Demonstration of Isthmocele Surgical Repair

To describe the surgical treatment of a uterine isthmocele.

Demonstration of the laparoscopic technique with narrated video footage.

Cesarean section rate has been increasing despite the World Health Organization's recommendation of a maximum 15%, with some countries reaching rates as high as 50%. The choice of delivery method is a complex topic based on physical and psychologic health, social and cultural context, and quality of maternity care. With the increasing number of cesarean sections, a new entity was recognized, the isthmocele [1]. A uterine isthmocele is a dilatation of the uterine cesarean scar and functions as a reservoir collecting blood during menstruation. Isthmocele prevalence ranges from 19% to 84%[2]. The most frequent complaint relates to intermittent postmenstrual bleeding (30%). Isthmocele can be a cause of infertility and pelvic pain [3]. Interstitial pregnancy is a known complication with a mortality rate up to 2.5%. The diagnosis can be made by transvaginal ultrasound and/or magnetic resonance imaging but also by hysteroscopy or hysterosalpingography. Treatment can be done by controlling the symptoms with oral combined contraceptive (decreasing metrorrhagia) or with surgical correction improving symptoms and/or fertility [4-7]. Isthmocele correction seems to improve secondary infertility in patients in whom a fertility workup did not find other cause [8,9]. Surgical approach can be done by vaginal route with hysteroscopy; abdominal route with laparoscopy, robotic or laparotomy; or through a combine procedure with both routes. Hysterectomy is the definitive treatment, but for those who want to preserve fertility, isthmocele correction can be offered. For laparoscopic surgery, several ways have been described to detect the isthmocele such as Foley catheter, hysteroscopy, methylene blue, and Hegar probe. When we do laparoscopy, we prefer concomitant use of hysteroscopy. There is a trending opinion that patients with a smaller isthmocele could be treated hysteroscopically (2.5 mm according to Jeremy et al [10] and 3.0 mm described by Marotta et al [11]). The goal of hysteroscopy correction is to remove the inflammatory infiltration in the endocervix, cutting the superior and inferior edges of the defect enabling normal blood evacuation of the uterus. By contrast, those with a larger isthmocele (with <2.5-3.0-mm residual myometrium) and a risk of perforation during hysteroscopy could be better treated by laparoscopy. This is especially important in patients interested in pregnancy because of the risk of uterine perforation [12]. There is still no strong evidence that hysteroscopic correction leads to an increased number of uterine ruptures compared with laparoscopy, but myometrium thickness seems to be greater after laparoscopic correction. Myometrium thickness is an independent risk factor for uterine rupture [13], and therefore, laparoscopic correction is preferred over hysteroscopic in women with a pregnancy desire. Finally, after surgical correction of an isthmocele, we recommend a 6-month interval before attempting pregnancy.

Laparoscopic treatment is important in women who are symptomatic, have thin endometrium, and desire a pregnancy. Key strategies are (1) dissection of the vesicouterine pouch laterally to avoid entering the bladder wall; (2) transillumination with hysteroscopy; (3) cut with cold scissors avoiding thermal damage of remaining myometrium; and (4) suture with figure 8 in multiple layers. No evidence of using a specific suture is available.

Surgical treatment of a uterine isthmocele is a good option in women who are symptomatic and infertile. Laparoscopic treatment guided by hysteroscopy is a good option if residual myometrium is <3 mm.