GynecologyGynecologyГинекология2079-56962079-5831Consilium Medicum3497010.26442/20795696.2020.3.200189REVIEWОБЗОРResearch ArticleCesarean scar defects: diagnosis and treatment in non-pregnant womenДефект рубца на матке после кесарева сечения: диагностика и лечение вне беременностиhttps://orcid.org/0000-0002-6795-1033MartynovSergey A.МартыновСергей Александрович
Russian Federation

D. Sci. (Med.)

д-р мед. наук, вед. науч. сотр. гинекологического отд-ния

s_martynov@oparina4.ruKulakov National Medical Research Center for Obstetrics, Gynecology and PerinatologyФГБУ «Национальный медицинский исследовательский центр акушерства, гинекологии и перинатологии имени академика В.И. Кулакова» Минздрава России0907202022361007072020Copyright ©; 2020, Consilium MedicumCopyright ©; 2020, ООО "Консилиум Медикум"2020Consilium MedicumООО "Консилиум Медикум"https://creativecommons.org/licenses/by-nc-sa/4.0https://gynecology.orscience.ru/2079-5831/article/view/34970

The aim of the review was to summarize information on clinical manifestations, diagnostic features, as well as methods for correction of scar defects after cesarean section (CS) outside pregnancy. “Lack of the scar after CS”, “niche”, “isthmocele” are a myometrium defect in the area of scar after CS, which is most often detected by ultrasound, sonohysterography or magnetic resonance imaging and is manifested by postmenstrual bleeding from the genital tract. In some cases, it can cause menorrhagia, dyspareunia, pelvic pain, infertility, uterine rupture during subsequent pregnancy and childbirth. Conservative therapy or surgical treatment with laparoscopy, laparotomy or vaginal approach is carried out depending on the symptoms, size of the defect, the thickness of the residual myometrium, as well as the woman’s reproductive plans.

Целью обзора явилось обобщение информации относительно клинических проявлений, особенностей диагностики, а также способов коррекции дефектов рубца после кесарева сечения (КС) вне беременности. «Дефект рубца после КС», «ниша», «истмоцеле» представляют собой дефект миометрия в зоне рубца после КС, который чаще всего выявляется с помощью ультразвукового исследования, соногистерографии или магнитно-резонансной томографии и проявляется постменструальными кровяными выделениями из половых путей. В ряде случаев может быть причиной меноррагий, диспареунии, тазовых болей, бесплодия, разрыва матки во время последующей беременности и родов. Консервативная терапия или хирургическое лечение лапароскопическим, лапаротомным или вагинальным доступом проводится в зависимости от симптоматики, размеров дефекта, толщины остаточного миометрия, а также репродуктивных планов женщины.

cesarean scar defectnicheisthmoceleрубец на маткенишаистмоцелеRobson SJ, de Costa CM. Thirty years of the World Health Organization`s target caesarean section rate: time to move on. Med J Aust 2017; 206: 181–5.Setubal A, Alves J, Osorio F et al. Treatment for uterine isthmocele, a pouch-like defect at the site of cesarean section scar. J Minim Invasive Gynecol 2017. https://doi.org/doi:10.1016/j.jmig.2017.09.022Краснопольский В.И., Буянова С.Н., Щукина Н.А., Логутова Л.С. Несостоятельность шва (рубца) на матке после КС: проблемы и решения (редакционная статья). Рос. вестн. акушера-гинеколога. 2015; 3: 4–8.[Krasnopol’skii V.I., Buianova S.N., Shchukina N.A., Logutova L.S. Nesostoiatel’nost’ shva (rubtsa) na matke posle KS: problemy i resheniia (redaktsionnaia stat’ia). Ros. vestn. akushera-ginekologa. 