: a Unique Case Study

An isthmocele is a niche or defect in the inner uterine wall at the site of a Cesarean section (C-section). Dr. Seckin and colleagues recently presented a unique case study of diffuse peritoneal endometriosis following a Cesarean scar isthmocele that establishes a possible link between isthmocele and endometriosis.

Peritoneal endometriosis

The peritoneum is the membrane lining the abdominal cavity. However, due to its role in immunity and secretion of fluids, doctors now consider it to be an organ of its own. Peritoneal endometriosis is one of the most common forms of endometriosis and occurs in varied forms.

Peritoneal endometriosis is difficult to diagnose and evades imaging techniques such as ultrasound and MRI. Thus, laparoscopic deep excision surgery is the only way to visualize and confirm peritoneal endometriosis.

Case study: peritoneal endometriosis following a C-section

Dr. Seckin’s team presented the case of a patient age 44 who had three prior C-section deliveries and an appendectomy at the American Society for Reproductive Medicine (ASRM) annual meeting in Baltimore, Maryland. After her third C-section 14 years ago, the patient started showing symptoms of endometriosis including dysmenorrhea, dyspareunia, chronic pelvic pain, left leg pain, urinary symptoms, and failed embryo transfers.

Initial investigations revealed a retroverted uterus with a fluid-filled Cesarean scar defect (an isthmocele). After identifying the bladder borders with contrast dyes, the isthmocele margins were excised by laparoscopy. A three-layer closure was then performed to maintain uterine integrity and preserve the patient’s fertility. The team used aqua blue contrast (ABC™) to identify and excise all lesions.

Histopathological observations indicated multiple endometriosis foci within the isthmocele membrane that were quite distinct from intrauterine endometrium. The lesions also indicated the presence of peritoneal endometriosis.

Two weeks after the procedure, imaging tests confirmed the formation of a thick anterior uterine wall with the patient reporting only minor discomfort and near-complete symptom alleviation.

Isthmocele and endometriosis

This case indicates a likelihood of endometriosis within the isthmocele after a C-section. Dr. Seckin and his team, therefore, suggest that wide excision of the isthmocele can help study possible endometriosis lesions in that area and remove them completely via laparoscopic excision surgery.