In the management of cesarean scar defects, is there a superior surgical method for treatment?
According to this meta-analysis, which compared the data on laparoscopic, hysteroscopic, vaginal, and combined laparoscopic and hysteroscopic repair of cesarean scar defects, combined laparoscopic and hysteroscopic repair was associated with a shorter duration of abnormal bleeding. Combined laparoscopy and hysteroscopy also was found to decrease the depth of the defect when compared with vaginal repair. Although the findings are statistically significant, it is unclear if they are clinically significant; long-term outcomes are similarly unclear. More randomized controlled trials are required in order to make a clear distinction as to which method of repair is superior.
Study strengths and weaknesses
This is the first meta-analysis to compare the different surgical techniques to correct a CSD. The authors were able to compare many of the characteristics regarding the routes of repair, including hysteroscopy, laparoscopy, and vaginal. The authors were able to analyze the combined laparoscopic and hysteroscopic approach, which facilitates evaluation of the location and satisfaction of defect repair during the procedure.
Some weaknesses of this study include the limited amount of RCTs available for review. All studies were also from China, where the rate of CSDs is higher. Therefore, the results may not be generalizable to all populations. Given that the included studies were done at different sites, it is difficult to determine surgical expertise and surgical technique. Additionally, the studies analyzed varied by which techniques were compared; therefore, indirect analyses were conducted to compare certain techniques. There was limited follow-up for these patients (anywhere from 3 to 6 months), so long-term data and future pregnancy data are needed to determine the efficacy of these procedures.
CSDs are a rising concern due to the increasing cesarean delivery rate. It is critical to be able to identify as well as correct these defects. This is the first systematic review to compare 4 techniques of managing CSDs. Based on this article, there may be some additional benefit from combined hysteroscopic and laparoscopic repair of these defects in terms of decreasing bleeding and decreasing the scar defect depth. However, how these results translate into long-term outcomes for patients and their future pregnancies is still unknown, and further research must be done.
STEPHANIE DELGADO, MD, AND XIAOMING GUAN, MD, PHD
