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Isthmocele Repair: Counseling, Surgical Techniques & Complications

Faith Taylor • Updated Oct 30, 2024 • 33 hits

When treating isthmocele, gynecologists utilize a wide range of approaches based on symptom severity and patient reproductive goals. This variation in repair methods has led to a lack of standardization, resulting in inconsistent patient outcomes. To help close the gap, gynecologic surgeon Dr. Chuck Miller walks through his preferred isthmocele repair technique, covering strategies for both asymptomatic and symptomatic cases, and detailing the need for standardized treatment guidelines.

This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.

The BackTable OBGYN Brief

• For patients with an asymptomatic isthmocele, intervention is not needed unless they are actively trying to conceive. If the myometrium is thin, follow-up is necessary if pregnancy is being considered.

• Symptomatic patients with abnormal bleeding may benefit from surgical intervention or progesterone treatment. However if medical therapy fails and they are no longer interested in pregnancy, hysterectomy may be an option.

• There are multiple techniques for treating isthmocele, including ultrasound-guided suction D&C, robotic resection, and various surgical approaches.

• The choice between hysteroscopic and robotic approaches should be based on the thickness of the myometrium and the size of the defect to achieve optimal outcome

• Dr. Miller recommends an aggressive robotic-assisted resection of the isthmocele, which has led to higher pregnancy rates in his practice compared to traditional methods.

• Complications after isthmocele repair are rare. The primary risks include bleeding from uterine vessels, difficulty dissecting the bladder after multiple C-sections, and occasional infection or failure of repair.

• There is currently no consensus on optimal isthmocele treatment, highlighting the need for standardization.

Counseling Patients: Asymptomatic vs. Symptomatic Isthmocele

When counseling patients with isthmocele, a tailored approach is necessary based on symptoms and future reproductive plans. For patients with an asymptomatic isthmocele, Dr. Miller recommends no immediate intervention unless they are actively pursuing pregnancy or complications arise. If pursuing pregnancy, close follow-up is advised, especially if the myometrium above the defect is thin.

For symptomatic patients, particularly those experiencing abnormal bleeding, the approach is more proactive. Dr. Miller suggests medical management, such as progesterone therapy, as a first-line treatment. If medical therapy fails, surgical options like hysteroscopic or robotic/laparoscopic repair may be considered, depending on the severity of the defect and the patient's fertility goals. In cases where pregnancy is no longer a consideration, hysterectomy can also be an option, though it is rarely necessary.

[Dr. Amy Park]
I realized that people come to you because you're REI, but like for Mark, they're going to come to you with a C-section ectopic. How about the people who just have the abnormal bleeding and-- because they're like different scenarios where you're going to encounter this, how do you end up approaching that? Because it seems like they're different scenarios, the bleeding patient, the infertility patient, the asymptomatic patient. How would you counsel these patients?

[Dr. Chuck Miller]
I think that's great. In terms of counseling a patient who is really-- Let's take two examples of that. Patients coming in who are asymptomatic and for some reason you're doing a yearly scan, you're looking at this patient for something else, maybe a cyst in her ovary and all of a sudden you see a C-section defect. Obviously, unless that patient is actually looking to achieve pregnancy and has a thick myometrium above the C-section scar, I wouldn't do anything. That's an asymptomatic patient, even interested in pregnancy in the future, I wouldn't do anything. I'd talk to her about the fact that, "Look if you're having trouble, this is something that could be a factor."

If on the other hand, you notice that this is very, very thin myometrium, but she is asymptomatic, I would say to her, again, "I don't need to do anything now, but if you are attempting pregnancy, we need to have follow-up, okay? We need to have follow-up." The patient who is bleeding and is symptomatic, you can consider using progesterones on these people, there have been a couple papers that have suggested use of progesterone works very well, or follow the same type of approach that we do.

Obviously, if someone is not interested in pregnancy any longer, that patient is a candidate. If medical therapy does not work out, bring in hysterectomy. That patient is a candidate for a hysterectomy then. Obviously, we don't do that many, but you can. I don't see that many patients, but certainly if it is a thicker area, you can do this hysteroscopically and see how they do. If they're sitting on the fence, they are candidates for robotic or laparoscopic correction.

