Laparoscopic resection of Isthmocele complicated by a communicating deep pelvic abscess of the vesico-uterine pouch: A case report

Laparoscopic resection of Isthmocele complicated by a communicating deep pelvic abscess of the vesico-uterine pouch: A case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Laparoscopic resection of Isthmocele complicated by a communicating deep pelvic abscess of the vesico-uterine pouch: A case report Prabath J Randombage, V J Meegoda, Rishita P Shah, Friederike Keane, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6439200/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background Caesarean scar defects (CSDs), or isthmocele, are wedge-shaped defects in the anterior uterine wall following caesarean section. Rarely, they can result in abscess and fistula formation. We present a rare case of isthmocele with a communicating deep pelvic abscess in the vesico-uterine pouch, causing severe pelvic pain and vaginal spotting. Case-Presentation: A 36-year-old woman with three previous caesarean sections presented with vaginal spotting and colicky pelvic pain for three months. She had been using a Mirena IUS (Intra-Uterine system) for postpartum contraception for 15 months. While transvaginal ultrasound was inconclusive, an MRI revealed a bulging isthmocele at the caesarean scar. Combined operative hysteroscopy and laparoscopy were performed. Hysteroscopy identified a bulge at the scar site suggestive of an isthmocele, while laparoscopy revealed adhesions and a 4×2 cm boggy mass in the vesico-uterine pouch consistent with a pelvic abscess. Adhesiolysis and drainage of altered blood and inspissated pus were successfully performed. The Mirena IUS was repositioned, and bladder integrity was confirmed. The patient had an uneventful recovery, with complete resolution of symptoms. Pus cultures were sterile. Conclusion CSD diagnosis remains challenging, with no established criteria. CSDs can occasionally lead to pelvic abscess formation and should be considered in patients presenting with post-caesarean pelvic pain. This case underscores the importance of careful utero-vesical pouch dissection to differentiate the isthmocele and abscess, minimizing organ injury. As caesarean rates rise, isthmocele incidence is likely to increase, necessitating diagnostic and treatment guidelines. Minimal access surgery, as demonstrated here, is a feasible approach. Isthmocele Deep pelvic abscess Minimal access surgery Figures Figure 1 Figure 2 Background Caesarean section (CS) is the most common surgical procedure performed in Obstetrics and Gynaecology practice and has increased in frequency over the last decade 1 . Cesarean scar defects (CSD) are becoming increasingly common consequently 2 . Most studies define it as “thinning of the myometrium or a triangular defect in the myometrium with contact with the endometrial cavity”. This can be identified by transvaginal ultrasound (TVUS) or saline infusion sono-hysterography as a triangular hypoechoic defect anterior to caesarean section scar 3 . The prevalence of an isthmocele as diagnosed by TVUS ranges from 24–70% with most women being asymptomatic 4 . The obstetric sequalae of CSD are well described which includes abnormal placentae (placenta accreta or placenta previa) and scar breakdown 5 . Gynaecological symptoms and sequalae include abnormal uterine bleeding, infertility, dysmenorrhea, chronic pelvic pain and cesarean scar ectopics. CSD is possibly associated with an increase in risk of complications during some gynecologic procedures like uterine evacuation, endometrial ablation, hysterectomy, and insertion of an intrauterine device 3 . The pathophysiology for AUB is that the isthmocele at the lower uterine segment causes delayed menstruation 6 . There are many possible explanations for dysmenorrhea, and pelvic pain which include abnormal contraction of the myometrium because of the continuous efforts of the uterus to empty the altered menstrual material of the isthmocele, presence of lymphocytic infiltration and anatomical distortion 7 . Very rarely, isthmocele may cause the formation of an abscess secondary to the collection of menstrual blood and mucus, which are infection-promoting factors 8 . There can be a fistula tract between the isthmocele and these deep pelvic abscesses. We present a unique and rare case of a women who had an Isthmocele which communicated via a fistulous tract with a deep pelvic abscess in the vesicouterine pouch. A literature search did not find this kind of communicating abscess at this anatomical location. Case Presentation A 36-year-old with three previous caesarean sections presented to the gynaecology clinic with unscheduled vaginal spotting and significant pelvic pain. She described the pain as being colicky in nature and confined to an area below the umbilicus. Pain was continuous for the last 3 months and did not respond to simple analgesics. The pain exacerbated after each menstrual period. She did not have symptoms of dyspareunia, dyschezia or uralgia. Her identical twin sister had pelvic pain and was recently diagnosed with endometriosis. The Mirena was inserted at the time of her last caesarean section 15 months ago. She had an initial breakthrough bleeding with the Mirena which stopped and then recently recurred – occurring occasionally and non-cyclically. Her abdominal and vaginal examinations were unremarkable. The MRI of the abdomen and pelvis did not reveal endometriosis, however raised the suspicion for a CSD with a bulging isthmocele and an improperly placed Mirena (Figure-1). Preoperative discussion included the clinical impression that the isthmocele was unlikely to be the cause of the pain as she was amenorrheic with the Mirena. After counselling, the woman opted for a combined procedure of hysteroscopy & laparoscopy and a change of Mirena IUS. Hysteroscopy using a vaginoscopic approach was uneventful. The axis of the uterus at the fundus was found to be at right angles to the axis of the cervix with the