| ObjectiveIn order to explore the advantages and disadvantages of each operation and provide the basis for the selection of clinical treatment plan,the effect of four different surgical methods on the patients with cicatricial diverticulum who were ineffective in drug treatment was analyzed retrospectively.Data and methods91 patients with previous cesarean scar defect who was admitted to Qilu Hospital of Shandong between University from May 2014 to May 2018 was analyzed retrospectively.According to the different surgical treatment methods,they were divided into 24 cases of abdominal incision healing defect resection and repair(A group),28 cases of vaginal incision healing defect resection and repair(B group),26 cases of incision healing defect resection and repair under hysteroscopy and laparoscopy(C group),13 cases of incision healing defect electrotomy under hysteroscopy(D group).The clinical data of the patients were collected,including age,reproductive history,history of last cesarean section,perioperative indicators,improvement of menstruation,recovery of diverticulum,and rate of reincarnation.Evaluation criteria:1.Improvement criteria of menstruation after operation-significant effect:menstruation within 7 days(including 7 days).Effective:the number of days of menstruation after operation was shortened by 2 days but more than 7 days.Invalid:prolonged menstruation or non-compliance with the above conditions.2.Improvement standard of diverticulum cure:TVS did not detect the liquid dark area of the anterior wall of the uterus,and no sign of the formation of cicatricial diverticulum was found.Effective:TVS showed that the liquid dark area in the anterior wall of uterus was smaller than that before operation.Invalid:TVS showed no change or increase in the liquid dark area of the anterior wall of the uterus.3.Re-delivery rate after operation:contraception for more than one year after operation,the number of re-delivery in each group/the number of people with fertility requirements after operation in each group.Statistical analysis was done by SPSS 22.0.Measurement data was marked by,mean ± standard deviation(x±s)single factor analysis of variance was used for multi-group comparison,t-test was used for intra-group comparisoi,rate(%)was used for count data,and χ2test was used,P<0.05 was set as the difference with statistical significance.Results1.General clinical characteristicsIn this study,91 subjects were included.82 cases(90.11%,82/91)showed prolonged menstruation,with an average of 15.02± 3.86 days,including 4 cases with dysmenorrhea.The asymptomatic patients with normal menstruation were 9(9.89%,9/91).82 patients with prolonged menstruation were included in group A(20 cases),group B(25 cases),group C(24 cases)and group D(13 cases).Nine asymptomatic patients were included in group A(4 cases),group B(3 cases),group C(2 cases)and group D(0 case).There were 24 cases,28 cases,26 cases and 13 cases in group A、B,C and D respectively.The age range of 91 patients were 26-45 years old,the average age of was 33.45±4.12 years old,and the average number of cesarean section was 1.32±0.49.There was no significant difference in the mean age(33.08±3.55,34.68±4.88,32.00±4.04,33.38± 2.53)and the mean number of cesarean sections(1.33±0.48,1.21±0.42,1.31±0.47,1.54±0.66)between four groups,P>0.05.The premenstrual period of the four groups(excluding 9 asymptomatic patients)was 14.90±3.29 days,15.06±5.23 days,15.08±3.20 days,14.92 ± 3.44 days,respectively.No significant statistical difference was observed between the all groups(P>0.05)2.research results of different operation methods2.1 intraoperative adjuvant therapyIn group A,there were 9 cases(9/24,37.50%)with hysteroscopy.In group B there were 4 cases(4/28,14.29%)combined with laparoscopy;12 cases combined with hysteroscopy,accounting for 42.86%(12/28);7 cases combined with laparoscopy,accounting for 25.00%(7/28).In group D,there were 13 cases,8 cases(8/13,61.54%)combined with laparoscopy.2.2 comparison of general indexes of operationThere were significant differences in operation time,intraoperative bleeding volume and postoperative hospital stay in groups A、B、C and D(P<0.05).The operation time in repair group by hysteroscopy and laparoscopy was longer than that of the other three groups,the difference was statistically significant(P<0.05);the operation time of abdominal repair and vaginal repair group was