Postoperative morphologic changes of the isthmocele and clinical impact in patients treated by channel-like (360°) hysteroscopic technique

Paolo Casadio; Antonio Raffone; Andrea Alletto; Francesco Filipponi; Diego Raimondo; Alessandro Arena; Mariangela La Rosa; Agnese Virgilio; Camilla Franceschini; Giampietro Gubbini; Mario Franchini; Roberto Paradisi; Jacopo Lenzi; Antonio Travaglino; Antonio Mollo; Josè Carugno; Renato Seracchioli

doi:10.1002/ijgo.14387

Postoperative morphologic changes of the isthmocele and clinical impact in patients treated by channel-like (360°) hysteroscopic technique

Int J Gynaecol Obstet. 2023 Jan;160(1):326-333. doi: 10.1002/ijgo.14387. Epub 2022 Aug 23.

Authors

Paolo Casadio¹, Antonio Raffone^{1

2}, Andrea Alletto^{1

2}, Francesco Filipponi^{1

2}, Diego Raimondo¹, Alessandro Arena^{1

2}, Mariangela La Rosa^{1

2}, Agnese Virgilio^{1

2}, Camilla Franceschini^{1

2}, Giampietro Gubbini³, Mario Franchini⁴, Roberto Paradisi¹, Jacopo Lenzi⁵, Antonio Travaglino⁶, Antonio Mollo⁷, Josè Carugno⁸, Renato Seracchioli^{1

2}

Affiliations

¹ Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.
² Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
³ Department of Gynecology, Madre Fortunata Toniolo Clinic, Bologna, Italy.
⁴ Department of Obstetrics and Gynecology, Tuscany Health Agency, Florence, Italy.
⁵ Section of Hygiene, Public Health and Medical Statistics, Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy.
⁶ Anatomic Pathology Unit, Department of Advanced Biomedical Sciences, School of Medicine, University of Naples Federico II, Naples, Italy.
⁷ Gynecology and Obstetrics Unit, Department of Medicine, Surgery and Dentistry "Schola Medica Salernitana", University of Salerno, Baronissi, Italy.
⁸ Obstetrics, Gynecology and Reproductive Science Department, University of Miami, Miller School of Medicine, Miami, Florida, USA.

Abstract

Objective: To evaluate the changes in (1) residual myometrial thickness (RMT), (2) cesarean scar defect (CSD) size, and (3) clinical symptoms, before and after channel-like (360°) hysteroscopic resection for the treatment of CSD.

Methods: A single-center, observational, prospective, cohort study was carried out enrolling all symptomatic patients of childbearing age, diagnosed with CSD and routinely scheduled for channel-like (360°) hysteroscopic resection from July 2020 to July 2021 at the Division of Gynecology and Human Reproduction Physiopathology, Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Univeristaria di Bologna. University of Bologna, Italy. The primary outcome was the difference in mean RMT before and after the procedure. Secondary outcomes were the differences before and 4 months after the surgery in: (1) CSD size measured by transvaginal ultrasound, (2) visual analog scale (VAS) scores for the symptoms, and (3) abnormal uterine bleeding (AUB) rate. Lastly, patients' satisfaction was assessed by the global impression of improvement (PGI-I) score.

Results: We found a significant difference before and after the procedure in: (1) mean RMT (+2.0 mm; P < 0.001); mean size of the CSD (base: +1.6 mm; height: -2.5 mm; transverse diameter: -3.2 mm; volume: -263.7 mm³ ; P < 0.001); (2) mean VAS score for dyspareunia (-5.84; P < 0.001), dysmenorrhea (-8.94; P < 0.001), pelvic pain (-2.94; P < 0.001); (3) AUB rate (91% vs. 3%; P < 0.001). Lastly, the mean PGI-I score ± SD was 1.7 ± 0.9.

Conclusion: Channel-like (360°) hysteroscopic resection for the treatment of patients with symptomatic CSD may lead to an increase in RMT, decrease in CSD, and improvement of symptoms after the procedure, with high patient satisfaction.

Keywords: bleeding; cesarean section; cesarean section scar; defect; hysteroscopy; isthmocele; metroplasty; niche; pain; treatment; uterus.

MeSH terms

Cesarean Section / adverse effects
Cicatrix / pathology
Cicatrix / surgery
Cohort Studies
Female
Humans
Hysteroscopy* / methods
Pregnancy
Prospective Studies
Treatment Outcome
Uterine Diseases* / surgery