Mirena lying transversely in the cavity. The Mirena was retrieved with a grasper. There was no bulge of the isthmocele as suggested by MRI. A clear view uterine manipulator size 7 was inserted to aid with uterine manipulation. A four-port laparoscopy with palmers point entry was performed. An anteverted normal sized uterus, fixed in anteflexion and anteversion by a thick left adhesion band anterior to the left round ligament was noted initially. The left fallopian tube was adherent to the anterior abdominal wall. Bipolar diathermy and cold scissors were used for complete freeing of these adhesions. The uterus was found to be still fixed in anteversion and anteflexion with an isthmocele communicating with a 4x2cm boggy mass in the uterovesical pouch. The left paravesical space was then opened to aid dissection of the bladder and the adhesion complex in the anterior compartment. The caesarean scar incised, and dark coloured blood drained from right lateral aspect of incision which confirmed the opening of the isthmocele. For further exploration of the probable abscess methylene blue 150ml was inserted into the bladder to ensure that there was no bladder injury and help delineate the bladder. The abscess cavity was opened and inspissated pus removed within surgical gauze inserted through the 10mm port (Fig. 2 ). Pus was sent for culture which later revealed no growth. The caesarean scar was closed using absorbable 1 − 0 continuous sutures laparoscopically. The uterine manipulator was removed and the new Mirena IUS inserted under laparoscopic vision. Routine closure was done after thorough peritoneal washout. The woman was discharged the following day as her recovery was uneventful. Further follow up revealed that her pain symptoms had improved drastically. Discussion Symptoms and Diagnosis: Secondary dysmenorrhea and chronic pelvic pain are common symptoms in gynaecology practice with a wide range of differential diagnosis. Caesarean section defects are rarely considered even though a cross-sectional study showed that in women with CSD, 39.6% had chronic pelvic pain and 53.1% had dysmenorrhea 9 . Adenomyosis is another cause for dysmenorrhea occurring in the uterine scar in 28% of patients 9 . There is no evidence that CSDs cause endometriosis which is another cause for pelvic pain. A retrospective study described unusually situated endometriosis (abdominal wall endometriosis) in 10 women all of whom had previous caesarean sections or laparotomy to treat endometriosis 10 . The main symptom in the case reported is pelvic pain. With a background of a family history of endometriosis, previous caesarean sections and multiparity, the alternative diagnosis were endometriosis, adenomyosis or post-operative adhesions. However, the MRI did not reveal features of endometriosis, but that of CSD. The MRI could not differentiate the isthmocele with the abscess in the vesicouterine pouch. Other case reports included a woman where the abscess was within the uterine caesarean section scar 8 a utero-cutaneous fistula after cesarean section which presented as a subcutaneous abscess day 22 post operatively 11 . In these case reports a fistula diagnosis was made preoperatively both by MRI and confirmed at hysteroscopy which did not happen in the index case. There is no consensus about making the diagnosis of CSD. Importantly, as the majority are asymptomatic, radiological identification in a woman with symptoms suggestive of a CSD like AUB, pain, or infertility needs to be considered. TVUS is the primary modality for identifying CSDs which has been reported since 1990. There are four key findings: a wedge defect, outward protruding and hematoma, inward protruding of the scar or retraction of the scar 12 . Some described it as a triangular anechoic area where the apex points to the anterior. The defect also may appear as a cystic mass between the bladder and lower uterine segment which can be intermittently filled with debris 13 . Saline infusion sonography (SIS) has increased sensitivity and specificity for detection of CSD by enhancing the defect. SIS could also determine mobile and hyperechogenic material suggesting altered blood 14 . CSDs also can be diagnosed by direct visualisation at hysteroscopy. They appear as a bulging pouch or wedge which contains blood covered by a fibrotic ring on the anterior uterine wall near to cervical canal 6 (Fig. 2 ). MRI clearly delineates the defect which is beneficial in planning surgery especially if other pathologies coexist (e.g. adenomyosis) (Fig. 1 ). In our case report a preoperative diagnosis was not made which may have been due to the rarity of the complication, undefined characteristics in the making the diagnosis and unawareness of radiologists of the condition. Treatment Though medical treatment may be tried, surgery is the most common choice of treatment for CSD. Approaches include hysteroscopy, laparoscopy (including robotics assisted), vaginal repair, laparotomy, and combined techniques. Surgery should be only offered to symptomatic patients. There is insufficient evidence at present to offer surgery to prevent obstetric complications like uterine rupture. Hysteroscopy is the most reported approach for treatment of CSDs 15 . This is usually done by resection of fibrotic scar tissue surrounding the defect and flattening the area ensuring that there is no pouch for blood to accumulate. In our case hysteroscopy alone was not \ possible as there was no bulge seen but also may have resulted in bladder injury due to the dense adhesions with the bladder. A deep pelvic abscess requires laparoscopic drainage. Laparoscopy becomes the technique of choice if the residual myometrial thickness is < 3 mm. The described procedure is excision of fibrotic tissue and closure of the defect laparoscopically by interrupted or continuous sutures. A Hegar dilator or uterine manipulator can be placed in the cervix to ensure the continuity between the cervical canal and lower uterine walls 16 . If it is associated with