Effectiveness of vaginal metroplasty for treating cesarean scar defect: a comparative analysis of techniques

Objective: To evaluate the effectiveness of metroplasty via vaginal access in patients with uterine scar after cesarean section (CS).

Materials and methods: This comparative prospective study included 100 patients with a confirmed diagnosis of cesarean scar defect who were planning to become pregnant. The first group of patients (n=50) underwent metroplasty using vaginal access, 10 patients underwent laparotomy (group 2), and the third group (n=40) underwent metroplasty using traditional laparoscopic access. All patients in the study groups were evaluated based on the following criteria: complaints; condition of the uterine scar six months after surgery, as determined by ultrasound data; duration of surgery; amount of blood loss; characteristics of the pain syndrome experienced in the first six hours after surgery; and presence of complications. A comparative analysis of the results of the three surgical treatment methods was conducted.

Results: The following characteristics were identified in the study groups: after CS, the main complaints included menstrual cycle disorders, such as prolonged spotting after menstruation, heavy and frequent menstruation with a regular cycle (menorrhagia, polymenorrhea), painful menstruation, and secondary infertility. Following metroplasty in the study groups, clinical manifestations regressed in all patients after six months. The mean minimum thickness of the myometrium in the scar area increased significantly: in group 1, it ranged from 3.8 to 5.35 mm with a mean value of 5.3 (0.8) mm; in group 2, it ranged from 4.5 to 5.2 mm with a mean value of 4.9 (0.3) mm; and in group 3, it ranged from 3.8 to 5.3 mm with a mean value of 4.7 (0.5) mm. The “scar thickness, mm” indicator dynamics were significantly different before and after metroplasty in all the study groups (p<0.0001). The use of the vaginal method of uterine scar correction showed comparable results, with the following features noted: the duration of the operation in group 1 ranged from 20 to 55 min, with a median time of 35 (30; 40) min; in group 2, the duration of the operation ranged from 75 to 120 min, with a median time of 95 (90; 120) min; and in group 3, the duration of the operation ranged from 70 to 135 min, with a median time of 95 (90; 110) min. This is associated with a more technically simplified surgical correction technique that does not require a laparoscopic stand. Group 1 differed significantly from groups 2 and 3 (p_1,2=0.0003 and p_1,3<0.0001, respectively). The following features were identified when assessing the severity of pain syndrome using VAS: in group 1, the VAS score ranged from 1 to 5 points, with a median of 2 (2; 3); in group 2, it ranged from 6 to 7 points, with a median of 6 (6; 7); and in group 3, it ranged from 4 to 6 points, with a median of 5 (4; 5). Group 1 significantly differed from groups 2 and 3 (p_1,2= 0.00002 and p_1,3= 0.00030, respectively), whereas groups 2 and 3 did not differ significantly in terms of VAS scores (p_2,3= 0.79). Histological examination of the uterine scar in the study material revealed moderate to severe expression of markers of chronic endometritis (CD 138, CD 56, and CD 20), indicating a chronic inflammatory process, concurrent infertility, miscarriage, and failed in vitro fertilization attempts. In several cases, endometrioid lesions were observed in the study material.

Conclusion: The study demonstrated that vaginal access metroplasty is highly effective and has certain advantages over traditional laparoscopic techniques. Therefore, it can be considered the preferred surgical treatment option in areas with limited resources and appropriately qualified specialists.