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Isthmocele Repair Techniques

A wide variety of surgical techniques are employed by different physicians to repair an isthmocele, as no single method is universally accepted. The choice of approach often depends on myometrial thickness and defect size. Patients with a smaller isthmocele or thicker myometrium may undergo hysteroscopic treatment, which involves shaving down the defect, while those with a larger isthmocele or thinner myometrial wall typically require a robotic-assisted resection.

Dr. Miller advocates for his method of an aggressive robotic-assisted resection, involving full-thickness removal of the isthmocele and multi-layered suturing through the endometrium. Initially, 3-0 sutures were employed, but after observing instances of failure, the technique was modified to utilize 0 sutures which led to a marked improvement. Compared to literature values Dr. Miller reported a significant increase in the percent of improved outcomes in both pregnancy and delivery rates when utilizing this technique in his practice.

[Dr. Amy Park]
Watching the videos, I was the program chair for SGS last year and the year before I was co-chair, so I watched a lot of videos and there's so many ways to treat it. There's ultrasound-guided suction D&C. There's robotic or laparoscopic resection. There's wedge resection. There's "take down the bladder" types. Do you use bulldog clamps? There's like a million different ways that I've seen. I've seen huge chunks of the uterus taken out. I've seen Foley placements. I've seen post-op estro-- I'm just curious, what are your thoughts?

[Dr. Chuck Miller]
I do it right. My technique is the right one.

[Dr. Amy Park]
[laughs]

[Dr. Chuck Miller]
Let's start off saying there's three general approaches. It is transvaginal and just to shave down the defect, that's hysteroscopic. There's transvaginal where you're actually going in and removing the defect. That's done a lot in Asia, much more performed in Asia than in the United States and Europe. We primarily-- If there's a lot of myometrium above the defect, we will shave. We'll do it hysteroscopically. If on the other hand that defect, again the myometrium is very thin, the defect is very large, we will do a robotic-assisted resection.

Now, it's really funny how I was presenting this at ESGE, European Society meeting, this year and I was accosted by a doctor whose fellow had presented on sustainability. I was doing a robotic isthmocele repair. Frank said to me that I don't understand sustainability because I can do this laparoscopically. You're Chuck Miller, you've been doing laparoscopic surgery for 40 years. I looked at him and I said, "Frank, I do this particular surgery better via the robot, and that is because I am one of these people who does a very wide excision on the isthmocele."

I take that entire isthmocele out, I go back on either side. I say, "I don't want to see a wedge. I want to see a round defect that I repair." You can imagine how much I'm resecting with this. Then I will put in a layer of suture that goes through and through, and those are interrupted mattresses. I generally put in four, one at each corner and then two between. I then take the long end of each of the end mattress sutures and run it to the other side.

Then I have another set of-- so those are mid-level sutures, and these are old PDS, and then I come and imbricate it with an old V-Loc suture. It is a real aggressive repair. One of the things that I've noted is if you look at literature, no one can get by about a 50% delivery rate at best, a 50% pregnancy rate and even lower delivery rate. We have been able to march that up much higher with this aggressive approach and found, Amy, that we've really not had failures with this since I changed it. It was really Artie, Mark, who said change the suture because we're using 3-0 and had some failure. It's when we went to the 0 and we went to through-and-through suture that the technique really has become just awesome for us and our patients.

[Dr. Amy Park]
0 PDS, you said series of interrupted mattress sutures for the--

[Dr. Chuck Miller]
The through and through the first layer.

[Dr. Amy Park]
What do you do for the endometrial cavity?

[Dr. Chuck Miller]
Yes, we go all the way through the endometrium. We do take down the bladder. We go all the way through and through the entire myometrium and the endometrium. We found when we left endometrium, we had more of a defect at the end. Different than what we do with myomectomy--

[Dr. Mark Hoffman]
As measured by ultrasound?

[Dr. Chuck Miller]
As measured by ultrasound, saline, yes, absolutely. All these patients, before I release them, I get salines on all of them, Mark. I found that when we went-- when we do myomectomies, Mark, we always teach about, "Stay above the endometrium, stay above the endometrium." This is just the opposite, go through the endometrium. We put in multiple-layer closure and they're thick sutures. Again, myomas, I always repair with 3-0. These are 0's.

