Study Of Risk Factors For Cesarean Scar Diverticulum And The Comparison Of Two Surgical Procedures For Its Treatment

BackgroundCesarean scar diverticulum(CSD)is a long-term complication after cesarean section.Due to the high rate of cesarean delivery in China,CSD is also gradually raising concerns.Patients with CSD may experience prolonged menstruation,chronic pelvic pain,secondary infertility,and an increased risk of complications such as cesarean scar pregnancy,placenta praevia,placental implantation,and uterine rupture in subsequent pregnancies,which can seriously affect a woman’s reproductive health and fertility safety.To prevent these adverse outcomes,it is important to identify the risk factors for CSD and to develop appropriate diagnostic and therapeutic methods.Part One:A meta-analysis of risk factors for the formation of cesarean scar diverticulumObjectiveIn this study,the outcome indicators of several clinical studies were pooled by meta-analysis to investigate the high risk factors for CSD formation,with the aim of finding the cause of CSD,preventing the occurrence of CSD,and reducing the prevalence of CSD.It is possible to better safeguard the quality of life and reproductive safety of women after cesarean section through this study.MethodsThe literature published in Chinese and English databases on risk factors for the formation of CSD was searched,and the search period was from the establishment of the database to November 31,2022.The literature was selected strictly according to the inclusion and exclusion criteria,and the information and valid data were extracted.Data were analyzed using Review Manager 5.3 and Stata 15.A fixed-effect model or random-effect model was selected for data merging to measure the combined OR and 95%CI of each influencing factor.ResultsA total of 28 studies with a sample size of 8198 cases were included in this study,including 2333 patients with CSD.The results showed that posterior uterine position,BMI before delivery,number of cesarean deliveries≥2,gestational diabetes,hypertensive disorders of pregnancy,premature rupture of membranes,postpartum infection,elective cesarean delivery,incision near the internal cervical orifice,singlelayer sutured uterine incision were risk factors for the development of CSD(P<0.05).These ORs and 95%CIs were 3.49(2.88,4.24),2.69(1.91,3.79),2.94(2.42,3.57),2.07(1.35,3.17),2.45(1.71,3.52),3.05(2.51,3.70),2.75(2.04,3.70),3.27(1.98,5.40),2.53(2.26,2.84),4.40(2.64,7.34).Age and multiple pregnancy were not risk factors for the formation of CSD(P>0.05),these ORs and 95%CIs were 1.09(0.99,1.21),2.56(0.52,12.58).Part Two:A meta-analysis of the comparison of two surgical approaches in the treatment of CSD by combined laparoscopy and hysteroscopyObjectiveA meta-analysis was performed to compare two different surgical procedures in combined hysteroscopic and laparoscopic surgery which were "scar diverticulum repair after excision" and "folding suture method" in the treatment of cesarean scar diverticulum(CSD),in order to provide evidence to support optimal clinical treatment options and guide the clinical treatment of patients with symptomatic CSD with fertility needs.MethodsThe literature on the study of two different surgical procedures in the treatment of CSD by combined laparoscopy and hysteroscopy were searched in various English and Chinese databases published up to November 31,2022.Literature that met the inclusion criteria were selected and data analysis was conducted by using Review Manager 5.3 and Stata 15.The ORs value and 95%CIs were used for dichotomous variables and ordered variables,and continuous variables applied mean difference(MD)values as effect sizes,as well as 95%CIs,were used to express the confidence range of the respective effect sizes.ResultsA total of 9 high-quality literature were included in this study,with a cumulative sample size of 486 cases.Among them,248 cases underwent the surgical procedure of the "folding suture method" and 238 cases of the "scar diverticulum resection and repair".Results suggested that compared with "scar diverticulum resection and repair"surgery,the "folding suture method" had shorter operative time,less intraoperative bleeding,less postoperative abdominal drainage,shorter hospitalization time,higher postoperative residual myometrial thickness(RMT)changes,higher effective rate.In contrast,there were no significant differences in the time to first postoperative anal exhaust time and postoperative re-pregnancy rate between the two groups.The specific effect sizes and 95%CIs were as follows.There were statistically significant indicators between the two groups(P<0.05):operative time:MD=-16.36,95%CI(-18.37,-14.36),intraoperative bleeding:MD=-42.36,95%CI(-65.71,-19),postoperative abdominal drainage:MD=-55,95%CI(-60.65,-49.34),hospitalization time:MD=-1.95,95%CI(2.57,-1.33),postoperative RMT changes:MD=0.23,95%CI(0.13,0.34),effective rate:OR=2,95%CI(1.23,3.25);There were no significant differences between the two groups(P>0.05):first postoperative anal exhaust time:MD=-0.24,95%CI(-1.04,0.56),postoperative pregnancy rate:OR=1.91,95%CI(0.91,4.02).Conclusion1.Risk factors for CSD included posterior uterine,BMI before delivery,the number of cesarean deliveries ≥ 2,gestational diabetes,hypertensive disorders of pregnancy,premature rupture of membranes,postpartum infection,elective cesarean delivery,incision near the internal cervical orifice,single-layer sutured uterine incision.2.The patients with CSD treated by the "folding suture method" had less surgical trauma,better postoperative recovery,more postoperative diverticular muscle thickening,and higher effective rate.However,there was no significant difference in the postoperative pregnancy rate between the two groups.Obviously,the comparison of postoperative pregnancy rate was limited by the postoperative follow-up time of the two groups,and the sample sizes for comparison were small,thus,the reliability of the results is low.Therefore,more large sample size clinical trials are still needed to study.