O-058 Long-term anatomical and functional outcomes following laparoscopic repair of severe cesarean scar defect

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Abstract Study question Does laparoscopic repair provide durable long-term anatomical, clinical, and reproductive outcomes for patients with severe cesarean scar defects over extended follow-up? Summary answer Long-term laparoscopic repair achieves good anatomical results, symptom resolution, low recurrence, and favorable reproductive outcomes in severe CSD cases, demonstrating durable benefits over extended follow-up. What is known already Characterized by myometrial thinning or dehiscence at the cesarean incision site, CSD can cause abnormal bleeding, pelvic pain, subfertility, and obstetric complications such as scar pregnancies, uterine rupture, or placenta accreta spectrum disorders. Surgical approaches—hysteroscopic, vaginal, and laparoscopic—aim to alleviate symptoms and improve reproductive outcomes. Hysteroscopic treatment suits limited-depth CSDs, but full-thickness repairs via vaginal or laparoscopic methods are indicated for severe cases with residual myometrial thickness (RMT) <2–3 mm. Studies have demonstrated significant short- and mid-term improvements in RMT, symptom resolution, and fertility outcomes following laparoscopic repair. However, data on long-term outcomes are limited. Study design, size, duration This retrospective study included 33 patients who underwent laparoscopic repair for severe CSD at a referral center for fertility surgery between November 2008 and January 2021. Severe CSD was defined as RMT <2.5 mm. The median follow-up was 6.4 years (range: 2.2–14.2 years). Participants/materials, setting, methods Participants were patients with severe CSD presenting with abnormal bleeding, pelvic pain, and/or fertility desire. The surgery involved laparoscopic excision of the CSD and double-layer suturing. The study aimed to evaluate the long-term anatomical and functional outcomes. Outcomes were evaluated three months after surgery and annually through clinical and ultrasound examinations to assess symptoms and echographic recurrences. Main results and the role of chance The median age of patients was 38 years (range: 28–43), and the median BMI was 24.3 kg/m² (range: 18.3–37.5). At presentation, 33.3% of patients reported abnormal bleeding, 30.3% pelvic pain, and 81.8% expressed a desire for future pregnancies. Ultrasound evaluation revealed a median CSD length of 15 mm (range: 11–23), a depth of 9 mm (range: 7–16), and a preoperative RMT of 1.0 mm (range: 0–2.3). Postoperative RMT significantly increased to a median of 5.0 mm (range: 1.0–9.0) at three months (p<.00001) and remained stable throughout follow-up. At one year, symptom resolution was achieved in 90.9% of patients with abnormal bleeding and 100% with pelvic pain. One patient (3.0%) experienced repair failure, necessitating a hysterectomy, and one (3.0%) had a recurrence of severe CSD. Symptom recurrence occurred in 9.1% of patients with abnormal bleeding and 30.0% with pelvic pain during follow-up and was always associated with adenomyosis, endometriosis, or fibroids. Among 24 patients attempting pregnancy, 79.2% achieved clinical pregnancy, with 62.5% live births. All deliveries occurred via elective cesarean section. No cases of CSD ectopic pregnancy, placenta accreta spectrum disorder, preterm delivery, uterine rupture, postpartum hemorrhage, or other severe obstetric complications were observed. Limitations, reasons for caution The study’s retrospective design and single-center nature may limit generalizability. The relatively small sample size, especially in the subgroup with very long-term follow-up, necessitates cautious interpretation of results. Wider implications of the findings This study reinforces laparoscopic repair as a valuable technique for managing severe CSD. It seems reasonable to recommend a single postoperative ultrasound to confirm the surgery’s efficacy, while subsequent routine-specific evaluations may not be necessary for asymptomatic patients. Future research should validate these findings through studies focusing on long-term outcomes. Trial registration number No

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