[Dr. Mark Hoffman]
It's interesting. See, most people repair myomectomies with 2-0 or 0 V-Loc these days.

[Dr. Chuck Miller]
Yes, a lot of do, but we've never since my fellowship. That's a lot of myomectomies, dude. I repair with 3-0.

[Dr. Mark Hoffman]
No, I saw things working with you, I still don't think I've ever seen, but-- No, and before V-Loc, we were sewing everything. I was telling my fellow MIGS surgeons or my residents that happen to do running locked Vicryl to close these layers and then tying them, and they were just like--

[Dr. Amy Park]
It's like first layer, mattress sutures, then you're using 0 PDS, V-Loc or just running?

[Dr. Chuck Miller]
No, running. We're using the PDS ends and running to the other side and tying and running to the other side and tying. They're already placed. Okay? In my mattress, I tie the one end very short. I use 8-inch sutures and so I have length on one side. I sew a side, then run left to right and I run right to left, and I tie those.

[Dr. Amy Park]
Oh, like a little purse string, like this around?

[Dr. Chuck Miller]
Not a purse string, it's a running.

[Dr. Amy Park]
Running? Okay.

[Dr. Chuck Miller]
It's a running, but it's only partial thickness. I find that I keep folding in the defect more and more. Then my final layer is an imbrication with 0 V-Loc.

[Dr. Amy Park]
Okay.

[Dr. Chuck Miller]
We find that we really have-- generally at least we'll have about 6 to 7 millimeters of myometrium now that is functional. We do not see the fluid. We just do not see fluid.

[Dr. Amy Park]
That's interesting because I have seen these aggressive resections on videos and I'm like, "Oh my gosh, that uterus, there's nothing left. It's a big whack." Then, a couple of the videos I watched, they showed the follow-up imaging with either sonohyst or pelvic ultrasound and it looks fine. The uterus is such a forgiving organ.

[Dr. Chuck Miller]
Yes. Far different than the ovary, isn't it? [chuckles] Far different than the ovary or the tube.

[Dr. Amy Park]
It's like when you're talking about a 6-centimeter uterus that's non-gravid, no fibroids or whatever, and you're resecting that far back. I guess you're just taking out all the abnormal tissue.

[Dr. Chuck Miller]
Yes, and you're putting it-- and at the same time, you're lining the tissue up very nicely. It's not only that, it's just that you're bringing that healthy tissue together.

[Dr. Mark Hoffman]
I guess big picture with the uterus, it's normally 6 to 7 centimeters long. A gravid uterus, think about how big it gets, obviously. It's massive differences. Little bits here, I guess, it stretches, it overcomes that.

[Dr. Chuck Miller]
We are actually in the process of finally writing this up. My newest partner, my ex-fellow, Molly McKenna is writing up our data finally. We have nearly 200 cases. It's not a small number at all. I've been doing niches for a long time, at a time when, Mark, a lot of people in the country weren't doing them. I was a natural go-to. I'd see people from all over the country.

[Dr. Mark Hoffman]
I think we've all seen the C-section scar topics and pregnancies in that area and the repairs of those things. What you're doing is a more aggressive version of that, taking out that whole area. The one thing that I had a harder time understanding was the hysteroscopic resection. Because I think if we're talking about the defect being the issue, the fitness of the myometrium being the issue, how does shaving more or shaving cervix away improve things? That to me seemed to take a problem and make it bigger.

[Dr. Chuck Miller]
Great question. I'll tell you, there's a couple things that you're doing. First of all, you're shaving that defect down so that the fluid will come out of the cervix. Basically, what you're doing is you're shaving the caudal aspect. You're smoothing it out. You get the fluid coming out of the cervix. By the same token, number two is you're desiccating or excising the inflammatory tissue in the rest of the isthmocele. Basically, you're coming back to normal tissue.

