Podcast Transcript: Decoding Isthmocele: Causes and Considerations

[Dr. Amy Park]
-in all the meetings. 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-

[Dr. Chuck Miller]
Yes.

[Dr. Mark Hoffman]
-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-

[Dr. Chuck Miller]
Right.

[Dr. Amy Park]
-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.

[Dr. Mark Hoffman]
Wow.

[Dr. Chuck Miller]
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-

[Dr. Mark Hoffman]
Bipolar?

[Dr. Chuck Miller]
-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.