Commentary
With the increase in cesarean sections worldwide, it is imperative that physicians properly inform their patients as to potential procedure risks. One potential postcesarean section problem that is receiving increasing attention is the isthmocele or niche.
Defined as an anechoic area in the cesarean section scar, it has been noted to occur in 24%-69% of women undergoing transvaginal sonography, and 56%-78% of women evaluated with transvaginal saline infused sonogram. While most cesarean section defects are asymptomatic, the isthmocele has been noted to be associated with abnormal uterine bleeding, including prolonged menstruation or postmenopausal spotting, and fertility concerns ( BJOG. 2014;121:145-56 ).
Dr. Charles E. Miller
Interestingly, it has been 40 years since Stewart, et al. first reported the relationship of abnormal uterine bleeding and cesarean section ( Br. J. Gynaecol. 1975;82:682-6 ). Bloody fluid can be generated at the isthmocele site, which travels up the endometrial canal, thus impacting implantation. The niche can also be the site of ectopic pregnancy implantation.
In this edition of Master Class in gynecologic surgery, I have asked my newest partner, Dr. Kirsten Sasaki, to share our views on this increasingly important subject. Dr. Sasaki completed her internship and residency at Tufts Medical Center, Boston, where she was awarded the Outstanding Chief Resident Clinician Award. Dr. Sasaki then went on to become our second fellow in the Fellowship in Minimally Invasive Gynecologic Surgery in affiliation with AAGL and SRS at Advocate Lutheran General Hospital, Park Ridge, Ill. Once again, Dr. Sasaki was singled out for her excellent teaching and research capabilities. Ultimately however, it was her tremendous surgical skills and surgical sense that led Dr. Aarathi Cholkeri-Singh and I to invite her into our practice.
Dr. Miller is clinical associate professor at the University of Illinois at Chicago, immediate past president of the International Society for Gynecologic Endoscopy (ISGE), and a past president of the AAGL. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in private practice in Naperville, Ill., and Schaumburg, Ill.; the director of minimally invasive gynecologic surgery and the director of the AAGL/SRS fellowship in minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill.; and the medical editor of this column, Master Class. Dr. Miller is a consultant and on the speakers bureau for Ethicon. He is also a consultant, on the speakers bureau, and has received grant and research support from Intuitive Surgical.