2015; 3: 4–8 (in Russian).]Monteagudo A, Carreno C, Timor-Tritsch IE. Saline infusion sonohysterography in nonpregnant women with previous cesarean delivery: the ‘niche’ in the scar. J Ultrasound Med 2001; 20: 1105–15.Tulandi T, Cohen A. Emerging manifestations of Cesarean scar defect in reproductive-aged women. J Minim Invasive Gynecol 2016; 23: 893–902.Osser OV, Jokubkiene L, Valentin L. High prevalence of defects in Cesarean section scars at transvaginal ultrasound examination. Ultrasound Obstet Gynecol 2009; 34: 90–7.Karli P, Sahin B, Kara F. The incidence of isthmocele may be higher than reported. J Surg Med 2018; 2 (3): 283–7.Vervoort AJ, Uittenbogaard LB, Hehenkamp WJ et al. Why do niches develop in caesarean uterine scars? Hypotheses on the aetiology of niche development. Hum Reprod 2015; 30: 2695–702.Schepker N, Garcia-Rocha GJ, Versen-Hoynck F et al. Clinical diagnosis and therapy of uterine scar defects after caesarean section in non-pregnant women. Arch Gynecol Obstet 2014. https://dx.doi.org/10.1007/s00404-014-3582-0Аракелян А.С., Мартынов С.А., Хорошун Н.Д. и др. Диагностика и хирургическая коррекция несостоятельности рубца на матке после КС с использованием лапароскопии и гистероскопии. В кн.: Сухих Г.Т., Адамян Л.В. (ред.). Материалы XXIX конгресса «Новые технологии в диагностике и лечении гинекологических заболеваний», Москва, 7–10 июня 2016 г. М., 2016; с. 179–80.[Arakelian A.S., Martynov S.A., Khoroshun N.D. et al. Diagnostika i khirurgicheskaia korrektsiia nesostoiatel’nosti rubtsa na matke posle KS s ispol’zovaniem laparoskopii i gisteroskopii. V kn.: Sukhikh G.T., Adamian L.V. (red.). Materialy XXIX kongressa «Novye tekhnologii v diagnostike i lechenii ginekologicheskikh zabolevanii’, Moscow, 7–10 iiunia 2016 g. Moscow, 2016; p. 179–80 (in Russian).]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: 289–96.Van der Voet LF, Vervoort AJ, Veersema S et al. Minimally invasive therapy for gynaecological symptoms related to a niche in the caesarean scar: a systematic review. BJOG 2014; 121: 145–56.Gubbini G, Centini G, Nascetti D et al. Surgical hysteroscopic treatment of cesarean-induced isthmocele in restoring fertility: prospective study. J Minim Invasiv Gynecol 2011; 18: 234–7.Osser OV, Jokubkiene L, Valentin L. Cesarean section scar defects: agreement between transvaginal sonographic findings with and without saline contrast enhancement. Ultrasound Obstet Gynecol 2010; 35: 75–83.Osser OV, Valentin L. Clinical importance of appearance of Cesarean hysterotomy scar at transvaginal ultrasonography in non-pregnant women. Obstet Gynecol 2011; 117: 525–32.Regnard C, Nosbusch M, Fellemans C et al. Cesarean section scar evaluation by saline contrast sonohysterography. Ultrasound Obstet Gynecol 2004; 23: 289–92.Tang X, Wang J, Du Y et al. Caesarean scar defect: Risk factors and comparison of evaluation efficacy between transvaginal sonography and magnetic resonance imaging. Eur J Obstet Gynecol Reprod Biol 2019; 242: 1–6.Satpathy G, Kumar I, Matah M, Verma A. Comparative accuracy of magnetic resonance morphometry and sonography in assessment of post-cesarean uterine scar. Indian J Radiol Imaging 2018; 28: 169–74.Wong W, Fung WT. Magnetic resonance imaging in the evaluation of cesarean scar defect. Gynecol Minim Invasive Ther 2008; 7: 104–7.Waniorek A. Hysterography after cesarean section. With special reference to the effect of subsequent delivery on the hysterographic findings. Am J Obstet Gynecol 1966; 94 (1): 42–9.Tahara M, Shimizu T, Shimoura H. Preliminary report of treatment with oral contraceptive pills for intermenstrual vaginal bleeding secondary to a cesarean section scar. Fertil Steril 2006; 86: 477–9.Zhang X, Yang M, Wang Q et al. Prospective evaluation of five methods used to treat cesarean scar defects. Int J Gynaecol Obstet 2016;134: 336–9.Thurmond AS, Harvey WJ, Smith SA. Cesarean section scar as a cause of abnormal vaginal bleeding: diagnosis by sonohysterography. J Ultrasound