The surgical treatment of isthmocele aims to avoid retention of menstrual blood at the level of the defect, eliminating post-menstrual spotting pattern and its consequences. The hysteroscopic approach is a symptomatic treatment, while laparoscopic or vaginal treatment aims to repair the defect, so are considered a restorative treatment. As a general rule, it is accepted that in cases in which the residual myometrium thickness at the level of the isthmocele is greater than 3 mm, the hysteroscopic approach is an adequate and safe option. However, if the endometrial thickness at this level is less than 3 mm, the laparoscopic approach should be preferred because of the risk of uterine perforation and allows to restore the uterine wall at that level.
After surgical treatment, a new questions arise, such as whether a spontaneous vaginal delivery is safe after the completion of the isthmoplasty. The recommendation of the Global Congress of Hysteroscopy Research Committee is the to perform an elective cesarean section no later than week 38 of gestation due to the risk of uterine rupture.
It is important to bear in mind that post-menstrual bleeding in patients with a previous caesarean section may be related to the presence of an isthmocele and that they can also cause secondary infertility. It is also important to remember that the only treatment of this condition is surgical and that hormonal treatments do not solve the problem.
Dearest
I agree on the surgical indication in the surgical treatment of isthmocele. In my experience I continue to treat all isthmoceles with resectoscopic technique even when which the residual myometrium thickness is less than 3 mm. This is possible and correct, without uterine perforation or damage of the bladder, if we use a procedure with miniaturized instruments that do not require dilation of the cervical canal.It is also important to work in the fovea, very gently, using only the roller with vaporization technique (thermal damage less than 1 mm.!) After treatment Hysteroscopic surgery is also possible a vaginal delivery in the same way that it is possible after a caesarean section (read the Guidelines)