Some people talk about simply shaving it down the caudal portion and desiccating the top. We go ahead and actually excise the cephalad side as well. We're not trying to shave it down, but we're trying to take out that tissue immediately next to the defect, which is the inflammatory tissue. We also do that at the top of the isthmocele. Now, Mark, we're not going to do that with a woman who has a 3-millimeter myometrium. That has to have a thick myometrium. It is a case that is very specific for us to do. It's that there's problems with fluid or there's problems with inflammation, there's problems with bleeding, and you're just going in to take away the inflammatory tissue and to give an exit for the fluid.

[Dr. Mark Hoffman]
You're using a resectoscope?

[Dr. Chuck Miller]
Yes. It's all done by a resectoscopy. Now it's interesting. Amy, I got to come back to one of the things you said. You mentioned some people put in a curette and curette out the area, and that's the way they treat C-section ectopics. The trouble with that treatment is you've still left the isthmocele. What we now do with ectopics and we now have not so many, we have probably about eight at this point that my team has done, and we go in and we'll do an isthmocele repair on the ectopic. We'll do that same repair and repair the isthmocele robotically or laparoscopically right at that time.

We've been able to follow up these patients. Most subsequently became pregnant successfully. Many of these isthmocele patients who have been longstanding fertility patients, Mark, get pregnant on their own because they're in the environment that the uterus is better. In this case, every one of these has had great repair, thick myometrium after their repair after a C-section ectopic. I truly believe-- We don't use bulldog clamps for these. We don't give them methotrexate. We take them back as soon as we realize that this is a C-section ectopic and go in, take out the pregnancy, and repair the uterus after the isthmocele has been resected.

[Dr. Mark Hoffman]
The ones I've done, the ones I've seen, I guess the true isthmocele repairs that I've done are those pregnancies, are those C-section scar ectopics. Open it up, evacuate it, cut up the edges and then do full thickness-- do a stitch all the way through and through bringing the thick muscle to the thick muscle. We haven't done a ton. I don't have a reproductive practice. I've got, "Hey, we got one ultrasound, we've got a patient with a C-section scar ectopic. You need to fix it."

Those are the ones we've done. I've been able to follow them and see them come back. The few that I've done, they've done great. They come back. They've had term pregnancies. You're always fingers crossed the pregnancy makes its way into the fundus or into the uterine cavity. That full-thickness closure, I guess, is not going to be that different than when you do it without the pregnancy. Sometimes there's not a whole lot of uterus left. When you get down and open these things up, you're sewing cervix to lower uterine segment. That can be tough.

[Dr. Chuck Miller]
Yes. That does happen, absolutely, more often than we'd like. That concerned me when I started doing these, because I was down to the cervix. I found that those repairs do very well. I think you can feel comfortable because, let's face it, some of those niches, some of those isthmoceles are because people have gone so low and actually have come into the cervix in terms of their repairs. That is actually one of the reasons why you're there in the first place, but they do well.

[Dr. Amy Park]
Mark mentioned this earlier, but I guess I got to circle back to the hysteroscopic resection. I'm assuming that it's just the niches, these uterine defects from a prior C-section and you're just removing the endometrium and ablating it and then trying to get rid of that abnormal area. Even though it's thinner in that area, the assumption is by getting rid of the abnormal endometrium, even though there's a myometrial defect, that it'll improve. Is there data to show that it's better with the more aggressive approach than the hysteroscopic approach?

[Dr. Mark Hoffman]
Are you getting endometrium when you resect those isthmoceles and you send them to path? What's pathology showing?

[Dr. Chuck Miller]
Yes. You're seeing endometritis, you're seeing some adeno, you're seeing inflammation, you're seeing fibrosis. Amy, the trouble with what you asked-- the problem with what you asked, "What is better, an aggressive approach, laparoscopic, robotic versus hysteroscopic?" they're really two different situations. I'm not going to do a hysteroscopic resection for a woman who has a thin myometrium, who has a huge isthmocele defect, just like I'm not going to do a robotic approach for a woman who has just a little area that is causing some fluid, but the myometrium itself is thick.

The other thing that happens is as I look because, again, I do salines on all these people, after you do the hysteroscopic approach, there is some remodeling. Now no one talks about that. No one talks about that. When I look back and I know that I've shaved this area, there is some remodeling. The myometrium looks thicker. The defect itself is smaller. I can't explain that. I just know what I see.