an abscess in the vesico-uterine pouch as in our case, the authors recommend dissecting the para vesical spaces with the use of intravesical methylene blue for proper delineation of the bladder prior to abscess drainage 16 . The most critical step in laparoscopy is to correctly recognize the isthmocele intraoperatively. There are several techniques described which include laparoscopic visualization after dissecting the uterovesical peritoneum, concurrent hysteroscopy and moreover, hysteroscopic transillumination for better identification of the edges of the pouch 17 . The efficacy of laparoscopic treatment of an isthmocele was shown in the first large prospective cohort study that evaluated the resolution of symptoms in 101 women 18 . This showed a reduction in postmenstrual spotting and dysmenorrhea with an increase in the residual myometrial thickness by ultrasound scans at 6 months follow up 18 . The surgical treatment in our index case (which included treating the isthmocele as well as draining the abscess) showed significant improvement of symptoms. The vaginal approach has become less popular with the development in minimal access surgery. Review of the literature describes the dissection of the bladder off the cervix and the uterus, opening of the uterovesical space, identifying the scar, repairing it by excising the fibrotic tissues and suturing the defect with interrupted sutures 19 . Alternatively, the Isthmocele can be treated via a combined laparoscopic, hysteroscopic and vaginal approach. Conclusions With the growing number of cesarean sections in modern obstetric practice, the sequalae and complications of CSDs are more likely to be encountered by gynaecologists. The most common symptom of CSD is AUB mainly as postmenstrual spotting. However, patients can present with pain, infertility, scar ectopic pregnancies, and more rarely abscess, and fistula formation. It is therefore important to be mindful of these types of presentations. This case reports discusses the presentation, imaging, surgical findings, and laparoscopic treatment of an isthmocele which communicated with an abscess in the uterovesical pouch. More studies need to be done to establish the diagnostic features of CSDs and the optimal routes and steps of management which would be required in the future. Abbreviations CSD - Cesarean Scar Defects IUS - Intra Uterine System MRI - Magnetic Resonance Imaging CS - Cesarean Section TVUS - Trans-Vaginal Ultrasound Scan AUB - Abnormal Uterine Bleeding SIS - Saline Infusion Sonography Declarations Ethics approval and patient consent to participate – Not applicable Patient Consent for publication – Patient consent is taken to publish data without revealing any personal information that can trace back to the patient. The Consent form was signed by the patient (can be sent to editorial committee if needed) Availability of data & materials - Not applicable Competing interests – None Funding – None Author contributions - Prabath J Randombage – Conceptualization, Identification of patient, planning investigation & management. Writing – review & editing V J Meegoda - Writing – original article, review & editing Rishita P Shah – Conceptualization, Identification of patient, planning investigation & management. Writing – review & editing Friederike Keane – Conceptualization, Identification of patient, planning investigation & management. Writing – review & editing Shankar D K Visvanathan – Supervision Acknowledgments – Not applicable Conflict of interest – No conflict of interest among any of the authors References Tulandi T, Cohen A. Emerging manifestations of cesarean scar defect in reproductive women. J Minim Invasive Gynecol 2016;23 (06):893–902 Doi: 10.1016/j.jmig.2016.06.020 Poidevin LO. The value of hysterography in the prediction of cesarean section wound defects. Am J Obstet Gynecol 1961; 81:67–71 Doi: 10.1016/S0002-9378(16)36308-6 Amanda M. Tower, MD, and Gary N. Frishman, MD. Cesarean Scar Defects: An Underrecognized Cause of Abnormal Uterine Bleeding and Other Gynecologic Complications. Journal of Minimally Invasive Gynecology (2013) 20, 562–572 Van der Voet LLF, Limperg T, Veersema S, et al. Niches after cesarean section in a population seeking hysteroscopic steriliza- tion. Eur J Obstet Gynecol Reprod Biol 2017;214:104–108 Doi: 10.1016/j.ejogrb.2017.05.004 Landon M. Cesarean delivery. In: Gabbe S, editor. Obstetrics: Normal and Problem Pregnancies. 5th ed. Philadelphia, PA: Churchill Living- ston Elsevier; 2007. p. 486–520. Belinda Centeio L, Scapinelli A, Depes D, Lippi U, Lopes R. Findings in patients with postmenstrual spotting with prior cesarean section. J Minim Invasive Gynecol. 2010;17:361–364. Piergiorgio Iannone, Giulia Nencini, Gloria Bonaccorsi et al. Isthmocele: From Risk Factors to Management Istmocele: de fatores de risco ao manejo. Rev Bras Ginecol Obstet 2019;41:44–52. Diaz-Garcia C, Estellés JG, Escrivá AM, Mora JJ, Torregrosa RR, Sancho JM. Scar abscess six years after cesarean section: Laparo- scopic and hysteroscopic management. J Minim Invasive Gynecol 2009;16(06):785–788 Doi: 10.1016/j.jmig.2009.07.020 Wang CB, Chiu WW, Lee CY, et al. Cesarean scar defect: correlation between Cesarean section number, defect size, clinical symptoms and uterine position. Ultrasound Obstet Gynecol. 2009;34:85–89 Marqueta M, Lorenzo H, Munoz H, et al. Unusually located endometri- osis: review of our cases between 2007-2010. J Minim Invasive Gynecol. 2011;18:S123–S124. Thubert T, Denoiseux C, Faivre E, et al. Combined conservative surgi- cal and medical treatment of a uterocutaneous fistula. J Minim Invasive Gynecol. 2012;19:244–247. Chen HY, Chen SJ, Hsieh FJ. Observation of cesarean section scar by transvaginal ultrasonography. Ultrasound Med Biol. 1990;16: 443–447. Fischer RJ. Symptomatic cesarean scar diverticulum: a case report. J Reprod Med. 2006;51:742–744. Thurmond AS, Harvey WJ, Smith SA. Cesarean section scar as a cause of abnormal vaginal bleeding: diagnosis by sonohysterography. J Ultra- sound Med. 1999;18:13–16. Gubbini G, Casadio P, Marra E. Resectoscopic correction of the "isthmocele" in women with postmenstrual abnormal uterine bleed- ing and secondary infertility. J Minim Invasive Gynecol. 