Four Surgical Strategies for the Treatment of Caesarean Scar Defect: A Systematic Review and Network Meta-Analysis.

ABSTRACT Objective This network meta-analysis compared treatment via laparoscopy (LP), hysteroscopy (HP), combined laparoscopy with hysteroscopy (LH), and vaginal repair (VR) for reducing intermittent abnormal uterine bleeding and caesarean scar defect (CSD) diverticulum depth in patients with CSD. Data Sources Electronic databases (PubMed, EMBASE, CENTRAL, MEDLINE, ClinicalTrials.gov, Chinese Biomedical Literature Database, and China National Knowledge Integrated) were searched for articles published through June 13, 2018. Methods of Study Selection The search included randomized controlled trials (RCTs) and observational studies of surgical treatment for CSD. Standardized mean difference (SMD) and 95% confidence intervals (CI) were reported. Randomized controlled trials were evaluated by the Cochrane risk-of-bias tool, observational studies by Risk of Bias in Nonrandomized Studies of Intervention (ROBINS-I), and overall evidence quality by grade. Data were analyzed by STATA (version 15.0, StataCorp, College Station, TX, USA) and R software for windows (version 3.5.0, R Core Team, 2018). Tabulation, Integration, and Results Ten studies (n = 858; 4 RCTs and 6 observational studies) were included. Patients who underwent uterine diverticulum resection by LH had a shorter duration of abnormal uterine bleeding than that by HP (SMD = 1.36, 95% CI, 0.37 to 2.36, p = .007) and VR (SMD = 1.58, 95% CI, 0.97 to 2.19, p Conclusion Laparoscopy with hysteroscopy reduced intermittent abnormal uterine bleeding and scar depth more than the other surgical interventions. Larger clinical trials are warranted to verify this analysis.