[Dr. Mark Hoffman]
Are you giving it two fresh edges to stick together?

[Dr. Chuck Miller]
Yes. Well, it's not written and that could be to a degree, but I don't know why. Again, with these patients-- and truth is, guys, we've seen marvelous pregnancy rates. When you look at the pregnancy rates in a publication of people doing hysteroscopic approach, there's a guy by the name of Gambini who talks about 41 patients and 41 pregnancies. That may be a little bit-- [laughs] that may be a little bit exciting, but I'm sure the pregnancy rate is good and you will examine other literature, you see excellent pregnancy rates with this technique, but it is in a very special population, one that does not lend itself to a laparoscopic or you don't need to do a laparoscopic approach, I should say.

Isthmocele Repair Complications

Post-operative complications following isthmocele repair are generally minimal due to the forgiving nature of the uterus. The primary risks include potential bleeding during dissection near the uterine vessels and complications with the bladder, particularly in patients with multiple C-sections. There is also the possibility of a failed repair, where the niche remains, but with more aggressive surgical techniques, such failures are rare. Other potential risks include infections and endometritis, but overall, the procedure is considered safe.

[Dr. Mark Hoffman]
What's the future look like for this? I think we talk about diagnosis, we talk about treatment options. What's on the horizon?

[Dr. Chuck Miller]
I think standardization, Mark. I think like anything else-- the one thing that disappoints me about surgery and continues to disappoint me about surgery, and that is we've never grasped best practices. We've never really been willing for all of us to get into the sandbox and play together and figure out best practices. There's so many studies available. You're going to end up-- Hopefully, we will be published. You're going to get my technique of doing this. Like Amy said, she was head of SGS and the program and she saw a million presentations, a million different ways stepped right up. There's got to be consensus. We got to be able to introduce consensus.

[Dr. Mark Hoffman]
We can joke about it, but we asked you, "How'd you do it?" and you said, "The right way, my way."

[Dr. Chuck Miller]
Yes.

[Dr. Mark Hoffman]
Part of what we see at AAGL is a lot of pioneers, a lot of people doing things that we're told couldn't be done. These are people and I won't-- I think ego is a bad word in many circles. I think when you have people who have worked very hard and have learned a lot and have become experts, I think you have some justification in talking about a topic with some semblance of authority, but a lot of people have that same authority, in a room like that, have very different opinions. Consensus becomes a challenge in an environment like that.

[Dr. Chuck Miller]
You're absolutely right, but it is something that we could get. If you got a number of people who do this procedure very often and sat them in a room and talked through a protocol, I think it would be worthwhile. I kid about the fact that my way is the best way. I have some numbers that support that, but nevertheless, I would listen to someone say to me, "Could we modify it this way? Could we do this? Why don't we do this? Compare this to that." I would love to be able to have a standard way of proceeding with these. My gosh, just like we do hysterectomy.

[Dr. Mark Hoffman]
We don't have a standardization for C-section. How long have we've been doing those?

[Dr. Chuck Miller]
Now, that's true, but we do, everybody-- we may have-- you may do something from the contralateral side or the ipsilateral side, but we all basically do a similar technique to hysterectomy. We really have improved the steps.

[Dr. Amy Park]
C-section, there's a Green Journal article on standardized, like evidence-based C-section. It was all the things that I talked about, like not doing sharp, doing blunt, not doing the bladder flap, don't close the peritoneum. All these things that I was like, "Man, I can tell I have not done obstetrics in a long time." I talked to the residents in there-- Yes, and I don't want to, but it's like there's all kind of things. I saw a really good-- it was like Chinese article in the Green Journal about treatment of-- I can't remember, I think it was C-section scar. They had like criteria, the size, the beta, laparoscopic, vaginal, whatever, and I thought it was quite good.

[Dr. Chuck Miller]
I remember the article, if it's the same article you're referring to, they did some of these C-section-- this was a C-section ectopic study.

[Dr. Amy Park]
Yes.

[Dr. Chuck Miller]
They did talk about going up into the isthmocele with energy and resecting with a loop resectoscope. My God, that scares the hell [laughs] out of me. The thing that I also found in that article was their follow-up in patients was quite low. Yes, there are a lot of techniques, but then what is the follow-up? What are they doing? What's the pregnancy rate? What are we doing with bleeding? That's what I mean by best practices. I think all of us in surgery, somewhere along the line, have to start playing in the sandbox better. We really do.

