O-108 C-section scar defect: Hysteroscopic vs laparoscopic repair

Abstract

Abstract Objective: To present a systematic review of the literature on the hysteroscopic and laparoscopic repair of cesarean scar niche and offer an evidence-based approach to the treatment of cesarean scar niche. Data sources: A thorough search of the PubMed/Medline, Embase, and Cochrane databases was performed. (PROSPERO registration number CRD42020190668). Methods of study selection: Studies from the last 20 years that addressed cesarean scar niche repair were collected. Both authors screened for study eligibility and extracted data. All prospective and retrospective studies of more than ten women were included. Tabulation and integration: The initial search identified 666 articles [PRISMA flow chart]. We excluded duplicates, case reports, reviews, video articles, and technique articles. We also excluded studies describing only laparotomy or vaginal repair as these were not of the scope of this review. A total of 31 articles met the inclusion criteria, 21 for hysteroscopic resection and 13 for laparoscopic or combined repair (4 articles tested both modalities and appear in both tables). Results: For abnormal uterine bleeding (AUB), hysteroscopic remodeling relieved symptoms in 60%-100% of cases and laparoscopy in 78%-94%. Secondary infertility was not evaluated in all studies. We found that after hysteroscopic and laparoscopic treatment, 46%-100% and 37.5%-90% of those who wished to conceive became pregnant following the procedure, respectively. Pain and dysmenorrhea seem to be uncommon. All studies that tested improvement of pain had less than ten women. However, it would appear that between 66% and 100% of women who complain of pain or dysmenorrhea will note a marked improvement to full resolution. Conclusion: cesarean scar niche or cesarean scar defect is usually asymptomatic. For symptomatic women, a repair is a valid option. For those with RMT (Residual Myometrial thickness) >2-3 mm, hysteroscopic remodeling is the modality of choice with an improvement in AUB, secondary infertility, and pain. For women with a RMT <2-3 mm, laparoscopic repair with simultaneous hysteroscopic guidance shows similar results. Since available data is limited, no cutoff for the correct choice between hysteroscopy or laparoscopy can be concluded. We recommend 2.5 mm as the cutoff value based on common practice and expert opinion, although no significance between hysteroscopic and laparoscopic treatment was shown.