2008;15: 172–175. Donnez O, Jadoul P, Squifflet J, Donnez J. Laparoscopic repair of wide and deep uterine scar dehiscence after cesarean section. Fertil Steril. 2008;89:974–980. Donnez O, Donnez J, Orellana R, Dolmans MM. Gynecological and obstetrical outcomes after laparoscopic repair of a cesarean scar defect in a series of 38 women. Fertil Steril 2017;107(01): 289–296.e2 Doi: 10.1016/j.fertnstert.2016.09.033 Vervoort A, Vissers J, Hehenkamp W, Brölmann H, Huirne J. The effect of laparoscopic resection of large niches in the uterine caesarean scar on symptoms, ultrasound findings and quality of life: a prospective cohort study. BJOG 2018;125(03):317–325 Doi: 10.1111/1471-0528.14822 Khoshnow Q, Pardey J, Uppal T. Transvaginal repair of caesarean scar dehiscence. Aust N Z J Obstet Gynaecol. 2010;50:94–95. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 27 Feb, 2026 Reviews received at journal 19 May, 2025 Reviewers agreed at journal 19 May, 2025 Reviews received at journal 17 May, 2025 Reviewers agreed at journal 14 May, 2025 Reviewers invited by journal 14 May, 2025 Editor invited by journal 21 Apr, 2025 Editor assigned by journal 20 Apr, 2025 Submission checks completed at journal 20 Apr, 2025 First submitted to journal 13 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6439200","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":456648731,"identity":"5a698885-cf7d-4991-8308-722d40181436","order_by":0,"name":"Prabath J Randombage","email":"","orcid":"","institution":"Faculty of Medicine Ragama, University of Kelaniya","correspondingAuthor":false,"prefix":"","firstName":"Prabath","middleName":"J","lastName":"Randombage","suffix":""},{"id":456648732,"identity":"1561ed42-7c61-4291-97e2-6a10dfb6ab67","order_by":1,"name":"V J Meegoda","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAklEQVRIiWNgGAWjYBAC9mYGNiBlAeHxMNgAScbGA/i0MDYzg7RIwLSkgcQa8GtpQNVyGEzj19LOf+zRjRqJaH729osP3tSct1vbfhhoS41NNB6HsRvnHJPIndlzpthwzrHbydvOJAK1HEvLbcDjF+kcNoncDTdy0qR52G4nmx0AamFsOExAyz+J3P333wC1/DuXbHb+IX4tgiAtuW1AWyTYj0nzth2wM7tBwBZpZmYz6dw+idwZZ3KYDef2JSeY3QDakoDHL3z8B59J53yzye1vP/7wwZtvdvZm59MfPvhQY4NTCxLgMQCRiWCVCYSVgwD7AxBpT5ziUTAKRsEoGEkAAHapYGFLQC3tAAAAAElFTkSuQmCC","orcid":"","institution":"Teaching Hospital Peradeniya","correspondingAuthor":true,"prefix":"","firstName":"V","middleName":"J","lastName":"Meegoda","suffix":""},{"id":456648738,"identity":"7349d93e-aa0b-45fb-8f28-5d2d100ec418","order_by":2,"name":"Rishita P Shah","email":"","orcid":"","institution":"Whipps Cross University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Rishita","middleName":"P","lastName":"Shah","suffix":""},{"id":456648739,"identity":"601a9cee-92ec-4d19-8a80-200bc6b7cec8","order_by":3,"name":"Friederike Keane","email":"","orcid":"","institution":"Whipps Cross University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Friederike","middleName":"","lastName":"Keane","suffix":""},{"id":456648740,"identity":"9dc79de4-1671-4b1a-ae0a-1a8f5b50f405","order_by":4,"name":"Shankar D K Visvanathan","email":"","orcid":"","institution":"Whipps Cross University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Shankar","middleName":"D K","lastName":"Visvanathan","suffix":""}],"badges":[],"createdAt":"2025-04-13 12:38:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6439200/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6439200/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82902561,"identity":"cc04cc7d-f345-477e-8cde-04d8c512c6a7","added_by":"auto","created_at":"2025-05-16 13:41:22","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":590921,"visible":true,"origin":"","legend":"\u003cp\u003eIt’s an MRI image of the sagital section of the pelvis The section gives a clear view of the isthmocele communicating with a deep pelvic abscess in the vesico-uterine pouch\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6439200/v1/35013bcd58ff06e4d203136b.png"},{"id":82901590,"identity":"b2d75450-c0ec-4c53-8880-41b25dbba858","added_by":"auto","created_at":"2025-05-16 13:33:22","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1054777,"visible":true,"origin":"","legend":"\u003cp\u003eHysteroscopic and laparoscopic view of the isthmocele and communicating deep pelvic abscess in the vesico-uterine pouch\u003c/p\u003e\n\u003cp\u003eImage a – Hysteroscopic view of the Mirena IUS\u003c/p\u003e\n\u003cp\u003eImage b – Hysteroscopic view of the fibrotic ring between anterior uterine wall \u0026amp; cervical canal suggesting an isthmocele\u003c/p\u003e\n\u003cp\u003eImage c – Laparoscopic view of the isthmocele \u0026amp; the communicating deep pelvic abscess in vesico-uterine pouch\u003c/p\u003e\n\u003cp\u003eImage d – Laparoscopic view of dissecting and opening into the isthmocele\u003c/p\u003e\n\u003cp\u003eImage e – Laparoscopic view of te opening into the abscess of the vesico-uterine pouch\u003c/p\u003e\n\u003cp\u003eImage f – Laparoscopic view of the sutured cesarean scar defect and final outcome\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6439200/v1/8e59ce8755abb34dcb0ec6dc.png"},{"id":82902563,"identity":"f2592536-efc1-4809-8eae-35365d684678","added_by":"auto","created_at":"2025-05-16 13:41:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3468569,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6439200/v1/89abab47-7529-4058-81d5-cbf413bf1b14.