[Dr. Amy Park]
Yes, I just looked up real quick, I love the internet, it was from May 2023, Green Journal, Dan et al. They looked at almost 1,000 women with first trimester C-section ectopic. Then they used a clinical classification based on thickness and gestational sac diameter. An optimal surgical option for each type was recommended, and they looked at the overall success rate of first-line treatment with new classification grouping, it was 97.5%.

It was basically the anterior myometrial thickness of the scar and diameter of gestational sac were confirmed to be independent risk factors for intra-op hemorrhage during C-section ectopic pregnancy treatment. They did try and do criteria, and then they had nice pictures in this article, and they classified it types A1, 2A, 2B, 3A, 3B, so it was interesting.

[Dr. Chuck Miller]
It is interesting. In my mind, here's your chance to treat the patient and to excise the isthmocele. That's why my way of looking at this is that hysteroscopic is not the way to go, but rather a laparoscopic excision like you had talked about, Mark, is in my mind the best way because you're treating the isthmocele at the same time. If I remember correctly, and again I don't have it in front of me, I'm not as savvy as your generation is in terms of being able to pluck articles in a moment. If I remember, a lot of these patients did not come back for subsequent repair. I would be concerned about a lady who has an ectopic that you evacuate and then say, "Go get pregnant again." That'd be concerning to me.

[Dr. Amy Park]
Yes, I don't think they talk specifically about the follow-up rate here.

[Dr. Mark Hoffman]
This is your chance, Chuck. Next time you go to AAGL in the fall, you can [crosstalk]

[Dr. Chuck Miller]
As soon as I get my thousandth ectopic, Mark. [laughs]

[Dr. Mark Hoffman]
You won't need to if you get our buddies around the country to come up with a way. Doesn't have to be the right way, just has to be a way that we-

[Dr. Chuck Miller]
A way.

[Dr. Mark Hoffman]
-can track. Then you have a baseline. Then you can make adjustments and compare that to some baseline that was consensus, which is not the highest form of research, but then you use that as a baseline, but yes standardization, because we're all using different techniques.

[Dr. Chuck Miller]
I'm learning from Philip Connix about Bayesian analysis in terms of the hypothesis, et cetera. It may be something that we're going to, that we're doing expert thought, because people obviously are getting more and more and more experience, and start off with people and then build on the hypothesis. There may be something to Bayesian analysis. He may be right.

[Dr. Amy Park]
We had Brett Einerson from University of Utah, who does all this amazing research on placenta accreta spectrum. I asked him about C-section topic. He said, "Thank you for taking care of placenta accreta prior to its formation, because it's part of placenta accreta spectrum, basically, first trimester." Early treatment is obviously better than having placenta accreta. In the remodeling data that's coming around, talking about his data and his research, it's like the way the uterus remodels around the scar is the main problem.

[Dr. Mark Hoffman]
If you do these, and if you take these out, you see the defect. It's there, and to take it out and take the pregnancy out or even suction it out, and not repair the defect, and to Chuck's point, I think when you've done a few of these and you see the defect that's left behind with the Cesarean scar pregnancies and what was there before, you've got to close that space. This is a giant hole in the lower uterine segment. It's like a bomb went off. Even the ones that are very early, when you're not-- the ones we've done for the most part, we catch them early enough, the blood loss is 10 cc's. They're not a huge, bloody procedure, but the defect is significant even in the smallest, earliest ones.

[Dr. Chuck Miller]
And so thin.

[Dr. Mark Hoffman]
Oh, it's paper thin.

[Dr. Chuck Miller]
Yes.

[Dr. Mark Hoffman]
Basically, it's the outer layer of the uterus. We're in front of the serosa, but a very thin myometrial layer, and then just nothing. Yes, to leave that open and just close it over. Yes, I would do full thickness and then imbricate a layer over top of that. Again, not because I learned the right way to do it, because you do some research and read a few articles and try to figure it out, because the data just wasn't there.

