Salvatore Giovanni Vitale1, Artur Ludwin2,3, George Angelos Vilos4, Péter Török5, Jan Tesarik6, Amerigo Vitagliano7, Ricardo Bassil Lasmar8, Benito Chiofalo9. 1. Obstetrics and Gynecology Unit, Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy. sgvitale@unict.it. 2. Department of Gynecology and Oncology, Jagiellonian University, Krakow, Poland. 3. Ludwin & Ludwin Gynecology, Private Medical Center, Krakow, Poland. 4. Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada. 5. Faculty of Medicine, Institute of Obstetrics and Gynaecology, University of Debrecen, Debrecen, Hungary. 6. MARGen Clinic, Granada, Spain. 7. Unit of Gynecology and Obstetrics, Department of Women and Children's Health, University of Padua, Padua, Italy. 8. Department of Surgery and Specialities, Federal Fluminense University, Niterói, Brazil. 9. Gynecologic Oncology Unit, Department of Experimental Clinical Oncology, IRCCS Regina Elena National Cancer Institute, Rome, Italy.
Abstract
PURPOSE: To investigate the effectiveness and risks of different surgical therapies for isthmocele in symptomatic women with abnormal uterine bleeding, infertility, or for the prevention of obstetric complications, considering safety and surgical complications. METHODS: PubMed/MEDLINE, Scopus, Embase, Science Direct, and Cochrane Library were systematically searched (n° CRD4201912035) for original articles on the surgical treatment of isthmocele published between 1950 and 2018. Data synthesis was completed using MedCalc 16.4.3. The body of evidence was assessed using the GRADE methodology. RESULTS: We retrieved 33 publications: 28 focused on a single surgical technique, and five comparing different techniques. Meta-analysis showed an improvement of symptoms in 85.00% (75.05-92.76%) of women after hysteroscopic correction, 92.77% (85.53-97.64%) after laparoscopic/robotic correction, and 82.52% (67.53-93.57%) after vaginal correction. Hysteroscopic surgery was associated with the lowest risk of complications (0.76%, 0.20-1.66%). CONCLUSIONS: We found adequate evidence supporting the use of surgery for the treatment of symptomatic isthmocele, as it was found to improve the bleeding symptoms in more than 80% of patients. Differently, we found a lack of evidence regarding the role of surgery with the purpose of improving fertility or reducing the risk of obstetric complications in women with asymptomatic isthmocele. The hysteroscopic correction of isthmocele may be the safest and most effective strategy in those patients with adequate residual myometrial thickness overlying the isthmocele. Laparoscopic and vaginal surgeries may be the preferred options for patients with a thinner residual myometrium over the defect (< 2.5 mm) and when hysteroscopic treatment is inconclusive.
PURPOSE: To investigate the effectiveness and risks of different surgical therapies for isthmocele in symptomatic women with abnormal uterine bleeding, infertility, or for the prevention of obstetric complications, considering safety and surgical complications. METHODS: PubMed/MEDLINE, Scopus, Embase, Science Direct, and Cochrane Library were systematically searched (n° CRD4201912035) for original articles on the surgical treatment of isthmocele published between 1950 and 2018. Data synthesis was completed using MedCalc 16.4.3. The body of evidence was assessed using the GRADE methodology. RESULTS: We retrieved 33 publications: 28 focused on a single surgical technique, and five comparing different techniques. Meta-analysis showed an improvement of symptoms in 85.00% (75.05-92.76%) of women after hysteroscopic correction, 92.77% (85.53-97.64%) after laparoscopic/robotic correction, and 82.52% (67.53-93.57%) after vaginal correction. Hysteroscopic surgery was associated with the lowest risk of complications (0.76%, 0.20-1.66%). CONCLUSIONS: We found adequate evidence supporting the use of surgery for the treatment of symptomatic isthmocele, as it was found to improve the bleeding symptoms in more than 80% of patients. Differently, we found a lack of evidence regarding the role of surgery with the purpose of improving fertility or reducing the risk of obstetric complications in women with asymptomatic isthmocele. The hysteroscopic correction of isthmocele may be the safest and most effective strategy in those patients with adequate residual myometrial thickness overlying the isthmocele. Laparoscopic and vaginal surgeries may be the preferred options for patients with a thinner residual myometrium over the defect (< 2.5 mm) and when hysteroscopic treatment is inconclusive.
Authors: Marietta Gulz; Sara Imboden; Konstantinos Nirgianakis; Franziska Siegenthaler; Tilman T Rau; Michael D Mueller Journal: J Clin Med Date: 2022-02-22 Impact factor: 4.241
Authors: Stavros Karampelas; Georges Salem Wehbe; Laurent de Landsheere; Dominique A Badr; Linda Tebache; Michelle Nisolle Journal: J Clin Med Date: 2021-12-10 Impact factor: 4.241