The effect of isthmocele size on symptoms in the postoperative period of symptomatic isthmocele patients admitted to OUR clinic

Aim: Isthmocele, also known as a niche, is a pouch-like form encountered on the previous scar line based on delivery by cesarean section. It may progress asymptomatically or symptomatically. Symptomatic patients may seek treatment for the reasons such as pelvic pain, spotting between two menstrual cycles, postcoital bleeding, dysmenorrhea, dyspareunia, and secondary infertility. The treatment is medical or surgical; various surgical procedures have been adopted and their superiorities over one another have been discussed in recent years. Our study aims to evaluate the hysteroscopic (H/S) approach implemented on patients with advanced-stage isthmocele and contribute to the literature to reveal its impact on the symptoms. Patients and Method: A total of 47 patients who sought medical advice in the Gynecology and Obstetrics Clinic in the Faculty of Medicine at Ondokuz Mayıs University between the dates of January 2014 and June 2022 with symptoms of isthmocele and were diagnosed with Grade 3 Isthmocele during medical examinations conducted and treated with scar repair through the H/S approach were retrospectively examined in our study upon receiving the ethics committee approval. The preoperative and postoperative symptoms, quality of life changes, and analgesic uses of the patients were recorded. Pain intensities of the patients were evaluated by scoring between 1-10 through the VAS (Visual Analog Scale). The quality of life was evaluated through SF-36 scoring. The isthmocele surface area was recorded through TVUSG. Only the patients matching with Grade 3 (base x height/2 >25 mm2) isthmocele as a result of the measurements were included in the study by using the classification proposed by Gubbini et al. (1), and the study was divided into two patient groups being above and below 36, the median. Patients between 18 and 45 years of age who were diagnosed with symptomatic Grade 3 Isthmocele and anteverted uterus (the anterior deviation of the long axis of the uterus endometrial cavity over the axis of the cervix) position and residual myometrial thickness of >2.5mm and also did not have an expectancy of pregnancy but did not prefer the hormonal methods of contraception were included in the study. Patients under 18 years of age, patients with ongoing pregnancies, those operated on under emergency conditions (cervical dilation was established as 4 cm and above), and those with (suspicious) malignancies, levonorgestrel intrauterine devices (IUDs), and extra-uterine pathologies were excluded from the study. The cavity was dilated through saline and isthmoplasty was performed through H/S. Findings: Although dyspareunia, dysmenorrhea, duration of menstruation and postmenstrual spotting, and analgesic use did not vary across the two groups, a negative statistically significant correlation was obtained between the significant isthmocele values of the postoperative symptoms and values of the quality of life changes and the correlation coefficient was attained as -0.338 (p=0.020). No statistically significant difference was found between the size of the isthmocele and other variables (p>0.050). Conclusion: In light of the data obtained, the H/S has been an effective method in patients with Grade 3 Isthmocele and a distinct remission has been observed in the symptoms of the patients. The quality of life of the patients has gotten worse as the size of the isthmocele has gotten larger and the surgical method has become efficient. All surgical approaches must be conducted by evaluating the factors such as patient selection, complications, cost, and the ease of procedure together, and prospective data with larger series are required in order to determine the best approach. Keywords: isthmocele, hysteroscopy, postmenstrual spotting, pelvic pain