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Study Objective: To prospectively investigate whether the application of vaginal repair (VR) of cesarean section scar defect (CSD) combined with a gonadotropin-releasing hormone agonist (GnRHa) achieve better clinical outcomes than VR alone., Design: A randomized clinical trial., Setting: University Hospital., Patients: A total of 124 women with CSD were undergoing expectant management from December 2016 to September 2021. 61 were randomized to VR+ GnRHa and 63 to VR alone., Intervention: Vaginal repair combined with GnRHa and vaginal repair alone., Measures and Main Results: The primary outcome was the duration of menstruation and thickness of the remaining muscular layer (TRM) at 6 months after surgery. Secondary outcomes included the length, width, and depth of the CSD; operation time; estimated blood loss; hospitalization time; and operative complications. Women were treated with either VR (n = 63) or VR + GnRHa (n = 61). Menstruation and TRM in patients pre vs post comparisons either with VR or VR + GnRHa are significantly improved (p <.05). Significant differences in menstruation duration and TRM occurred in patients treated with VR + GnRHa compared with those treated with VR (p <.05). Moreover, the rate of CSD after surgery in the VR group was significantly higher than that in the VR + GnRHa group (p = .033), and CSD patients in the VR + GnRHa group achieved better therapeutic effects than those in the VR group (p = .017). Patients who received VR + GnRHa had a shorter menstruation duration and a greater increment of TRM postoperatively than patients treated with VR alone (p = .021; p = .002, respectively)., Conclusion: VR + GnRHa therapy has a greater potential to improve scar healing and reduce the number of menstruation days than VR alone for symptomatic women with CSD., (Copyright © 2024 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objective: To establish a prediction model to help doctors determine which patients with cesarean scar defect are more suitable for transvaginal repair., Design: Retrospective analysis., Setting: Xinhua Hospital and Shanghai First Maternity & Infant Hospital between June 2014 and May 2021., Patients: 1015 women who underwent transvaginal repair of cesarean scar defect (CSD)., Interventions: All enrolled patients underwent CSD repair performed by the same gynecologist and his team. And followed up a clinic visit at 6 months to record their menstruation and measure multiple parameters of the CSD by Magnetic Resonance Imaging., Main Outcomes and Measures: CSD patients are categorized as optimal healing group when the menstruation duration is no more than 7 days, meanwhile the thickness of residual myometrium is no less than 5.39 mm after vaginal repair. The final nomogram is constructed to predict surgical outcomes based on preoperative variables., Results: The key factors that determine optimal healing are the timing of cesarean section (elective or emergency), menstrual cycle, CSD length, width, depth, and the thickness of the lower uterine segment. With the prediction model, scores are given to each parameter according to the statistics. Total scores range from 0 to 25 points, with a cutoff point of 16.5. When a score is greater than 16.5, the transvaginal repair can achieve optimal healing. Uterine position (anteflexion or retroflexion) and preoperative thickness of residual myometrium are the key factors affecting postoperative thickness of residual myometrium. The width of the CSD and the thickness of the lower uterine segment are the key factors affecting abnormal uterine bleeding symptoms (p < 0.01)., Conclusions: For the first time, we established a prediction model system that may predict the repair effect of CSD and can potentially be useful in future clinical trials to determine which patients are more suitable for surgery or other treatment options., (Copyright © 2023 AAGL. Published by Elsevier Inc. All rights reserved.)

Background: The aim of this study was to evaluate the effect of vaginal repair in patients with cesarean section diverticulum (CSD) who had one or two previous cesarean sections (CSs)., Methods: From January 2012 to December 2014, 248 women with CSD underwent vaginal repair surgery in Shanghai First Maternity and Infant Hospital. These included 193 women with one previous cesarean section and 55 women with two previous cesarean sections. Excision and suture of CSD was performed through a vaginal approach. The duration of menstruation, the length, width and depth of the CSD and thickness of the remaining muscular layer (TRM) were evaluated before and after surgery by transvaginal three-dimensional (3D) color Doppler ultrasound., Results: A total of 221 (89.11%) women were followed-up for more than 3 months, and 168 (67.74%) women were followed-up for more than 6 months. There were significant differences in the average duration of menstruation (7.77 ± 2.05 and 8.02 ± 2.06 days VS 13.99 ± 3.71 days), the average size of CSD (5.54*9.19*5.60 and 5.75*9.04*6.18 mm VS 7.99*12.43*6.62 mm) and the TRM (7.61 ± 2.52 and 7.60 ± 3.00 mm VS 2.51 ± 1.02 mm) after surgery compared with those figures before surgery. The results of this study reveal that vaginal repair could shorten the duration of menstruation and improve anatomical defects (P < 0.05). Moreover, there was no significant difference in the effect of clinical repair between women with one or two previous cesarean sections (P > 0.05)., Conclusion: In CSD patients, the clinical effectiveness of vaginal repair was equivalent between women with one or two previous cesarean sections.