longer than that of hysteroscopic electrotomy group,the difference was statistically significant(P<0.05)The amount of bleeding and the days of hospitalization in the abdominal resection and repair group were significantly higher than those in the other three groups(P<0.05).There was no significant difference in hospitalization expenses between four groups(P>0.05).2.3 menstrual recovery after operation(1)Postoperative menstrual days:Among 82 PCSD patients with prolonged menstruation(excluding 9 asymptomatic patients),the mean postoperative menstrual period of four groups was 9.10±3.01days,8.70±3.71 days,8.48±2.52days,9.38±4.15 days,respectively.There was no significant difference between the four groups(P>0.05).The postoperative menstrual days of 9 asymptomatic patients were<7 days.(2)Significant effect and improvement of postoperative symptoms:The symptomatic effective rates of four groups were 50.00%(12/24)、64.29%(18/28)、53.85%(14/26)、46.15%(6/13),respectively.There was no significant difference between the four groups(χ2=1.642,P=0.650).The symptomatic improvement rates were 83.33%(20/24),82.14%(23/28),92.31%(24/26),76.92%(10/13),respectively.No significant statistical difference was observed between the all groups(χ2=1.203,P=0.799).2.4 recovery of diverticulumThree months after operation,transvaginal ultrasound showed that the cure rates of diverticulum in group A,B,C and D were 62.50%(15/24),64.29%(18/28),61.54%(16/26)and 38.46%(5/13),respectively.No significant statistical difference was observed between the all groups(χ2=2.784,P=0.426).2.5 reproductionThere were 11,12,13 and 4 people in group A,B,C and D respectively.There was no significant difference between four groups(χ2=1.351,P=0.717),which was comparable in the abdominal repair group,there were 8 cases of successful delivery,and the rate of re-delivery was 72.73%(8/11);in the vaginal repair group,there were 7 cases of successful delivery,and the rate of re-delivery was 58.33%(7/12);in the combined hysteroscopic and laparoscopic group,there were 2 cases of successful delivery,and the rate of re delivery was 15.38%(2/13);in the hysteroscopic group,there was only one case of vaginal delivery,and the rate of re-delivery was 25.00%(1/4).There was no significant difference in the rate of postpartum in the transvaginal group,laparoscopy combined hysteroscopy group and hysteroscopic electrotomy group(adjusted by Bonferroni,P>0.0083).The rate of postpartum in abdominal repair group was higher than laparoscopy combined hysteroscopy group,the difference was statistically significant(adjusted by Bonferroni,P<0.0083).2.6 recurrenceFour patients recurred after the operation,one in the transvaginal group recurred within 2 years,two recurred in the laparoscopy combined hysteroscopy group within 6 months,one recurred in the hysterectomy group within 6 months.The recurrence rates of group A,B,C and D were 0.00%,3.60%,7.70%and 7.70%,respectively There was no significant difference between groups((χ2=2.408,P=0.576)Research conclusionTransabdominal repair,vaginal repair,laparoscopy combined hysteroscopy repair and hysteroscopic electrotomy are effective method to treat previous cesarean scar defect.The choice of operation should be individualized.There are more hospital days and slower recovery after abdominal resection and repair,but it has a high rate of re delivery,which is feasible for those with fertility requirements;Vaginal repair cannot explore the internal conditions of the uterine cavity and the pelvic cavity,and the frequency of use of auxiliary endoscopic instruments during the operation is high,which increases the cost.but the clinical effect is similar to that of abdominal resection and repair,which is more minimally invasive than that of abdominal operation;Laparoscopic combined hysteroscopy repair can explore the internal conditions of the uterine cavity and the pelvic cavity at the same time during the operation.It is recommended for the patients with complications.The advantages of hysteroscopic electrotomy are shorter operation time,quicker recovery after operation,and it is suitable for the patients with intrauterine illness.No matter what kind of operation is chosen;the patients may recur the scar diverticulum after operation It is essential to avoid the risk factors of the formation of scar diverticulum during cesarean section. |
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