What are the risk factors for unsuccessful surgery in hysteroscopic isthmocele resection?

Objectives: This study aims to present the postoperative results of patients who underwent a hysteroscopic isthmocele resection, identify factors affecting patients who experienced surgical failure, and develop a new treatment algorithm for managing an isthmoceles, whose treatment remains unclear.

Material and methods: The hospital records of women who underwent hysteroscopic istmocele resection due to postmenstrual spot-bleeding at a tertiary central university hospital were examined. The patients were divided into two groups: successful surgery (Group 1) and unsuccessful surgery (Group 2) after hysteroscopic isthmocele resection. To evaluate the results of unsuccessful surgery in patients with failed hysteroscopic isthmocele resection, the number of caesarean sections, BMI and isthmocele area were considered as candidate predictors.

Results: During the study period, 53 patients who met the inclusion criteria and underwent hysteroscopic isthmocele resection were evaluated. Surgical success was detected in 34 patients (64.1%), while unsuccessful surgery was detected in 19 patients (35.9%). In the ROC analysis performed to predict an unsuccessful surgery, AUC was detected as 0.717, sensitivity was 79%, specificity was 68% and p value was 0.009 in patients with a BMI > 27.5. In patients with previous caesarean sections, the number > 2.5; AUC was 0.765, sensitivity was 58%, specificity was 91% and p value was 0.002 in the receiver operating characteristic (ROC) analysis. In patients with isthmocele area > 23.5 mm², AUC was 0.781, sensitivity was 63%, specificity was 91% and p value was 0.001 in the ROC analysis. In the multivariate regression analysis, the effect of the isthmocele area in predicting unsuccessful surgery was determined to be a statistically significant independent variable [OR: 1.239, 95% CI (1.050-1.462), p = 0.011].

Conclusions: Although a hysteroscopic isthmocele resection is recommended for patients with an RMT over 3 mm, certain factors increase the risk of surgical failure. If an isthmocele area exceeds 23.5 mm², the number of previous caesarean sections is three or more or a person's BMI is 27.5 or higher, the risk of unsuccessful hysteroscopic surgery is high. In these patients, isthmocele repair should be performed via the laparoscopy, laparotomy or vaginal approach.