IERA (Instituto Extremeño de Reproducción Asistida), Badajoz, Spain.
Unidad Cirugía Reproductiva, Centro Gutenberg, Málaga, Spain.
Ultrasound Obstet Gynecol. 2023 Sep;62(3):336-344. doi: 10.1002/uog.26171.
The purpose of this State-of-the-Art Review was to provide a strategic analysis, in terms of strengths, weaknesses, opportunities and threats (SWOT analysis), of the current evidence regarding the management of uterine isthmocele (Cesarean scar defect). Strengths include the fact that isthmocele can be diagnosed on two-dimensional transvaginal ultrasound, and that surgical repair may restore natural fertility potential and prevent secondary infertility, as well as reduce the risk of miscarriage and other obstetric complications. However, there is a lack of high-quality evidence regarding the best diagnostic method and criteria, as well as the potential benefits of surgical repair with respect to fertility. There is a need for experienced surgeons skilled in the various isthmocele repair techniques. Isthmocele repair does not prevent the need for Cesarean delivery in subsequent pregnancies. There is increasing awareness regarding the accuracy of transvaginal ultrasound in diagnosing isthmocele. This may lead to surgical correction and prevention of obstetric and perinatal complications in subsequent pregnancies, including Cesarean scar pregnancy. Regarding threats, the existence of different surgical techniques means that there is a risk of selecting an inadequate approach if the type of isthmocele and the patient's characteristics are not considered. There is a risk of overtreatment when asymptomatic defects are repaired surgically. Finally, there is an absence of cost-effectiveness analyses to justify routine repair. Thus, while there are many data suggesting that isthmocele has an adverse effect on both natural fertility and the outcome of assisted reproduction techniques, high-quality evidence to support surgical isthmocele repair in all asymptomatic patients desiring future fertility are lacking. There is increasing agreement to recommend hysteroscopic repair of isthmocele as a first-line approach as long as the residual myometrial thickness is at least 2.5-3.0 mm. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
本综述旨在对子宫峡部憩室（剖宫产瘢痕缺损）管理的现有证据进行战略分析，从优势、劣势、机会和威胁（SWOT 分析）的角度进行分析。其优势包括：二维经阴道超声可诊断憩室，手术修复可能恢复自然生育潜能，预防继发性不孕，降低流产和其他产科并发症的风险。然而，关于最佳诊断方法和标准，以及手术修复对生育的潜在益处，缺乏高质量的证据。需要有经验的外科医生熟练掌握各种憩室修复技术。憩室修复并不能预防后续妊娠再次剖宫产的需要。经阴道超声诊断憩室的准确性越来越受到重视。这可能导致在后续妊娠中进行手术矫正，预防产科和围产期并发症，包括剖宫产瘢痕妊娠。威胁在于，不同的手术技术的存在意味着，如果不考虑憩室的类型和患者的特征，就有可能选择不适当的方法。对无症状缺陷进行手术修复存在过度治疗的风险。最后，缺乏成本效益分析来证明常规修复的合理性。因此，尽管有大量数据表明憩室对自然生育和辅助生殖技术的结局都有不良影响，但缺乏高质量的证据来支持所有有生育要求的无症状患者进行憩室手术修复。越来越多的人同意建议对憩室进行宫腔镜修复作为一线方法，只要残余子宫肌层厚度至少为 2.5-3.0 毫米。
