Journal of the European Society for Gynaecological Endoscopy


Isthmoceles — Accuracy of imaging diagnosis and clinical correlation with histology: A prospective cohort study

B. Amro1, M. Ramirez1, R. Farhan2, M. Abdulrahim2, Z. Hakim1, S. Alsuwaidi1, E. Alzahmi1, M. Tahlak1, P.R. Koninckx1,3, A. Wattiez1,4

1 Latifa Hospital, Dubai 9115, United Arab Emirates
2 Dubai Hospital, Dubai, United Arab Emirates
3 Prof em OBGYN, Catholic University Leuven, Belgium, University of Oxford, Oxford, UK, Universita Cattolica del Sacro Cuore, Rome Italy
4 Department of OBGYN, Faculty of Medicine, University Strasbourg, 6081 Strasbourg, France


Uterine Isthmocele, niche, caesarean scar defect, postmenstrual bleeding, MRI, transvaginal ultrasound

Published online: Jun 28 2024


Background: Isthmoceles are a growing clinical concern.

Objectives: To evaluate the accuracy of diagnosis of isthmoceles by imaging and to correlate the dimensions with clinical symptoms and histopathology.

Material and Methods: Prospective study of women (n=60) with ≥1 C-section undergoing hysterectomy. Isthmoceles were measured by imaging before surgery and macroscopically on the specimen after hysterectomy, followed by histological analysis.

Main outcome measures: Accuracy of isthmocele diagnosis, correlation with clinical symptoms, and histopathological findings.

Result: By imaging, isthmoceles were slightly deeper (P=0.0176) and shorter (P=0.0045) than macroscopic measurements. Differences were typically small (≤3mm). Defined as an indentation of ≥2 mm at site of C-section scar, imaging diagnosed 2 isthmoceles consequently not seen by histology and missed 3. Number of prior C-sections increased isthmocele severity but neither the incidence nor the remaining myometrial thickness (RMT) did. Severity correlated positively with symptoms and histology. However, clinical use was limited. Histological analysis revealed presence of thick wall vessels in 100%, elastosis in 40%, and adenomyosis in 38%. Isthmocele lining was asynchronous with the menstrual phase in 31%.

Conclusions: Dimensions of isthmoceles by imaging were largely accurate with occasionally large differences observed. Number of C-sections did not increase isthmocele incidence, only severity. Indication for surgery remains clinical, considering dimensions and symptoms.

What is new? Dimensions of isthmoceles should be confirmed before surgery since uterine contractions might change those dimensions. Symptoms increase with dimensions of isthmoceles but are not specific. Endometrial lining within the isthmocele can be asynchronous with the menstrual phase.