Standardization in Isthmocele Treatment

Despite a wealth of studies and individual expertise, a uniform approach to isthmocele repair remains elusive. Regarding future directions, Dr. Miller advocates for the standardization of surgical techniques in the management of isthmocele. Consensus in isthmocele repair can be particularly challenging due to the diversity of expert opinions and individualized approaches within the surgical community. However, establishing standardized guidelines would provide consistency in clinical practice, reduce variability in patient outcomes, and contribute to better reproductive health management.

[Dr. Mark Hoffman]
What's the future look like for this? I think we talk about diagnosis, we talk about treatment options. What's on the horizon?

[Dr. Chuck Miller]
I think standardization, Mark. I think like anything else-- the one thing that disappoints me about surgery and continues to disappoint me about surgery, and that is we've never grasped best practices. We've never really been willing for all of us to get into the sandbox and play together and figure out best practices. There's so many studies available. You're going to end up-- Hopefully, we will be published. You're going to get my technique of doing this. Like Amy said, she was head of SGS and the program and she saw a million presentations, a million different ways stepped right up. There's got to be consensus. We got to be able to introduce consensus.

[Dr. Mark Hoffman]
We can joke about it, but we asked you, "How'd you do it?" and you said, "The right way, my way."

[Dr. Chuck Miller]
Yes.

[Dr. Mark Hoffman]
Part of what we see at AAGL is a lot of pioneers, a lot of people doing things that we're told couldn't be done. These are people and I won't-- I think ego is a bad word in many circles. I think when you have people who have worked very hard and have learned a lot and have become experts, I think you have some justification in talking about a topic with some semblance of authority, but a lot of people have that same authority, in a room like that, have very different opinions. Consensus becomes a challenge in an environment like that.

[Dr. Chuck Miller]
You're absolutely right, but it is something that we could get. If you got a number of people who do this procedure very often and sat them in a room and talked through a protocol, I think it would be worthwhile. I kid about the fact that my way is the best way. I have some numbers that support that, but nevertheless, I would listen to someone say to me, "Could we modify it this way? Could we do this? Why don't we do this? Compare this to that." I would love to be able to have a standard way of proceeding with these. My gosh, just like we do hysterectomy.

[Dr. Mark Hoffman]
We don't have a standardization for C-section. How long have we've been doing those?

[Dr. Chuck Miller]
Now, that's true, but we do, everybody-- we may have-- you may do something from the contralateral side or the ipsilateral side, but we all basically do a similar technique to hysterectomy. We really have improved the steps.

[Dr. Amy Park]
C-section, there's a Green Journal article on standardized, like evidence-based C-section. It was all the things that I talked about, like not doing sharp, doing blunt, not doing the bladder flap, don't close the peritoneum. All these things that I was like, "Man, I can tell I have not done obstetrics in a long time." I talked to the residents in there-- Yes, and I don't want to, but it's like there's all kind of things. I saw a really good-- it was like Chinese article in the Green Journal about treatment of-- I can't remember, I think it was C-section scar. They had like criteria, the size, the beta, laparoscopic, vaginal, whatever, and I thought it was quite good.

[Dr. Chuck Miller]
I remember the article, if it's the same article you're referring to, they did some of these C-section-- this was a C-section ectopic study.

[Dr. Amy Park]
Yes.

[Dr. Chuck Miller]
They did talk about going up into the isthmocele with energy and resecting with a loop resectoscope. My God, that scares the hell [laughs] out of me. The thing that I also found in that article was their follow-up in patients was quite low. Yes, there are a lot of techniques, but then what is the follow-up? What are they doing? What's the pregnancy rate? What are we doing with bleeding? That's what I mean by best practices. I think all of us in surgery, somewhere along the line, have to start playing in the sandbox better. We really do.

[Dr. Amy Park]
Yes, I just looked up real quick, I love the internet, it was from May 2023, Green Journal, Dan et al. They looked at almost 1,000 women with first trimester C-section ectopic. Then they used a clinical classification based on thickness and gestational sac diameter. An optimal surgical option for each type was recommended, and they looked at the overall success rate of first-line treatment with new classification grouping, it was 97.5%.

