Isthmocele endometriosis: the relationship between cesarean section and endometriosis

Objective: To present a case of endometriosis within an isthmocele membrane and concomitant diffuse peritoneal endometriosis after cesarean sections. In addition, we describe a unique, color-contrasted surgical repair technique and propose a possible correlation between isthmocele formation and endometriosis. Design: Narrated video article featuring the diagnosis, unique surgical management, and pathological findings of a case of isthmocele endometriosis. Informed consent was obtained from the patient, and all identifiers were removed. Setting: University-affiliated hospital. Patient(s): A 44-year-old patient with three prior cesarean sections and a laparoscopic appendectomy, in none of which endometriosis was visualized. She presented with progressive pelvic pain, dysmenorrhea, dyspareunia, and secondary infertility with recurrent embryo transfer failures. The progressively debilitating symptoms started 14 years ago, shortly after her last cesarean section. Magnetic resonance imaging and ultrasound demonstrated a retroverted uterus and a prominent, thin, fluid -filled cesarean scar defect with a residual myometrial thickness of 1.1 mm. Intervention(s): A combined hysteroscopic and laparoscopic approach was performed to allow for complete resection of the defect and reconstruction of the myometrium. The bladder was backfilled with indocyanine green dye to help identify its borders. Methylene blue was added to the hysteroscopy irrigation solution to create contrast and assist with the isthmocele identification. Wide excision of the isthmocele was performed, followed by a three-layer closure and excision of all apparent peritoneal lesions using the Aqua Blue Contrast Technique. Main Outcome Measure(s): Restoration of normal anatomy, resection of isthmocele, and resolution of the symptoms. Result(s): In the pathological assessment, multiple foci of endometriosis were identified within the isthmocele membrane, clearly differentiated from intrauterine endometrial tissue. Additionally, all seven excised peritoneal specimens contained peritoneal endometriosis. Two weeks after the procedure, a transvaginal sonographic scan confirmed a thick anterior uterine wall with a myometrial thickness of 9.2 mm, and the patient reported almost complete resolution of her symptoms. Conclusion(s): This case demonstrates endometriosis within the isthmocele membrane, with concomitant symptomatic peritoneal endometriosis. We propose a laparoscopic isthmocele excision technique and a three-layer reconstruction, followed by peritoneal endometriosis excision using methylene blue contrast. We suggest a possible link between isthmocele and endometriosis and emphasize the need for wide excision of the isthmocele margins and maintaining clean borders, given the possibility of endometriosis within the isthmocele, which may be a cause or a contributor to the tissue weakness and isthmocele formation. (C) 2022 by American Society for Reproductive Medicine.