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Laparoscopic resection of Isthmocele complicated by a communicating deep pelvic abscess of the vesico-uterine pouch: A case report","fulltext":[{"header":"Background","content":"\u003cp\u003eCaesarean section (CS) is the most common surgical procedure performed in Obstetrics and Gynaecology practice and has increased in frequency over the last decade\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. Cesarean scar defects (CSD) are becoming increasingly common consequently\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Most studies define it as \u0026ldquo;thinning of the myometrium or a triangular defect in the myometrium with contact with the endometrial cavity\u0026rdquo;. This can be identified by transvaginal ultrasound (TVUS) or saline infusion sono-hysterography as a triangular hypoechoic defect anterior to caesarean section scar\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. The prevalence of an isthmocele as diagnosed by TVUS ranges from 24\u0026ndash;70% with most women being asymptomatic\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. The obstetric sequalae of CSD are well described which includes abnormal placentae (placenta accreta or placenta previa) and scar breakdown\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. Gynaecological symptoms and sequalae include abnormal uterine bleeding, infertility, dysmenorrhea, chronic pelvic pain and cesarean scar ectopics. CSD is possibly associated with an increase in risk of complications during some gynecologic procedures like uterine evacuation, endometrial ablation, hysterectomy, and insertion of an intrauterine device\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. The pathophysiology for AUB is that the isthmocele at the lower uterine segment causes delayed menstruation\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. There are many possible explanations for dysmenorrhea, and pelvic pain which include abnormal contraction of the myometrium because of the continuous efforts of the uterus to empty the altered menstrual material of the isthmocele, presence of lymphocytic infiltration and anatomical distortion\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. Very rarely, isthmocele may cause the formation of an abscess secondary to the collection of menstrual blood and mucus, which are infection-promoting factors\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. There can be a fistula tract between the isthmocele and these deep pelvic abscesses.\u003c/p\u003e \u003cp\u003eWe present a unique and rare case of a women who had an Isthmocele which communicated via a fistulous tract with a deep pelvic abscess in the vesicouterine pouch. A literature search did not find this kind of communicating abscess at this anatomical location.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 36-year-old with three previous caesarean sections presented to the gynaecology clinic with unscheduled vaginal spotting and significant pelvic pain. She described the pain as being colicky in nature and confined to an area below the umbilicus. Pain was continuous for the last 3 months and did not respond to simple analgesics. The pain exacerbated after each menstrual period. She did not have symptoms of dyspareunia, dyschezia or uralgia. Her identical twin sister had pelvic pain and was recently diagnosed with endometriosis. The Mirena was inserted at the time of her last caesarean section 15 months ago. She had an initial breakthrough bleeding with the Mirena which stopped and then recently recurred \u0026ndash; occurring occasionally and non-cyclically. Her abdominal and vaginal examinations were unremarkable. The MRI of the abdomen and pelvis did not reveal endometriosis, however raised the suspicion for a CSD with a bulging isthmocele and an improperly placed Mirena (Figure-1). Preoperative discussion included the clinical impression that the isthmocele was unlikely to be the cause of the pain as she was amenorrheic with the Mirena. After counselling, the woman opted for a combined procedure of hysteroscopy \u0026amp; laparoscopy and a change of Mirena IUS.\u003c/p\u003e \u003cp\u003eHysteroscopy using a vaginoscopic approach was uneventful. The axis of the uterus at the fundus was found to be at right angles to the axis of the cervix with the Mirena lying transversely in the cavity. The Mirena was retrieved with a grasper. There was no bulge of the isthmocele as suggested by MRI. A clear view uterine manipulator size 7 was inserted to aid with uterine manipulation. A four-port laparoscopy with palmers point entry was performed. An anteverted normal sized uterus, fixed in anteflexion and anteversion by a thick left adhesion band anterior to the left round ligament was noted initially. The left fallopian tube was adherent to the anterior abdominal wall. Bipolar diathermy and cold scissors were used for complete freeing of these adhesions. The uterus was found to be still fixed in anteversion and anteflexion with an isthmocele communicating with a 4x2cm boggy mass in the uterovesical pouch. The left paravesical space was then opened to aid dissection of the bladder and the adhesion complex in the anterior compartment. The caesarean scar incised, and dark coloured blood drained from right lateral aspect of incision which confirmed the opening of the isthmocele. For further exploration of the probable abscess methylene blue 150ml was inserted into the bladder to ensure that there was no bladder injury and help delineate the bladder. The abscess cavity was opened and inspissated pus removed within surgical gauze inserted through the 10mm port (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Pus was sent for culture which later revealed no growth. The caesarean scar was closed using absorbable 1\u0026thinsp;\u0026minus;\u0026thinsp;0 continuous sutures laparoscopically. The uterine manipulator was removed and the new Mirena IUS inserted under laparoscopic vision. Routine closure was done after thorough peritoneal washout. The woman was discharged the following day as her recovery was uneventful. Further follow up revealed that her pain symptoms had improved drastically.