Effectiveness of hysteroscopic resection of a niche VERSUS Expectant management in women with premenstrual spotting postmenstrual spotting

General or regional (spinal) anesthesia depending on the extent of the procedure and surgeon preference. duration of the intervention : 30 -60 minutes . surgeon : senior specialist of endoscopic surgery. *Positioning: Lithotomy position with appropriate padding to avoid nerve injury. Bladder should be emptied before the procedure. 3. Surgical Equipment: *Rigid hysteroscope (5–9 mm) with operative channel. *30° lens for better visualization. *Electrosurgical loop momopolar or bipolar resectoscope . *Uterine distension medium (normal saline for bipolar or glycine for monopolar energy). *Cervical dilators, if necessary. *Fluid management system to monitor inflow and outflow.Cervical Dilation (if required): Gradual dilation up to size compatible with the resectoscope. 2. Diagnostic Hysteroscopy: Initial inspection of uterine cavity to locate the cesarean scar defect, usually found at the anterior lower uterine segment. 4. Identification of Niche: Appears as a pouch or depression at the scar site, often with retained blood or mucus. 5. Resection Steps: a. Resect the Inferior Edge: Use a bipolar loop or scissors to excise the fibrotic and overhanging inferior edge of the niche to improve drainage and eliminate the pocket. *Remove any granulation tissue or polypoidal growth inside the niche. *Avoid aggressive resection of the superior edge to minimize thinning of the overlying myometrium. c. Coagulation: Apply light coagulation to bleeding points, avoiding excessive energy near the uterine serosa. 6.Fluid Balance Monitoring: Monitor input and output of distension fluid to avoid fluid overload (especially with glycine). strategies to assess the adherence to the intervention is accurate record of operative notes.