Background: The aim of this study was to develop and validate an individualized score based on preoperative parameters to predict patient outcomes after vaginal repair of cesarean section diverticulum., Methods: This is a retrospective cohort study (Canadian Task Force classification II-2). Patients were enrolled between Jun 11, 2012, to May 27, 2016. Multivariable logistic regression analyses were used to construct the predictive model. Then, we generated a nomogram to assess the individualized risk of poor prognosis after operation. This prediction model included information from 167 eligible patients diagnosed with cesarean section diverticulum who underwent vaginal repair. Class-A healing group was defined as CSD patients who had menstruation duration of no more than 7 days and a thickness of the remaining muscular layer of no less than 5.8 mm after vaginal repair according to conferences. Others were included in the non-class-A healing group. A final nomogram was computed using a multivariable logistic regression model., Results: The factors contained in the individualized prediction nomogram included the depth/ the thickness of the remaining muscular layer ratio, number of menstruation days before surgery, White blood cell and fibrinogen. This model demonstrated adequate discrimination and calibration (C-index = 0.718). There was a significant difference in the number of postmenstrual spotting days (12.98 ± 3.86 VS 14.46 ± 2.86, P = 0.022) and depth/ the thickness of the remaining muscular layer ratio (2.81 ± 1.54 VS 4.00 ± 3.09, P = 0.001) between two groups. Decision curve analysis showed that this nomogram was clinically useful., Conclusions: This cesarean section diverticulum score can predict the outcomes of cesarean section diverticulum and can be useful for counseling patients who are making treatment decisions.

Introduction: Cesarean section scar defects (CSDs) are one of the long‐term complications following cesarean section. They can be detected by transvaginal sonography, hysterosalpingography, sonohysterography and magnetic resonance imaging (MRI). Hysteroscopy is frequently used in evaluating endometrial disease. However, the description of CSDs by hysteroscopy is very limited. Only a few papers about hysteroscopy evaluation have been published. This is an exploratory study to compare hysteroscopic findings with myometrial thickness and post‐surgical outcomes. Material and methods: From February 2019 to December 2020, 143 women with CSDs were enrolled in the observational study. All women suffered from abnormal uterine bleeding and were evaluated in a standardized way with hysteroscopy before vaginal surgery. Dome‐shaped CSDs could be clearly observed in all patients under hysteroscopy. We recorded the pictures of each patient under hysteroscopy and classified them. All patients underwent outpatient review at 3 and 6 months after surgery to obtain menstrual information and CSD scar size by MRI or transvaginal sonography. Results: Pale mucosae in the defect were meager endometrial lining covering the surface of muscle layer, cyst lesions were some cyst lesions in the defect, increased local vascularization was a vascular tree with branching and irregular vascular distribution in defect, polypoid lesions were polypoid lesions in the defect, and serrated niches were two niches at the anterior uterine isthmus. The features of the CSDs observed under hysteroscopy were identified as five phenotypes: pale mucosae (90/143, 62.9%), cyst lesions (23/143, 16.1%), polypoid lesions (19/143, 13.3%), increased local vascularization (27/143, 18.9%) and serrated niches (7/143, 4.9%). The most common finding in scar defects under hysteroscopy was pale mucosae in the CSD. The results suggest that patients with increased local vascularization and serrated niches have a high risk of thinner residual myometrium before vaginal repair (p < 0.05). However, there was no significant difference in menstrual duration or in the outcome of vaginal repair for CSDs between these five phenotypes (p > 0.05). Conclusions: Patients with the abnormal blood vessel or serration phenotypes of defects under hysteroscopy may have a thinner residual myometrium. The phenotypes of hysteroscopic findings of CSDs have no correlation with the outcome of repair. [ABSTRACT FROM AUTHOR]