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSymptoms and Diagnosis:\u003c/h2\u003e \u003cp\u003eSecondary dysmenorrhea and chronic pelvic pain are common symptoms in gynaecology practice with a wide range of differential diagnosis. Caesarean section defects are rarely considered even though a cross-sectional study showed that in women with CSD, 39.6% had chronic pelvic pain and 53.1% had dysmenorrhea\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Adenomyosis is another cause for dysmenorrhea occurring in the uterine scar in 28% of patients\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. There is no evidence that CSDs cause endometriosis which is another cause for pelvic pain. A retrospective study described unusually situated endometriosis (abdominal wall endometriosis) in 10 women all of whom had previous caesarean sections or laparotomy to treat endometriosis\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe main symptom in the case reported is pelvic pain. With a background of a family history of endometriosis, previous caesarean sections and multiparity, the alternative diagnosis were endometriosis, adenomyosis or post-operative adhesions. However, the MRI did not reveal features of endometriosis, but that of CSD. The MRI could not differentiate the isthmocele with the abscess in the vesicouterine pouch. Other case reports included a woman where the abscess was within the uterine caesarean section scar\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e a utero-cutaneous fistula after cesarean section which presented as a subcutaneous abscess day 22 post operatively\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. In these case reports a fistula diagnosis was made preoperatively both by MRI and confirmed at hysteroscopy which did not happen in the index case.\u003c/p\u003e \u003cp\u003eThere is no consensus about making the diagnosis of CSD. Importantly, as the majority are asymptomatic, radiological identification in a woman with symptoms suggestive of a CSD like AUB, pain, or infertility needs to be considered. TVUS is the primary modality for identifying CSDs which has been reported since 1990. There are four key findings: a wedge defect, outward protruding and hematoma, inward protruding of the scar or retraction of the scar\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. Some described it as a triangular anechoic area where the apex points to the anterior. The defect also may appear as a cystic mass between the bladder and lower uterine segment which can be intermittently filled with debris\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. Saline infusion sonography (SIS) has increased sensitivity and specificity for detection of CSD by enhancing the defect. SIS could also determine mobile and hyperechogenic material suggesting altered blood\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eCSDs also can be diagnosed by direct visualisation at hysteroscopy. They appear as a bulging pouch or wedge which contains blood covered by a fibrotic ring on the anterior uterine wall near to cervical canal\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e). MRI clearly delineates the defect which is beneficial in planning surgery especially if other pathologies coexist (e.g. adenomyosis) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e). In our case report a preoperative diagnosis was not made which may have been due to the rarity of the complication, undefined characteristics in the making the diagnosis and unawareness of radiologists of the condition.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eTreatment\u003c/h3\u003e\n\u003cp\u003eThough medical treatment may be tried, surgery is the most common choice of treatment for CSD. Approaches include hysteroscopy, laparoscopy (including robotics assisted), vaginal repair, laparotomy, and combined techniques. Surgery should be only offered to symptomatic patients. There is insufficient evidence at present to offer surgery to prevent obstetric complications like uterine rupture. Hysteroscopy is the most reported approach for treatment of CSDs\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. This is usually done by resection of fibrotic scar tissue surrounding the defect and flattening the area ensuring that there is no pouch for blood to accumulate. In our case hysteroscopy alone was not \\ possible as there was no bulge seen but also may have resulted in bladder injury due to the dense adhesions with the bladder. A deep pelvic abscess requires laparoscopic drainage. Laparoscopy becomes the technique of choice if the residual myometrial thickness is \u0026lt;\u0026thinsp;3 mm. The described procedure is excision of fibrotic tissue and closure of the defect laparoscopically by interrupted or continuous sutures. A Hegar dilator or uterine manipulator can be placed in the cervix to ensure the continuity between the cervical canal and lower uterine walls\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. If it is associated with an abscess in the vesico-uterine pouch as in our case, the authors recommend dissecting the para vesical spaces with the use of intravesical methylene blue for proper delineation of the bladder prior to abscess drainage\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe most critical step in laparoscopy is to correctly recognize the isthmocele intraoperatively. There are several techniques described which include laparoscopic visualization after dissecting the uterovesical peritoneum, concurrent hysteroscopy and moreover, hysteroscopic transillumination for better identification of the edges of the pouch\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. The efficacy of laparoscopic treatment of an isthmocele was shown in the first large prospective cohort study that evaluated the resolution of symptoms in 101 women\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. This showed a reduction in postmenstrual spotting and dysmenorrhea with an increase in the residual myometrial thickness by ultrasound scans at 6 months follow up\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. The surgical treatment in our index case (which included treating the isthmocele as well as draining the abscess) showed significant improvement of symptoms. The vaginal approach has become less popular with the development in minimal access surgery. Review of the literature describes the dissection of the bladder off the cervix and the uterus, opening of the uterovesical space, identifying the scar, repairing it by excising the fibrotic tissues and suturing the defect with interrupted sutures\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. Alternatively, the Isthmocele can be treated via a combined laparoscopic, hysteroscopic and vaginal approach.