Isthmocele: controversial and unresolved issues

Isthmocele, also known as a niche or cesarean scar defect, is one of the most frequent remote complications of abdominal delivery. Despite numerous studies, the mechanisms of isthmocele development and its nature remain underexplored, but there is no doubt that this syndrome is polyetiologic. The problem of isthmocele and infertility attracts close attention of scientists all over the world. The niche is believed to be not only a cause of secondary infertility but also has a negative impact on the outcomes of assisted reproductive technologies. The pathogenetic approach to the treatment of isthmocele is surgical metroplasty performed by intrauterine (operative hysteroscopy), vaginal and abdominal (laparotomy, laparoscopy) accesses. Each of the listed methods of isthmocele correction has its own practical significance. Preference is given to vaginal techniques – operative hysteroscopy (if conditions exist) and vaginal surgery, which are characterized by a minimally invasive approach combined with high efficacy of restoration of myometrial damage. © 2025 Elsevier B.V., All rights reserved.