Med 1999; 18: 13–6.Ying-Yi Chen, Ching-Chang Tsai, Kuo-Chung Lan et al. Preliminary report on the use of a levonorgestrel intrauterine system for the treatment of intermenstrual bleeding due to previous cesarean delivery scar defect. J Obstet Gynaecol Res 2019; 45 (10): 2015–20. https://doi.10.1111/jog.14060Vervoort AJMW, Van der Voet LF, Hehenkamp WJK et al. Hysteroscopic resection of a uterine caesarean scar defect (niche) in women with postmenstrual spotting: a randomised controlled trial. BJOG 2018; 125: 326–34.Tanimura S, Funamoto H, Hosono T et al. New diagnostic criteria and operative strategy for cesarean scar syndrome: endoscopic repair for secondary infertility caused by cesarean scar defect. J Obstet Gynaecol Res 2015; 41: 1363–9.Raimondo G, Grifone G, Raimondo D et al. Hysteroscopic treatment of symptomatic cesarean-induced isthmocele: a prospective study. J Minim Invasive Gynecol 2015; 22: 297–301.Vervoort AJMW, Vissers J, Hehenkamp WJK et al. 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: 317–25.Ofili-Yebovi D, Ben-Nagi J, Sawyer E et al. Deficient lower segment cesarean section scars: Prevalence and risk factors. Ultrasound Obstet Gynecol 2008; 31: 72–7.Краснопольская К.В., Попов А.А., Чечнева М.А. и др. Прегравидарная метропластика по поводу несостоятельного рубца на матке после кесарева сечения: влияние на естественную фертильность и результаты ЭКО. Проблемы репродукции. 2015; 3: 56–62. DOI: 10.17116/repro201521356-62[Krasnopol’skaia K.V., Popov A.A., Chechneva M.A. et al. Pregravidarnaia metroplastika po povodu nesostoiatel’nogo rubtsa na matke posle kesareva secheniia: vliianie na estestvennuiu fertil’nost’ i rezul’taty EKO. Problemy reproduktsii. 2015; 3: 56–62. DOI: 10.17116/repro201521356-62 (in Russian).]Пучкова Н.В. Несостоятельный рубец на матке после кесарева сечения: диагностика, тактика ведения, репродуктивный прогноз. Автореф. дис. ... канд. мед. наук. М., 2014.[Puchkova N.V. Nesostoiatel’nyi rubets na matke posle kesareva secheniia: diagnostika, taktika vedeniia, reproduktivnyi prognoz. Avtoref. dis. ... kand. med. nauk. Moscow, 2014 (in Russian).]Seliger G, Chaoui K, Lautenschlager C et al. Technique of sonographic assessment of lower uterine segment in women with previous cesarean delivery: a prospective, pre/intraoperative comparative ultrasound study. Arch Gynecol Obstet 2018; 298: 297–306.Zhao W, Liu G, Yang Q, Zhang Ch. A new method using a Foley Catheter to locate the diverticulum in laparoscopic repair of uterine cesarean scar defects. Eur J Obstet Gynecol Reprod Biol 2018; 223: 14–7.Макиян З.Н., Адамян Л.В., Карабач В.В., Чупрынин В.Д. Новый метод хирургического лечения несостоятельности рубца на матке после кесарева сечения с помощью внутриматочного манипулятора с желобом. Акушерство и гинекология. 2020; 2: 104–10. https://dx.doi.org/10.18565/aig.2020.2.104-110[Makiian Z.N., Adamian L.V., Karabach V.V., Chuprynin V.D. Novyi metod khirurgicheskogo lecheniia nesostoiatel’nosti rubtsa na matke poslekesareva secheniia s pomoshch’iu vnutrimatochnogo manipuliatora szhelobom. Akusherstvo i ginekologiia. 2020; 2: 104–10. https://dx.doi.org/10.18565/aig.2020.2.104-110 (in Russian).]Perry CP, Presthus J, Nieves A. Laparoscopic uterine suspension for pain relief: a multicenter study. J Reprod Med 2005; 50: 657–70.Sipahi S, Sasaki K, Miller Ch. The minimally invasive approach to the symptomatic Isthmocele – what does the literature say? A step-by-step primer on laparoscopic isthmocele – excision and repair. Curr Opin Obstet Gynecol 2017; 29: 257–65. DOI: 10.1097/GCO.0000000000000380Zhang Y. A comparative study of transvaginal repair and laparoscopic repair in the management of patients with previous Cesarean scar defect.J Minim