Evaluation of Cesarean Scar Niche as a Predictor of Pelvic Adhesions and Surgical Difficulty in Women Undergoing Repeat Pelvic Surgery: A Comparative Cross-Sectional Study

Abstract

Background: The cesarean scar niche is a structural defect in the area of the cesarean incision and can potentially be linked to abnormal pelvic healing. Its association with pelvic adhesions and the complications of subsequent pelvic surgery is not fully understood.

Objective: To evaluate the association between cesarean scar niche and pelvic adhesions and surgical difficulty in women undergoing repeat pelvic surgery.

Material and Methods: This cross-sectional study compared 160 women undergoing repeat pelvic surgery who were equally divided into the niche group and the non-niche group defined using transvaginal ultrasonography. Preoperative documentation of niche characteristics and intraoperative assessment of operative parameters and pelvic adhesions were performed. Associations were evaluated using appropriate comparative tests and multivariable logistic regression.

Results: Pelvic adhesions were significantly more frequent in women with a cesarean scar niche, with greater severity and increased vesicouterine and dense bladder adhesions. The niche group was also more likely to have adhesiolysis, difficult dissection of the bladder, and extensive dissection. Operative time and blood loss were greater, and there was a longer hospital stay. This niche was still independently linked to the presence of pelvic adhesions after adjustment for the possible confounding factors (p=0.005). Three or more previous cesarean sections were also independently associated with adhesions.

Conclusions: Pelvic adhesions and increased surgical difficulty in repeat pelvic surgery were independently associated with cesarean scar niche. Niche assessment can be useful in anticipating operative complexity and planning surgery.

Keywords: Cesarean scar niche, isthmocele, pelvic adhesions, cesarean section, surgical difficulty