ISGE Newsletter

Enjoy the latest issue of the Hysteroscopy Newsletter.

Dear global friends following in love with hysteroscopy,

When Morris first described isthmocele in 1995 nobody would have thought that today isthmocele would be a hot topic in the endoscopic world.
It is important to emphasize that not all isthmoceles cause symptoms, infertility or pregnancy complication; and multiple techniques have been used for symptomatic isthmocele treatment.

The hysteroscopic repair appears to be the most popular and less invasive treatment to discuss with patients as the first choice. However, there is a trending opinion that isthmocele could be associated with a risk of uterine perforation and bladder injury when residual myometrial thickness (RMT) is less than 2–3 mm and several surgeons recommend laparoscopic or vaginal approach.

These reference values were established arbitrarily because no single case of uterine niche wall perforation and bladder injury has been reported yet independently from the size of RMT in the lecture. Since the removal of the local inflamed tissue may contribute to the improvement of symptoms, only hysteroscopic approach is suitable for visual confirmation, assessment and ablation. Therefore, resection should be performed not only of the fibrotic tissue underneath the isthmocele but also of the inflamed tissue placed around the niche and on the opposite site (the so-called channel-like 360° endocervical ablation).

Even if the ideal surgical treatment in symptomatic and infertile women with isthmocele remains to be elucidated, the channel-like 360° endocervical ablation using a miniresectoscope, appears to be a safe and feasible method when performed by surgeon with great knowledge of instrumentations and technologies.

In our future professional lives, we shouldn’t forget isthmocele any time that a patient with a previous cesarean section complains about abnormal uterine bleeding, pelvic pain, dysmenorrhea and secondary infertility. Furthermore, our passion to continuously stay on top of what is current in endoscopy leads to change our approaches and helps to find the optimal surgical treatment for isthmocele.

Never stop learning and improving!

Mario Franchini
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