Symptom relief through hysteroscopic treatment in patients with isthmocele: a retrospective single-center study

BACKGROUND: Isthmocele is a defect in the myometrium at the site of a previous uterine scar. It often presents with intermenstrual bleeding, dysmenorrhea, chronic pelvic pain, and secondary infertility, affecting patients' quality of life (QoL). The treatment of symptoms includes medical therapy and minimally invasive surgical approaches, such as hysteroscopic isthmoplasty. The aim of this study was to evaluate the efficacy of hysteroscopic isthmoplasty in treating isthmocele-related symptoms. The primary outcome was improvement of intermenstrual bleeding, primarily assessed as a reduction in symptom intensity. The impact of isthmoplasty on pelvic pain, dysmenorrhea, dyspareunia, obstetric outcomes, and improvement in QoL was also assessed. METHODS: The single-center observational study, conducted at Mauriziano Hospital, Turin, Italy, included women who underwent hysteroscopic isthmoplasty for intermenstrual bleeding between 2018 and 2023, performed in an outpatient setting without anesthesia. The median follow-up was 54 months. Clinical and medical history data were collected using a specific questionnaire. The intensity of symptoms was evaluated through the Numerical Rating Scale item (NRS). RESULTS: We included 32 patients (mean age 44 years). Hysteroscopic isthmoplasty was associated with symptom improvement in most patients: 56.3% of women reported no more intermenstrual bleeding, and the other 43.7% reported a decrease in its intensity (from 7.14 to 4.07 on NRS, P<0.01). The frequency of dysmenorrhea (from 71.9% to 46.9%) and non-hematic vaginal discharge (from 53.1% to 18.7%) decreased. QoL improved, with resolution of self-esteem issues where present (from 31.2% to 0%). No severe complications were reported. No statistically significant differences were observed between laser and bipolar techniques; however, this comparison was exploratory, and the study was not powered to detect differences between surgical approaches. CONCLUSIONS: Hysteroscopic isthmoplasty in an outpatient setting is an effective and well-tolerated procedure to treat isthmocele-related symptoms. However, the retrospective design and small sample size warrant caution in interpreting the findings. Larger prospective studies are needed to confirm these results.