Treatment of uterine scar cystoid diverticulum by hysteroscopy combined with laparoscopy

Fertil Steril. 2023 Oct;120(4):922-924. doi: 10.1016/j.fertnstert.2023.07.013. Epub 2023 Jul 25.

Abstract

Objective: To report a patient with prolonged intermenstrual bleeding and a cystic mass at a cesarean scar treated with laparoscopic folding sutures and hysteroscopic canalization.

Design: A 4.0 cm-cystic mass formed at the uterine scar caused continuous menstrual blood outflow in the diverticulum and was treated with hysteroscopy combined with laparoscopy.

Setting: University hospital.

Patients: A 38-year-old woman of childbearing age who had undergone two cesarean sections and two abortions reported vaginal bleeding for 10 years, which began shortly after the second cesarean section. Curettage was performed, but no abnormality was found. The patient unsuccessfully tried to manage her symptoms with traditional Chinese medicine and hormone drugs. The muscular layer of the lower end of the anterior wall of the uterus was weak, and there were cystic masses on the right side.

Intervention: The bladder was stripped from the lower uterine segment under laparoscopy, and the surrounding tissue of the mass at the uterine scar was separated. The position of the cesarean scar defect was identified by hysteroscopy combined with laparoscopy, and the relationship between the uterine mass and surrounding tissues was analyzed. An electric cutting ring resection on both sides of the obstruction was performed to eliminate the valve effect. The active intima of the scar diverticulum was destroyed by electrocoagulation, followed by laparoscopic treatment of the uterine scar diverticulum mass. An intraoperative tumor incision revealed visible bloody fluid mixed with intimal material. The uterine scar diverticulum defect was repaired using 1-0 absorbable barbed continuous full-thickness mattress fold sutures. Finally, the bilateral round ligament length was adjusted so that the uterus tilted forward.

Main outcome measures: Recovery of menstruation and anatomy of the uterine isthmus.

Results: The operation was successful, and the postoperative recovery was fast. There was no interphase bleeding at the 1-month follow-up, and the uterine scar diverticulum was repaired, with the thickness of the uterine scar muscle layer increasing to 0.91 cm.

Conclusion: The simple, straightforward procedure to resolve the abnormal cystic, solid mass formed because of the continuous deposition of blood in the uterine scar diverticulum involved laparoscopic folding and docking sutures combined with hysteroscopic canal opening.

Keywords: Mass; cesarean scar; diverticulum; hysteroscopy; vaginal bleeding.

Publication types

  • Case Reports
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Cesarean Section / adverse effects
  • Child
  • Cicatrix / complications
  • Cicatrix / diagnosis
  • Diverticulum* / complications
  • Diverticulum* / diagnosis
  • Diverticulum* / surgery
  • Female
  • Humans
  • Hysteroscopy / methods
  • Laparoscopy* / methods
  • Pregnancy
  • Treatment Outcome
  • Uterus / pathology