| Objective: Hysteroscopy-laparoscopic revision surgery and vaginal revision surgery were all effective minimally invasive therapy for previous cesarean scar defect(PCSD) in non-pregnant patients. However, uncertainty about the better strategy was the reason why this study was important. The aim of this systematic review was to compare the effectiveness and safety of hysteroscopy-laparoscopic revision surgery with vaginal revision surgery for PCSD in non-pregnant patients and provide a evidence of evidence-based medicine to guide clinical decision about the choice of surgical plan.Methods: We defined criteria for including and excluding studies in the review and designed search strategies according to the research purpose. A systematic electronic search of CNKI, Wangfang, VIP, CBM and Embase computerised bibliographicdatabases and FMRS, Ovid SP, Pub Med retrieval platforms was performed in accordance with the search strategies. We did not use any date restriction in the electronic searches for trials, and we last searched on 10 January 2016. To avoid missing, we also searched by the search engines of Baidu academic and Google academic. What's more, the reference lists in other published relevant systematic reviews, included studies, excluded studies and other related articles were searched for additional studies. All electronic retrieved literatures were imported to the reference management software-End Note X7. Then, two reviewers independently selected studies that were eligible for inclusion in the review. And they also independently extracted data according to the predesigned data collection form and assessed risk of bias in included studies according to the criteria for judging risk of bias in Cochrane collaboration's' Risk of bias' assessment tool which was recommended in Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0. We resolved any discrepancies through discussion, but when this way was unsuccessful, the disagreement required arbitration by another reviewer. Meta-analyses were conducted using Stata Version 12.0software, and using 'forest plots' to display those pooled results. If there was a sufficient number of studies(10 or more) in a meta-analysis, we used a 'funnel plot' and the tests of Begg and Egger for funnel plot asymmetry to explore reporting bias. We performed a sensitivity analysis by mean of excluding any one trial in a meta-analysis to determine the impact of this excluded study on the result and the degree of confirmation of the result. The GRADE method entailed an assessment of the quality of a body of evidence for each individual outcome, and those assessments were conducted using the software of GRADEprofiler Version 3.6.1.Results:Ultimately,15 studies(5 RCTs and 10 CCTs)were included in this systematic review,in which a total of 925 participants were enrolled,and all trials were written in Chinese.Meta-analyses showed that the difference was not statistically significant(P>0.05)in defect resection rate(RR??:1.11(0.93,1.32),z=1.15,P=0.249),menstruation recovery rate(RR??:1.09(0.96,1.25),z=1.30,P=0.194),overall complications rate(RR??:0.58(0.16,2.12),z=0.83,P=0.409),operation time(WMD??:-1.49(-3.82,0.83),z=1.26,P=0.207),postoperative hospitalization time(WMD??:3.93(-3.87,11.74),z=0.99,P=0.323),postoperative exhausting time(SMD??:0.38(-0.06,0.82),z=1.67,P=0.094)between hysteroscopy-laparoscopic revision surgery and vaginal revision surgery.In other words,it still couldn't deem that the thistwo kinds of surgeries had some difference on the above aspects.However,hysteroscopy-laparoscopic revision surgery was significantly(P<0.05)lower in intraoperative blood loss(WMD??:-18.04(-27.24,-8.84),z=3.84,P=0.000),and higher in hospitalization costs(WMD??:5085.69(3038.41,7132.97),z=4.87,P=0.000)than vaginal revision surgery.And none of the included articles described postoperative pregnancy rate.The assessment results of the quality of the evidence were as follow:the outcome of menstruation recovery rate was considered to be moderate,the outcome of defect resection rate,operation time and hospitalization costs were considered to be low,the outcome of overall complications rate,intraoperative blood loss,postoperative hospitalization time and postoperative exhausting time were considered to be very low.Conclusions: Compared with vaginal revision surgery, hysteroscopy-laparoscopic revision surgery for previous cesarean scar defect in non-pregnant patients had the advantage of less intraoperative blood loss and the disadvantage of higher hospitalization costs. While, at the moment there was not enough evidence to support the difference among them in defect resection rate, menstruation recovery rate, overall complications rate, operation time, postoperative hospitalization time, postoperative exhausting time. Overall, we graded the quality of the evidence as very low to moderate,was therefore insufficient to make solid conclusions. Still, future additional well-designed high-quality RCTs that include a sufficient sample size and strictly conform to the standard, with long-term follow-up, are needed to perform, especially multi-center randomized control clinical trials, to compare and analyze and provide evidence to evidence-based medicine. |
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