Diagnosis and management of isthmocele: a SWOT analysis
J A Dominguez 1 , L Alonso Pacheco 2 , E Moratalla 3 , J A Carugno 4 , M Carrera 5 , F Perez-Milan 6 , M Caballero 6 , J L Alcázar 7
The purpose of this State-of-the-Art Review was to provide a strategic analysis, in terms of strengths, weaknesses, opportunities and threats (SWOT analysis), of the current evidence regarding the management of uterine isthmocele.
Strengths include the fact that isthmocele can be adequately diagnosed on two-dimensional transvaginal ultrasound, and that surgical repair may restore natural fertility potential and prevent secondary infertility, as well as reduce the risk of abortion and other obstetrical complications.
However, there is a lack of high-quality evidence sustaining the best diagnostic method and criteria, as well as the potential benefits of surgical repair on fertility. There is an outstanding need for highly experienced surgeons with adequate skills in all applicable techniques, and isthmocele repair does not prevent the need for a Cesarean delivery in subsequent pregnancy.
Nevertheless, increasing awareness of the accuracy of transvaginal ultrasound in diagnosing isthmocele presents an opportunity for increased diagnosis of this pathology. This may lead to surgical correction and prevention of obstetric and perinatal complications in subsequent pregnancy, including cesarean scar pregnancy. Regarding threats, the existence of different surgical techniques creates a risk of selecting an inadequate approach if the type of isthmocele and patient's features are not considered.
There is a risk of overtreatment when asymptomatic defects are surgically repaired. Finally, there is an absence of cost-effectiveness analyses to justify the routine application of the repair. Thus, while there are many data suggesting that isthmocele decreases both natural fertility and the outcomes of assisted reproduction techniques, high-quality evidence to support surgical isthmocele repair in all asymptomatic patients desiring future fertility are lacking.
There is progressive agreement in recommending hysteroscopic repair of isthmocele as a first-choice approach as long as the residual myometrium thickness is at least 2.5-3 mm.