Is vaginal repair a good option for severe cesarean scar defect? Comparison of women with or without residual myometrium.

Study objective: To compare outcomes of vaginal surgery in women with moderate or severe symptomatic cesarean scar defect (with or without residual myometrium).

Design: Retrospective cohort study.

Setting: Gynecology department of a teaching hospital.

Patients: Fifty-three women, between January 2014 and December 2019, underwent vaginal surgery for symptomatic cesarean scar defect: 20 women with moderate defect (with residual myometrium) and 33 with severe defect (without residual myometrium).

Interventions: Vaginal surgical approach to repair cesarean scar defect.

Measurements: The main objective of this study was to evaluate the efficacy of vaginal surgery by comparing the myometrial residual thickness before and after surgery. The secondary objectives were evaluation of vaginal surgery efficacy on symptoms resolution, per and postoperative courses and subsequent fertility. Failure rate was evaluated as the need for a second surgery.

Main results: After vaginal surgery, the residual myometrium significantly increased from 2.4 ± 0.9 mm to 6.6 ± 2.4 mm (p <0.01) in the moderate group and from 0 mm to 4.4 ± 2.2 mm (p <0.01) in the severe group. The prevalence of abnormal uterine bleeding was significantly reduced after surgery in both groups (p<0.01). Pelvic pain was significantly reduced only in the moderate group (p<0.01). The rate of complications (5 vs. 9.1%) and second surgery (15 vs. 24.2%) were not significantly different between moderate and severe groups respectively. The median time to conceive (7 months versus 12 months); pregnancy rates (84.6 vs. 68.2%); and live birth rates (76.9 vs. 50%) were not statistically significant in the moderate and severe groups respectively, with 90% of pregnancies occurring naturally. Women delivered by caesarean section at 38 weeks of gestation in both groups and no uterine rupture was reported.

Conclusion: Despite the absence of residual myometrium, vaginal 65 repair of severe cesarean scar defect was effective in increasing myometrial thickness, in relieving bleeding symptoms, and in allowing to achieve pregnancy.