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Review
. 2020 Nov 3;12(11):e11317.
doi: 10.7759/cureus.11317.

Hysteroscopy in the Treatment of Myometrial Scar Defect (Diverticulum) Following Cesarean Section Delivery: A Systematic Review and Meta-Analysis

Bdour H Al Mutairi  1 , Ibtehal Alrumaih  1
Affiliations
Review

Hysteroscopy in the Treatment of Myometrial Scar Defect (Diverticulum) Following Cesarean Section Delivery: A Systematic Review and Meta-Analysis

Bdour H Al Mutairi et al. Cureus. .

Abstract

Various management approaches have been developed to treat symptoms and prevent complications of the cesarean diverticulum. This systematic review aims to report the outcomes and fertility-related effects of hysteroscopy on women with myometrial scar defects after the cesarean section. Following the formulation of the patient/population, intervention, comparison, and outcomes (PICO) criteria, a systematic search was conducted on seven databases. Finally, a total of 18 studies were included for this systematic review and meta-analysis. All of the included patients suffered from post-cesarean section scars and presented with abnormal bleeding, pain, or secondary infertility. The overall pooled symptomatic improvement rate was 78.83% (95% CI: 72.46-85.76%); however, there was significant heterogeneity among the analyzed studies (I2=87%; p-value: <0.001) and a significant risk of bias (p-value: <0.001). The overall resolution/improvement rate after adjusting for possible bias was higher, 92.82% (95% CI: 85.17-100%). The overall pregnancy rate was 69.77% (95% CI: 59.03-82.48%), while in the individual studies the rates varied, ranging from 25% to 80%. Nevertheless, there was moderate heterogeneity among the included studies (I2=56%; p-value=0.011). In contrast, there was no significant risk of bias among the included studies (p-value=0.100). Furthermore, the meta-regression analyses did not show any significant effect of different follow-up durations on the overall effect size for both outcomes. In conclusion, there is still a need for high-quality, comparative studies with larger sample sizes and long-term follow-up periods to draw firm conclusions. Moreover, future studies should consider the minimum myometrial thickness that is sufficient to complete a healthy pregnancy.

Keywords: caesarian scar; diverticulum; hysteroscopy; isthmocele; niche.

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Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Figure 1
Figure 1. PRISMA flowchart of the search and screening process
PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses; ISI: Institute for Scientific Information; VHL: Virtual Health Library; NYAM: New York Academy of Medicine; SIGLE: System for Information on Grey Literature in Europe
Figure 2
Figure 2. Forest plot for symptomatic improvement following hysteroscopic treatment of myometrial scar defect (diverticulum)
Figure 3
Figure 3. Baujat plot of the contribution of each study to the overall heterogeneity
Figure 4
Figure 4. A leave-one-out sensitivity analysis of the symptomatic improvement outcomes
Figure 5
Figure 5. Funnel plot of the symptomatic improvement outcomes*
*Five studies were added on the right side to enhance symmetry
Figure 6
Figure 6. Meta-regression of the follow-up duration and its effect on the symptomatic improvement outcomes
Figure 7
Figure 7. Forest plot for pregnancy rates following hysteroscopic treatment of myometrial scar defect (diverticulum)
Figure 8
Figure 8. Baujat plot of the contribution of each study to the overall heterogeneity (pregnancy rates)
Figure 9
Figure 9. Meta-regression of the follow-up duration and its effect on pregnancy rate outcomes
See this image and copyright information in PMC

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