Isthmocele Endometriosis- the Relationship between Cesarean Section and Endometriosis.

Study Objective We present a unique case of diffuse peritoneal endometriosis following cesarean section, involving the cesarean scar isthmocele and associated with secondary infertility, failed embryo transfers, and progressive pelvic pain. Design Case report of endometriosis within an isthmocele membrane and concomitant peritoneal endometriosis. Setting A combined hysteroscopic and laparoscopic approach in lithotomy position. Patients or Participants A 44-year-old patient with three prior cesarean-sections and a laparoscopic appendectomy, in none of which, endometriosis was visualized. She presented with dysmenorrhea, dyspareunia, and recurrent embryo transfer failures. The progressively debilitating symptoms started 14 years ago, shortly after her last cesarean-section. MRI and ultrasound demonstrated a retroverted uterus and a prominent, thin, fluid filled, cesarean scar defect. Interventions A combined hysteroscopic and laparoscopic approach was performed. Indocyanine green dye was used to identify the bladder borders and methylene blue was added to the hysteroscopy irrigation solution to create contrast. A wide excision of the isthmocele was performed followed by a three-layer closure and excision of all apparent peritoneal lesions using the AquaBlue contrast technique (ABCt™). Measurements and Main Results 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 following the procedure, transvaginal sonographic scan confirmed thick anterior uterine wall, and the patient reported only minor discomfort with almost complete resolution of her symptoms. Conclusion This case demonstrates endometriosis within the isthmocele membrane, with concomitant symptomatic peritoneal endometriosis. We propose a laparoscopic isthmocele excision technique with three-layer reconstruction, and 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 might be a cause or a contributor to the tissue weakness and isthmocele formation.