Commentary
The abnormal bleeding is often described by patients as spotting or bleeding that continues for days or weeks after menstrual flow has ended; it is believed to result from an accumulation of blood in the defect and a lack of coordinated muscle contractions, which leads to continued accumulation of blood and menstrual debris. Dysmenorrhea and chronic pelvic pain are thought to be associated with iatrogenic adenomyosis and/or a chronic inflammatory state created when accumulated blood and mucus are intermittently expelled. Secondary infertility can occur, it is believed, as accumulated fluid and blood interfere with the endocervical and even the endometrial environment and disrupt sperm transport, sperm quality, and embryo implantation. Difficulty in embryo transfer may also occur because of the distortion caused to the endometrial cavity. Many of the isthmoceles that we and others have diagnosed have been in patients undergoing invitro fertilization. The patients are often found to have an accumulation of fluid in the endometrial canal and isthmocele during stimulation for either a fresh or frozen embryo transfer, thus necessitating the cancellation of their cycle.
Treatment
The choice of treatment depends upon the patient’s symptoms and desire for future fertility, but it can include hormonal treatment, hysteroscopic resection, transvaginal repair, a laparoscopic or robot-assisted approach, and hysterectomy.
Little has been published on nonsurgical treatment, but this may be considered for patients whose primary symptoms are bleeding or pain and who desire the least invasive option. In a small observational study of women with an isthmocele and bleeding, symptoms were eliminated with several cycles of oral contraceptive pills (Fertil. Steril. 2006;86: 477-9).
Courtesy of Dr. Kirsten Sasaki
Robot-assisted isthmocele resection.
Hysteroscopic isthmocele correction or resection are the surgical techniques most frequently described in the literature, but, as with other surgical approaches, studies are small. Hysteroscopic repair has typically involved the use of electrical energy to desiccate or cauterize abnormal tissue and eliminate the outpouching in which blood and fluid accumulate. Hysteroscopic resection is another technique that has also been championed.
However, for patients who desire future pregnancy, we do not recommend a hysteroscopic approach because it does not reinforce the often-thinning myometrium covering the defect. We are concerned that if this area is simply desiccated or resected, and not reapproximated, the patient will be at greater risk of pregnancy-related complications, including cesarean scar ectopic pregnancy with potential uterine dehiscence.
Laparoscopic repair was first described by Dr. Olivier Donnez, who rightly pointed out that the laparoscopic approach offers an optimal view from above during dissection of the vesico-vaginal space. Dr. Donnez used a CO2 laser to excise fibrotic tissue, followed by laparoscopic closure (Fertil. Steril. 2008;89:974-80).
We have had success with a laparoscopic approach that uses concomitant hysteroscopy. The vesico-uterine peritoneum is incised over the anterior uterine wall, and the bladder is backfilled so that its boundaries may be identified prior to further dissection. With the area exposed, we perform a hysteroscopy to determine the exact location of the isthmocele. As the hysteroscope enters the thinned out isthmocele, the light will be more visible via laparoscopic visualization.
When performing conventional laparoscopy, the isthmocele is excised with an ultrasonic curved blade. We use this instrument because it has no opposing arm and because it enables precise tissue dissection in multiple planes. With harmonic energy, we can limit tissue dessication and destruction, lowering the risk of future pregnancy-related complications. Monopolar scissors are best when a robotic approach is used.
Once the isthmocele is resected, the clean edges are sutured together in two layers. The first layer is sutured in an interrupted mattress-style fashion, to prevent tissue strangulation and necrosis. We use a monofilament nonbarbed delayed-absorbable 3-0 PDS suture on a CT-1 needle – a choice that limits tissue trauma and postoperative inflammation.
Courtesy of Dr. Kirsten Sasaki
Robot-assisted repair of isthmocele resection.
Sutures are initially placed at each angle with one or two sutures placed between. These sutures must be placed deep to close the bottom of the defect. A second layer of suture is then placed to imbricate over the initial layer of closure. We utilize 3-0 PDS in a running or mattress style, or a running 3-0 V-Loc suture. Our patients return after 1-3 months for a postoperative image, and are instructed to wait at least 3 months after surgery before attempting conception.
In our experience, of more than 10 patients, symptoms ceased in all patients whose surgery was performed for the indication of abnormal uterine bleeding. The follow-up on our series of patients who underwent the procedure for secondary infertility is ongoing, but the preliminary results are very positive, with resolution of intrauterine fluid in all of the patients, as well as several successful pregnancy outcomes.