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Review
. 2023 Aug 9;22(1):e12532.
doi: 10.1002/rmb2.12532. eCollection 2023 Jan-Dec.

Prevalence, definition, and etiology of cesarean scar defect and treatment of cesarean scar disorder: A narrative review

Shunichiro Tsuji  1 , Yuri Nobuta  1 , Tetsuro Hanada  1 , Aike Takebayashi  1 , Ayako Inatomi  1 , Akimasa Takahashi  1 , Tsukuru Amano  1 , Takashi Murakami  1
Affiliations
Review

Prevalence, definition, and etiology of cesarean scar defect and treatment of cesarean scar disorder: A narrative review

Shunichiro Tsuji et al. Reprod Med Biol. .

Abstract

Background: Cesarean scar defects (CSD) are caused by cesarean sections and cause various symptoms. Although there has been no previous consensus on the name of this condition for a long time, it has been named cesarean scar disorder (CSDi).

Methods: This review summarizes the definition, prevalence, and etiology of CSD, as well as the pathophysiology and treatment of CSDi. We focused on surgical therapy and examined the effects and procedures of laparoscopy, hysteroscopy, and transvaginal surgery.

Main findings: The definition of CSD was proposed as an anechoic lesion with a depth of at least 2 mm because of the varied prevalence, owing to the lack of consensus. CSD incidence depends on the number of times, procedure, and situation of cesarean sections. Histopathological findings in CSD are fibrosis and adenomyosis, and chronic inflammation in the uterine and pelvic cavities decreases fertility in women with CSDi. Although the surgical procedures are not standardized, laparoscopic, hysteroscopic, and transvaginal surgeries are effective.

Conclusion: The cause and pathology of CSDi are becoming clear. However, there is variability in the prevalence and treatment strategies. Therefore, it is necessary to conduct further studies using the same definitions.

Keywords: cesarean scar defect; cesarean scar disorder; cesarean section; hysteroscopic surgery; secondary infertility.

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Conflict of interest statement

Takashi Murakami is an Editorial Board member of Reproductive Medicine and Biology and a co‐author of this article. To minimize bias, he was excluded from all editorial decision‐making related to the acceptance of this article for publication.

Figures

FIGURE 1
FIGURE 1
Schema representing the pathophysiology of cesarean scar disorder. The absence of endometrium and abnormal vascular development is visible on the surface of the cesarean scar defects (CSD). Occasionally, microhemorrhages can be directly observed in CSD. In the myometrium under CSD, ectopic endometrium and CD138‐positive plasma cells can be observed. Chronic inflammation generated in CSD may spread into the uterine cavity and induce chronic endometritis. Furthermore, endometriosis, a chronic inflammatory disease, is frequently found in the pelvis of patients with cesarean scar disorder (CSDi).
FIGURE 2
FIGURE 2
Magnetic resonance imaging findings before and after hysteroscopic surgery. Hysteroscopic surgery was performed for infertile women with cesarean scar disorder (CSDi) in each of the four independent cases (A–D). In all cases, the residual myometrial thickness increased, and postoperative pregnancies were established in all cases. Red arrows indicate pre‐ and post‐operative changes.
FIGURE 3
FIGURE 3
Treatment algorithm for secondary infertility in women with cesarean scar disorder. When residual myometrial thickness (RMT) is <2.2 mm, laparoscopic surgery with a hysteroscope is recommended because it is useful to accurately resect the cesarean scar defect (CSD). When RMT is ≥2.2 mm, hysteroscopic correction with laparoscopy is recommended because patients with cesarean scar disorder (CSDi) often have endometriosis. In both ways, the uterus is repositioned by suturing the round ligament to relieve tension on repaired CSD.
See this image and copyright information in PMC

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