Invasive Gynecol 2016; 23: 535–41.Ciebiera M, Ciebiera M, Czekanska-Rawska M, Jakiel G. Laparoscopic isthmocele treatment – single center experience. Videosurgery Miniinv 2017; 12: 88–95.Pomorski M, Fuchs T, Rosner-Tenerowicz A, Zimmer M. Sonographic evaluation of surgical repair of uterine cesarean scar defects. J Clin Ultrasound 2017; 45 (8): 455–60. https://doi.org/10.1002/jcu.22449Zhou J, Yao M, Wang H et al. Vaginal repair of Cesarean section scar diverticula that resulted in improved postoperative menstruation. J Minim Invasive Gynecol 2016; 23: 969–78.Luo L, Niu G, Wang Q et al. Vaginal repair of cesarean section scar diverticula. J Minim Invasiv Gynecol 2012; 19: 454–8.Dicle O, Kucukler C, Pirnar T et al. Magnetic resonance imaging evaluation of incision healing after cesarean sections. Eur Radiol 1997; 7: 31–4.Van der Voet LF, Jordans IP, Brolmann HA et al. Changes in the uterine scar during the first year after a caesarean section: a prospective longitudinal study. Gynecol Obstet Invest 2017. https://doi.10.1159/000478046Demers S, Roberge S, Bujold E. Laparoscopic repair of postcesarean uterine scar defect. J Minim Invasive Gynecol 2013; 20: 537.Grace L, Nezhat A. Should Cesarean Scar Defect Be Treated Laparoscopically? A Case Report an Review of the Literature. J Minim Invasive Gynecol 2016; 23 (5): 843. DOI: 10.1016/j.jmig.2016.01.030Robson SJ, de Costa CM. Thirty years of the World Health Organization`s target caesarean section rate: time to move on. Med J Aust 2017; 206: 181–5.Setubal A, Alves J, Osorio F et al. Treatment for uterine isthmocele, a pouch-like defect at the site of cesarean section scar. J Minim Invasive Gynecol 2017. https://doi.org/doi:10.1016/j.jmig.2017.09.022Краснопольский В.И., Буянова С.Н., Щукина Н.А., Логутова Л.С. Несостоятельность шва (рубца) на матке после КС: проблемы и решения (редакционная статья). Рос. вестн. акушера-гинеколога. 2015; 3: 4–8.[Krasnopol’skii V.I., Buianova S.N., Shchukina N.A., Logutova L.S. Nesostoiatel’nost’ shva (rubtsa) na matke posle KS: problemy i resheniia (redaktsionnaia stat’ia). Ros. vestn. akushera-ginekologa. 2015; 3: 4–8 (in Russian).]Monteagudo A, Carreno C, Timor-Tritsch IE. Saline infusion sonohysterography in nonpregnant women with previous cesarean delivery: the ‘niche’ in the scar. J Ultrasound Med 2001; 20: 1105–15.Tulandi T, Cohen A. Emerging manifestations of Cesarean scar defect in reproductive-aged women. J Minim Invasive Gynecol 2016; 23: 893–902.Osser OV, Jokubkiene L, Valentin L. High prevalence of defects in Cesarean section scars at transvaginal ultrasound examination. Ultrasound Obstet Gynecol 2009; 34: 90–7.Karli P, Sahin B, Kara F. The incidence of isthmocele may be higher than reported. J Surg Med 2018; 2 (3): 283–7.Vervoort AJ, Uittenbogaard LB, Hehenkamp WJ et al. Why do niches develop in caesarean uterine scars? Hypotheses on the aetiology of niche development. Hum Reprod 2015; 30: 2695–702.Schepker N, Garcia-Rocha GJ, Versen-Hoynck F et al. Clinical diagnosis and therapy of uterine scar defects after caesarean section in non-pregnant women. Arch Gynecol Obstet 2014. https://dx.doi.org/10.1007/s00404-014-3582-0Аракелян А.С., Мартынов С.А., Хорошун Н.Д. и др. Диагностика и хирургическая коррекция несостоятельности рубца на матке после КС с использованием лапароскопии и гистероскопии. В кн.: Сухих Г.Т., Адамян Л.В. (ред.). Материалы XXIX конгресса «Новые технологии в диагностике и лечении гинекологических заболеваний», Москва, 7–10 июня 2016 г. М., 2016; с. 179–80.[Arakelian A.S., Martynov S.A., Khoroshun N.D. et al. Diagnostika i khirurgicheskaia korrektsiia nesostoiatel’nosti rubtsa na matke posle KS s ispol’zovaniem laparoskopii i gisteroskopii. V kn.: Sukhikh G.T., Adamian L.V. (red.). Materialy XXIX kongressa «Novye tekhnologii v diagnostike i lechenii ginekologicheskikh zabolevanii’, Moscow, 7–10 iiunia 2016 g. Moscow, 2016; p. 179–80 (in Russian).]