Hysteroscopic Isthmoplasty: Step-by-Step Technique

Study Objective To demonstrate our technique for surgical hysteroscopy performed with a standard-size resectoscope or miniresectoscope in 3 cases of isthmocele. Design Step-by-step demonstration of the technique using slides, pictures, and video (educative video) (Canadian Task Force classification III). Setting Isthmocele is a characteristic semidiverticular anomaly of the anterior isthmic wall of the uterus, located at the site of a previous cesarean delivery scar. The etiopathogenesis of isthmocele remains poorly understood, although several hypotheses have been proposed. Factors that may possibly play a role in niche development include a very low incision through cervical tissue, inadequate suturing technique during closure of the uterine scar, surgical interventions that increase adhesion formation, and patient-related factors that impair wound healing or increase inflammation or adhesion formation. The treatment of isthmocele focuses on relieving symptoms (i.e., postmenstrual spotting, suprapubic pelvic pain, dysmenorrhea, dyspareunia, and infertility), and, consequently, asymptomatic cases should not be treated. Various surgical approaches have been described to treat isthmocele-related symptoms, including hysteroscopy, laparoscopy, vaginal, robotic, and combined techniques. Intervention Our local Institutional Review Board approved the study protocol. The procedures were performed in operative room using a 26 Fr and 16 Fr continuous-flow resectoscope under general anesthesia. The surgical technique involves resection of the fibrotic tissue of the lower margin and then the upper margin of the pouch using a cutting loop, until the underlying muscular tissue is reached, followed by resection of the inflamed and necrotic tissue of the base of the pouch. Similar surgical maneuvers are performed on the contralateral side (right anterolateral wall) for complete ablation of the isthmic region (inverted ablation). Conclusion According to the most recent literature, hysteroscopic hystmoplasty appears to be a safe and effective treatment option in cases of isthmocele with a niche at least 2 mm deep and a residual myometrial thickness of at least 3 mm to improve postmenstrual bleeding. When residual myometrial thickness is <3 mm, the hysteroscopic approach is not recommended, mainly because of the risk of bladder injury. In these symptomatic cases, laparoscopic or vaginal repair may be considered.