發表日期：2026/3/28
發表人：婦產科 吳加仁醫師、張紅淇醫師
發表場合：台灣婦產科醫學會年會

Introduction

    Isthmocele, or cesarean scar defect, is a pouch-like defect located at the anterior uterine isthmus following cesarean section. It is associated with abnormal uterine bleeding, chronic pelvic pain, dysmenorrhea, and secondary infertility. 
    Bladder endometriosis represents a rare manifestation of endometriosis and may arise from direct implantation during pelvic surgery or as part of deep infiltrating disease. The coexistence of isthmocele and bladder endometriosis is uncommon, and the underlying pathophysiology remains poorly understood.

Case Presentation

    A postpartum woman with a history of cesarean section due to placenta accreta presented with pelvic pain and more vaginal discharge. She denied gross hematuria but reported cyclical exacerbation of pelvic discomfort. The ultrasonography and hysteroscopy revealed a myometrial defect at the anterior lower uterine segment consistent with an isthmocele, with heterogenic content. (Fig 1) Additionally, a homogeneous mass was noted on the posterior bladder wall, raising suspicion for bladder endometriosis. (Fig 2) After counseling, the patient elected to undergo surgical management.

Surgical Technique

    Laparoscopic surgery was performed under general anesthesia. Dense adhesions were identified at the vesicouterine fold. (Fig 3) Careful adhesiolysis allowed separation of the bladder from the lower uterine segment. The fibrotic tissue of the isthmocele was excised to expose healthy myometrium, followed by layered repair of the uterine defect using non-locking sutures to restore uterine wall thickness. 
    Bladder endometriosis was managed using a bladder shaving technique, as there was no evidence of mucosal involvement via cystoscopic examination.  (Fig 4)
    The endometriotic nodule was completely excised without entering the bladder lumen. Bladder integrity was confirmed intraoperatively.