Laparoscopic combined with hysteroscopic repair or operative hysteroscopy in the treatment of symptomatic cesarean-induced diverticulum

Abstract

Objective: The postmenstrual bleeding with cesarean-induced diverticulum is a bothersome symptom and can be confused with other abnormal-uterine bleeding disease. The aim of the present study was to evaluate the efficacy and safety of laparoscopic combined with hysteroscopic repair vs operative hysteroscopy in treatment of symptomatic cesarean-induced diverticulum. Methods: Eighty-two women with cesarean-induced diverticulum who underwent either laparoscopic combined with hysteroscopic repair or operative hysteroscopy between January 2012 and September 2015 were retrospectively included in the study. We evaluated the menstrual duration before and after the surgery, the width, length and depth of the niche, operating time, blood loss, complications, and postoperative pregnancy status. Results: 62.2% (51/82) patients started to have postmenstrual bleeding immediately when they gained regular menstruation after their cesarean section. The laparoscopic group has longer operative time and greater blood loss (p<0.001). Both groups have a significant improvement in their menstruation duration ( p< 0.001). The patients in the laparoscopic repair group had a greater improvement in bringing the uterine bleeding into normal menstruation duration (P=0.046) and the same in pregnancy rate (P=0.505). The interval between operation and pregnancy in laparoscopic combined with hysteroscopic group was much longer than the hysteroscopic group (27 vs 10 months, p<0.001). Conclusion: the laparoscopic repair exhibited a better efficiency in bringing the uterine bleeding into normal menstruation duration and in improving the pregnancy rate However, there was not a clear absolute advantage for one of the two type of surgeries. Thus, patients with post-cesarean section diverticulum (PCSD) should choose with caution the type of surgery, considering the residual myometrial thickness (RMT), the age, the desire for further fertility and ovarian reserve capacity.

A systematic review and meta-analysis of the efficacy and safety of hysteroscopic electric resection versus vaginal surgery in the treatment of uterine scar defects after cesarean section

“…The treatment of symptomatic USD includes drug therapy and surgery. Drug therapy is limited, and surgery can better manage the defect, but there are still different ideas about the choice of surgery (13)(14)(15)(16)(17)(18). Surgical treatment usually includes hysteroscopic resection and vaginal surgery.…”

Niche-related outcomes after caesarean section and quality of life: a focus group study and review of literature

“…Reported outcomes, either by patients or clinicians, are summarised in Table 3. The most frequently reported gynaecological outcomes were prolonged menstrual bleeding [24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43], postmenstrual spotting [5,8,9,25,35,[44][45][46][47][48][49][50], dysmenorrhoea [5,8,9,25,27], dyspareunia [5,27,46] and (chronic) pelvic pain or abdominal pain [5,24,25,27,34,40,46,51,52...…”

“…Prevalence of abnormal adhesive placenta [26,27], successful vaginal birth after CS [27,[53][54][55] and uterine rupture or dehiscence [27,[56][57][58][59][60][61][62][63] were reported as obstetric outcomes. Fertility-related niche therapy studies reported on wish to conceive (secondary subfertility) [26,27,33,52], pregnancy [25,26,33,39,40,42,64] and miscarriage rate [26,27,33,39,42,43], the risk of caesarean scar pregnancy [27,33,40] and live birth rate [26,27,40,43]. Subsequent pregnancies were followed after niche therapy in four studies: mode and timing of delivery [39,42], risk of abnormal adhesive placenta [40] and risk of uterine dehiscence or rupture [39,40,43] were reported.…”

“…Fertility-related niche therapy studies reported on wish to conceive (secondary subfertility) [26,27,33,52], pregnancy [25,26,33,39,40,42,64] and miscarriage rate [26,27,33,39,42,43], the risk of caesarean scar pregnancy [27,33,40] and live birth rate [26,27,40,43]. Subsequent pregnancies were followed after niche therapy in four studies: mode and timing of delivery [39,42], risk of abnormal adhesive placenta [40] and risk of uterine dehiscence or rupture [39,40,43] were reported. Three publications reported on change in HRQoL, assessed using the validated SF-36 questionnaire, after niche therapy (surgical or hormonal) [8,9,24].…”

Analysis on clinical association of uterine scar diverticulum with subsequent infertility in patients underwent cesarean section

“…[ 5 ] The previous study found that laparoscopic combined with hysteroscopic repair had better efficiency in improving the abnormal uterine bleeding, regulating the normal menstruation duration, and increasing the pregnancy rate. [ 6 ] Other research demonstrated that hysteroscopy was more effective in the treatment of cesarean section scar diverticulum, while resectoscopic treatment was highly effective in women with abnormal uterine bleeding. [ 7 ] Therefore, different surgical treatment methods have their own advantages and disadvantages, which should be selected according to the type of disease.…”