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eWith the growing number of cesarean sections in modern obstetric practice, the sequalae and complications of CSDs are more likely to be encountered by gynaecologists. The most common symptom of CSD is AUB mainly as postmenstrual spotting. However, patients can present with pain, infertility, scar ectopic pregnancies, and more rarely abscess, and fistula formation. It is therefore important to be mindful of these types of presentations. This case reports discusses the presentation, imaging, surgical findings, and laparoscopic treatment of an isthmocele which communicated with an abscess in the uterovesical pouch. More studies need to be done to establish the diagnostic features of CSDs and the optimal routes and steps of management which would be required in the future.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCSD - Cesarean Scar Defects\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIUS - Intra Uterine System\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMRI - Magnetic Resonance Imaging\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCS - Cesarean Section\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTVUS - Trans-Vaginal Ultrasound Scan\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAUB - Abnormal Uterine Bleeding\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSIS - Saline Infusion Sonography\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eEthics approval and patient consent to participate\u0026nbsp;\u003c/strong\u003e\u0026ndash; Not applicable\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003ePatient Consent for publication\u0026nbsp;\u003c/strong\u003e\u0026ndash; Patient consent is taken to publish data without revealing any personal information that can trace back to the patient. The Consent form was signed by the patient\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e(can be sent to editorial committee if needed)\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAvailability of data \u0026amp; materials\u0026nbsp;\u003c/strong\u003e- Not applicable\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u0026ndash; None\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u0026ndash; None\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAuthor contributions -\u0026nbsp;\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cul type=\"disc\"\u003e\n \u003cul type=\"circle\"\u003e\n \u003cli\u003ePrabath J Randombage \u0026ndash; Conceptualization, Identification of patient, planning investigation \u0026amp; management. Writing \u0026ndash; review \u0026amp; editing\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eV J Meegoda - Writing \u0026ndash; original article, review \u0026amp; editing\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eRishita P Shah \u0026ndash; Conceptualization, Identification of patient, planning investigation \u0026amp; management. Writing \u0026ndash; review \u0026amp; editing\u003c/li\u003e\n \u003cli\u003eFriederike Keane \u0026ndash; Conceptualization, Identification of patient, planning investigation \u0026amp; management. Writing \u0026ndash; review \u0026amp; editing\u003c/li\u003e\n \u003cli\u003eShankar D K Visvanathan \u0026ndash; Supervision\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n\u003c/ul\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eAcknowledgments \u0026ndash;\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eConflict of interest \u0026ndash;\u0026nbsp;\u003c/strong\u003eNo conflict of interest among any of the authors\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eTulandi T, Cohen A. Emerging manifestations of cesarean scar defect in reproductive women. J Minim Invasive Gynecol 2016;23 (06):893\u0026ndash;902 Doi: 10.1016/j.jmig.2016.06.020 \u003c/li\u003e\n\u003cli\u003ePoidevin LO. The value of hysterography in the prediction of cesarean section wound defects. Am J Obstet Gynecol 1961; 81:67\u0026ndash;71 Doi: 10.1016/S0002-9378(16)36308-6 \u003c/li\u003e\n\u003cli\u003eAmanda M. Tower, MD, and Gary N. Frishman, MD. Cesarean Scar Defects: An Underrecognized Cause of Abnormal Uterine Bleeding and Other Gynecologic Complications. Journal of Minimally Invasive Gynecology (2013) 20, 562\u0026ndash;572 \u003c/li\u003e\n\u003cli\u003eVan der Voet LLF, Limperg T, Veersema S, et al. Niches after cesarean section in a population seeking hysteroscopic steriliza- tion. Eur J Obstet Gynecol Reprod Biol 2017;214:104\u0026ndash;108 Doi: 10.1016/j.ejogrb.2017.05.004 \u003c/li\u003e\n\u003cli\u003eLandon M. Cesarean delivery. In: Gabbe S, editor. Obstetrics: Normal and Problem Pregnancies. 5th ed. Philadelphia, PA: Churchill Living- ston Elsevier; 2007. p. 486\u0026ndash;520. \u003c/li\u003e\n\u003cli\u003eBelinda Centeio L, Scapinelli A, Depes D, Lippi U, Lopes R. Findings in patients with postmenstrual spotting with prior cesarean section. J Minim Invasive Gynecol. 2010;17:361\u0026ndash;364. \u003c/li\u003e\n\u003cli\u003ePiergiorgio Iannone, Giulia Nencini, Gloria Bonaccorsi et al. Isthmocele: From Risk Factors to Management Istmocele: de fatores de risco ao manejo. Rev Bras Ginecol Obstet 2019;41:44\u0026ndash;52.\u003c/li\u003e\n\u003cli\u003eDiaz-Garcia C, Estellés JG, Escrivá AM, Mora JJ, Torregrosa RR, Sancho JM. Scar abscess six years after cesarean section: Laparo- scopic and hysteroscopic management. J Minim Invasive Gynecol 2009;16(06):785\u0026ndash;788 Doi: 10.1016/j.jmig.2009.07.020 \u003c/li\u003e\n\u003cli\u003eWang CB, Chiu WW, Lee CY, et al. Cesarean scar defect: correlation between Cesarean section number, defect size, clinical symptoms and uterine position. Ultrasound Obstet Gynecol. 