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: 289–96.Van der Voet LF, Vervoort AJ, Veersema S et al. Minimally invasive therapy for gynaecological symptoms related to a niche in the caesarean scar: a systematic review. BJOG 2014; 121: 145–56.Gubbini G, Centini G, Nascetti D et al. Surgical hysteroscopic treatment of cesarean-induced isthmocele in restoring fertility: prospective study. J Minim Invasiv Gynecol 2011; 18: 234–7.Osser OV, Jokubkiene L, Valentin L. Cesarean section scar defects: agreement between transvaginal sonographic findings with and without saline contrast enhancement. Ultrasound Obstet Gynecol 2010; 35: 75–83.Osser OV, Valentin L. Clinical importance of appearance of Cesarean hysterotomy scar at transvaginal ultrasonography in non-pregnant women. Obstet Gynecol 2011; 117: 525–32.Regnard C, Nosbusch M, Fellemans C et al. Cesarean section scar evaluation by saline contrast sonohysterography. Ultrasound Obstet Gynecol 2004; 23: 289–92.Tang X, Wang J, Du Y et al. Caesarean scar defect: Risk factors and comparison of evaluation efficacy between transvaginal sonography and magnetic resonance imaging. Eur J Obstet Gynecol Reprod Biol 2019; 242: 1–6.Satpathy G, Kumar I, Matah M, Verma A. Comparative accuracy of magnetic resonance morphometry and sonography in assessment of post-cesarean uterine scar. Indian J Radiol Imaging 2018; 28: 169–74.Wong W, Fung WT. Magnetic resonance imaging in the evaluation of cesarean scar defect. Gynecol Minim Invasive Ther 2008; 7: 104–7.Waniorek A. Hysterography after cesarean section. With special reference to the effect of subsequent delivery on the hysterographic findings. Am J Obstet Gynecol 1966; 94 (1): 42–9.Tahara M, Shimizu T, Shimoura H. Preliminary report of treatment with oral contraceptive pills for intermenstrual vaginal bleeding secondary to a cesarean section scar. Fertil Steril 2006; 86: 477–9.Zhang X, Yang M, Wang Q et al. Prospective evaluation of five methods used to treat cesarean scar defects. Int J Gynaecol Obstet 2016;134: 336–9.Thurmond AS, Harvey WJ, Smith SA. Cesarean section scar as a cause of abnormal vaginal bleeding: diagnosis by sonohysterography. J Ultrasound Med 1999; 18: 13–6.Ying-Yi Chen, Ching-Chang Tsai, Kuo-Chung Lan et al. Preliminary report on the use of a levonorgestrel intrauterine system for the treatment of intermenstrual bleeding due to previous cesarean delivery scar defect. J Obstet Gynaecol Res 2019; 45 (10): 2015–20. https://doi.10.1111/jog.14060Vervoort AJMW, Van der Voet LF, Hehenkamp WJK et al. Hysteroscopic resection of a uterine caesarean scar defect (niche) in women with postmenstrual spotting: a randomised controlled trial. BJOG 2018; 125: 326–34.Tanimura S, Funamoto H, Hosono T et al. New diagnostic criteria and operative strategy for cesarean scar syndrome: endoscopic repair for secondary infertility caused by cesarean scar defect. J Obstet Gynaecol Res 2015; 41: 1363–9.Raimondo G, Grifone G, Raimondo D et al. Hysteroscopic treatment of symptomatic cesarean-induced isthmocele: a prospective study. J Minim Invasive Gynecol 2015; 22: 297–301.Vervoort AJMW, Vissers J, Hehenkamp WJK et al. 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: 317–25.Ofili-Yebovi D, Ben-Nagi J, Sawyer E et al. Deficient lower segment cesarean section scars: Prevalence and risk factors. Ultrasound Obstet Gynecol 2008; 31: 72–7.Краснопольская К.В., Попов А.А., Чечнева М.А. и др. Прегравидарная метропластика по поводу несостоятельного рубца на матке после кесарева сечения: влияние на естественную фертильность и результаты ЭКО. Проблемы репродукции. 