It was basically the anterior myometrial thickness of the scar and diameter of gestational sac were confirmed to be independent risk factors for intra-op hemorrhage during C-section ectopic pregnancy treatment. They did try and do criteria, and then they had nice pictures in this article, and they classified it types A1, 2A, 2B, 3A, 3B, so it was interesting.

[Dr. Chuck Miller]
It is interesting. In my mind, here's your chance to treat the patient and to excise the isthmocele. That's why my way of looking at this is that hysteroscopic is not the way to go, but rather a laparoscopic excision like you had talked about, Mark, is in my mind the best way because you're treating the isthmocele at the same time. If I remember correctly, and again I don't have it in front of me, I'm not as savvy as your generation is in terms of being able to pluck articles in a moment. If I remember, a lot of these patients did not come back for subsequent repair. I would be concerned about a lady who has an ectopic that you evacuate and then say, "Go get pregnant again." That'd be concerning to me.

[Dr. Amy Park]
Yes, I don't think they talk specifically about the follow-up rate here.

[Dr. Mark Hoffman]
This is your chance, Chuck. Next time you go to AAGL in the fall, you can [crosstalk]

[Dr. Chuck Miller]
As soon as I get my thousandth ectopic, Mark. [laughs]

[Dr. Mark Hoffman]
You won't need to if you get our buddies around the country to come up with a way. Doesn't have to be the right way, just has to be a way that we-

[Dr. Chuck Miller]
A way.

[Dr. Mark Hoffman]
-can track. Then you have a baseline. Then you can make adjustments and compare that to some baseline that was consensus, which is not the highest form of research, but then you use that as a baseline, but yes standardization, because we're all using different techniques.

[Dr. Chuck Miller]
I'm learning from Philip Connix about Bayesian analysis in terms of the hypothesis, et cetera. It may be something that we're going to, that we're doing expert thought, because people obviously are getting more and more and more experience, and start off with people and then build on the hypothesis. There may be something to Bayesian analysis. He may be right.

[Dr. Amy Park]
We had Brett Einerson from University of Utah, who does all this amazing research on placenta accreta spectrum. I asked him about C-section topic. He said, "Thank you for taking care of placenta accreta prior to its formation, because it's part of placenta accreta spectrum, basically, first trimester." Early treatment is obviously better than having placenta accreta. In the remodeling data that's coming around, talking about his data and his research, it's like the way the uterus remodels around the scar is the main problem.

[Dr. Mark Hoffman]
If you do these, and if you take these out, you see the defect. It's there, and to take it out and take the pregnancy out or even suction it out, and not repair the defect, and to Chuck's point, I think when you've done a few of these and you see the defect that's left behind with the Cesarean scar pregnancies and what was there before, you've got to close that space. This is a giant hole in the lower uterine segment. It's like a bomb went off. Even the ones that are very early, when you're not-- the ones we've done for the most part, we catch them early enough, the blood loss is 10 cc's. They're not a huge, bloody procedure, but the defect is significant even in the smallest, earliest ones.

[Dr. Chuck Miller]
And so thin.

[Dr. Mark Hoffman]
Oh, it's paper thin.

[Dr. Chuck Miller]
Yes.

[Dr. Mark Hoffman]
Basically, it's the outer layer of the uterus. We're in front of the serosa, but a very thin myometrial layer, and then just nothing. Yes, to leave that open and just close it over. Yes, I would do full thickness and then imbricate a layer over top of that. Again, not because I learned the right way to do it, because you do some research and read a few articles and try to figure it out, because the data just wasn't there.

Podcast Contributors

Dr. Chuck Miller

Dr. Charles (Chuck) Miller is the president and founder of the Advanced IVF Institute and the Advanced Gynecologic Surgery Institute in Naperville, Illinois.

Dr. Amy Park

Dr. Amy Park is the Section Head of Female Pelvic Medicine & Reconstructive Surgery at the Cleveland Clinic, and a co-host of the BackTable OBGYN Podcast.

Dr. Mark Hoffman

Dr. Mark Hoffman is a minimally invasive gynecologic surgeon at the University of Kentucky.

Cite This Podcast

BackTable, LLC (Producer). (2024, April 2). Ep. 50 – Decoding Isthmocele: Causes and Considerations [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.