2009;34:85\u0026ndash;89 \u003c/li\u003e\n\u003cli\u003eMarqueta M, Lorenzo H, Munoz H, et al. Unusually located endometri- osis: review of our cases between 2007-2010. J Minim Invasive Gynecol. 2011;18:S123\u0026ndash;S124. \u003c/li\u003e\n\u003cli\u003eThubert T, Denoiseux C, Faivre E, et al. Combined conservative surgi- cal and medical treatment of a uterocutaneous fistula. J Minim Invasive Gynecol. 2012;19:244\u0026ndash;247. \u003c/li\u003e\n\u003cli\u003eChen HY, Chen SJ, Hsieh FJ. Observation of cesarean section scar by transvaginal ultrasonography. Ultrasound Med Biol. 1990;16: 443\u0026ndash;447. \u003c/li\u003e\n\u003cli\u003eFischer RJ. Symptomatic cesarean scar diverticulum: a case report. J Reprod Med. 2006;51:742\u0026ndash;744. \u003c/li\u003e\n\u003cli\u003eThurmond AS, Harvey WJ, Smith SA. Cesarean section scar as a cause of abnormal vaginal bleeding: diagnosis by sonohysterography. J Ultra- sound Med. 1999;18:13\u0026ndash;16. \u003c/li\u003e\n\u003cli\u003eGubbini G, Casadio P, Marra E. Resectoscopic correction of the \u0026quot;isthmocele\u0026quot; in women with postmenstrual abnormal uterine bleed- ing and secondary infertility. J Minim Invasive Gynecol. 2008;15: 172\u0026ndash;175. \u003c/li\u003e\n\u003cli\u003eDonnez O, Jadoul P, Squifflet J, Donnez J. Laparoscopic repair of wide and deep uterine scar dehiscence after cesarean section. Fertil Steril. 2008;89:974\u0026ndash;980. \u003c/li\u003e\n\u003cli\u003eDonnez O, Donnez J, Orellana R, Dolmans MM. Gynecological and obstetrical outcomes after laparoscopic repair of a cesarean scar defect in a series of 38 women. Fertil Steril 2017;107(01): 289\u0026ndash;296.e2 Doi: 10.1016/j.fertnstert.2016.09.033 \u003c/li\u003e\n\u003cli\u003eVervoort A, Vissers J, Hehenkamp W, Brölmann H, Huirne J. The effect of laparoscopic resection of large niches in the uterine caesarean scar on symptoms, ultrasound findings and quality of life: a prospective cohort study. BJOG 2018;125(03):317\u0026ndash;325 Doi: 10.1111/1471-0528.14822 \u003c/li\u003e\n\u003cli\u003eKhoshnow Q, Pardey J, Uppal T. Transvaginal repair of caesarean scar dehiscence. Aust N Z J Obstet Gynaecol. 2010;50:94\u0026ndash;95. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Isthmocele, Deep pelvic abscess, Minimal access surgery","lastPublishedDoi":"10.21203/rs.3.rs-6439200/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6439200/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eCaesarean scar defects (CSDs), or isthmocele, are wedge-shaped defects in the anterior uterine wall following caesarean section. Rarely, they can result in abscess and fistula formation. We present a rare case of isthmocele with a communicating deep pelvic abscess in the vesico-uterine pouch, causing severe pelvic pain and vaginal spotting.\u003c/p\u003e\u003ch2\u003eCase-Presentation:\u003c/h2\u003e \u003cp\u003eA 36-year-old woman with three previous caesarean sections presented with vaginal spotting and colicky pelvic pain for three months. She had been using a Mirena IUS (Intra-Uterine system) for postpartum contraception for 15 months. While transvaginal ultrasound was inconclusive, an MRI revealed a bulging isthmocele at the caesarean scar. Combined operative hysteroscopy and laparoscopy were performed. Hysteroscopy identified a bulge at the scar site suggestive of an isthmocele, while laparoscopy revealed adhesions and a 4\u0026times;2 cm boggy mass in the vesico-uterine pouch consistent with a pelvic abscess. Adhesiolysis and drainage of altered blood and inspissated pus were successfully performed. The Mirena IUS was repositioned, and bladder integrity was confirmed. The patient had an uneventful recovery, with complete resolution of symptoms. Pus cultures were sterile.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eCSD diagnosis remains challenging, with no established criteria. CSDs can occasionally lead to pelvic abscess formation and should be considered in patients presenting with post-caesarean pelvic pain. This case underscores the importance of careful utero-vesical pouch dissection to differentiate the isthmocele and abscess, minimizing organ injury. As caesarean rates rise, isthmocele incidence is likely to increase, necessitating diagnostic and treatment guidelines. Minimal access surgery, as demonstrated here, is a feasible approach.\u003c/p\u003e","manuscriptTitle":"Laparoscopic resection of Isthmocele complicated by a communicating deep pelvic abscess of the vesico-uterine pouch: A case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-16 13:25:18","doi":"10.21203/rs.3.rs-6439200/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-27T08:56:05+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-19T07:55:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"338379934918775509407686569702621865916","date":"2025-05-19T06:37:55+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-17T16:11:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"34485988708804333636980179492739492311","date":"2025-05-14T15:47:36+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-14T15:32:01+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-04-21T11:13:41+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-21T01:28:57+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-21T01:26:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Women's Health","date":"2025-04-13T12:33:02+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a90391c2-bdf9-4981-8881-eb440955c1a0","owner":[],"postedDate":"May 16th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-09T03:53:12+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-16 13:25:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6439200","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6439200","identity":"rs-6439200","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}