2015; 3: 56–62. DOI: 10.17116/repro201521356-62[Krasnopol’skaia K.V., Popov A.A., Chechneva M.A. et al. Pregravidarnaia metroplastika po povodu nesostoiatel’nogo rubtsa na matke posle kesareva secheniia: vliianie na estestvennuiu fertil’nost’ i rezul’taty EKO. Problemy reproduktsii. 2015; 3: 56–62. DOI: 10.17116/repro201521356-62 (in Russian).]Пучкова Н.В. Несостоятельный рубец на матке после кесарева сечения: диагностика, тактика ведения, репродуктивный прогноз. Автореф. дис. ... канд. мед. наук. М., 2014.[Puchkova N.V. Nesostoiatel’nyi rubets na matke posle kesareva secheniia: diagnostika, taktika vedeniia, reproduktivnyi prognoz. Avtoref. dis. ... kand. med. nauk. Moscow, 2014 (in Russian).]Seliger G, Chaoui K, Lautenschlager C et al. Technique of sonographic assessment of lower uterine segment in women with previous cesarean delivery: a prospective, pre/intraoperative comparative ultrasound study. Arch Gynecol Obstet 2018; 298: 297–306.Zhao W, Liu G, Yang Q, Zhang Ch. A new method using a Foley Catheter to locate the diverticulum in laparoscopic repair of uterine cesarean scar defects. Eur J Obstet Gynecol Reprod Biol 2018; 223: 14–7.Макиян З.Н., Адамян Л.В., Карабач В.В., Чупрынин В.Д. Новый метод хирургического лечения несостоятельности рубца на матке после кесарева сечения с помощью внутриматочного манипулятора с желобом. Акушерство и гинекология. 2020; 2: 104–10. https://dx.doi.org/10.18565/aig.2020.2.104-110[Makiian Z.N., Adamian L.V., Karabach V.V., Chuprynin V.D. Novyi metod khirurgicheskogo lecheniia nesostoiatel’nosti rubtsa na matke poslekesareva secheniia s pomoshch’iu vnutrimatochnogo manipuliatora szhelobom. Akusherstvo i ginekologiia. 2020; 2: 104–10. https://dx.doi.org/10.18565/aig.2020.2.104-110 (in Russian).]Perry CP, Presthus J, Nieves A. Laparoscopic uterine suspension for pain relief: a multicenter study. J Reprod Med 2005; 50: 657–70.Sipahi S, Sasaki K, Miller Ch. The minimally invasive approach to the symptomatic Isthmocele – what does the literature say? A step-by-step primer on laparoscopic isthmocele – excision and repair. Curr Opin Obstet Gynecol 2017; 29: 257–65. DOI: 10.1097/GCO.0000000000000380Zhang Y. A comparative study of transvaginal repair and laparoscopic repair in the management of patients with previous Cesarean scar defect.J Minim Invasive Gynecol 2016; 23: 535–41.Ciebiera M, Ciebiera M, Czekanska-Rawska M, Jakiel G. Laparoscopic isthmocele treatment – single center experience. Videosurgery Miniinv 2017; 12: 88–95.Pomorski M, Fuchs T, Rosner-Tenerowicz A, Zimmer M. Sonographic evaluation of surgical repair of uterine cesarean scar defects. J Clin Ultrasound 2017; 45 (8): 455–60. https://doi.org/10.1002/jcu.22449Zhou J, Yao M, Wang H et al. Vaginal repair of Cesarean section scar diverticula that resulted in improved postoperative menstruation. J Minim Invasive Gynecol 2016; 23: 969–78.Luo L, Niu G, Wang Q et al. Vaginal repair of cesarean section scar diverticula. J Minim Invasiv Gynecol 2012; 19: 454–8.Dicle O, Kucukler C, Pirnar T et al. Magnetic resonance imaging evaluation of incision healing after cesarean sections. Eur Radiol 1997; 7: 31–4.Van der Voet LF, Jordans IP, Brolmann HA et al. Changes in the uterine scar during the first year after a caesarean section: a prospective longitudinal study. Gynecol Obstet Invest 2017. https://doi.10.1159/000478046Demers S, Roberge S, Bujold E. Laparoscopic repair of postcesarean uterine scar defect. J Minim Invasive Gynecol 2013; 20: 537.Grace L, Nezhat A. Should Cesarean Scar Defect Be Treated Laparoscopically? A Case Report an Review of the Literature. J Minim Invasive Gynecol 2016; 23 (5): 843. DOI: 10.1016/j.jmig.2016.01.030