Hysteroscopy in the Treatment of Myometrial Scar Defect (Diverticulum) Following Cesarean Section Delivery: A Systematic Review and Meta-Analysis

Various management approaches have been developed to treat symptoms and prevent complications of the cesarean diverticulum. This systematic review aims to report the outcomes and fertility-related effects of hysteroscopy on women with myometrial scar defects after the cesarean section. Following the formulation of the patient/population, intervention, comparison, and outcomes (PICO) criteria, a systematic search was conducted on seven databases. Finally, a total of 18 studies were included for this systematic review and meta-analysis. All of the included patients suffered from post-cesarean section scars and presented with abnormal bleeding, pain, or secondary infertility. The overall pooled symptomatic improvement rate was 78.83% (95% CI: 72.46-85.76%); however, there was significant heterogeneity among the analyzed studies (I(2)=87%; p-value: <0.001) and a significant risk of bias (p-value: <0.001). The overall resolution/improvement rate after adjusting for possible bias was higher, 92.82% (95% CI: 85.17-100%). The overall pregnancy rate was 69.77% (95% CI: 59.03-82.48%), while in the individual studies the rates varied, ranging from 25% to 80%. Nevertheless, there was moderate heterogeneity among the included studies (I(2)=56%; p-value=0.011). In contrast, there was no significant risk of bias among the included studies (p-value=0.100). Furthermore, the meta-regression analyses did not show any significant effect of different follow-up durations on the overall effect size for both outcomes. In conclusion, there is still a need for high-quality, comparative studies with larger sample sizes and long-term follow-up periods to draw firm conclusions. Moreover, future studies should consider the minimum myometrial thickness that is sufficient to complete a healthy pregnancy.