Comparative effectiveness of different laparoscopic metroplasty techniques in patients with significant uterine scar defects after cesarean section

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Objective: To improve the effectiveness of surgical management in patients with significant uterine scar defects (USD) after cesarean section (CS).

Materials and methods: This comparative prospective study included 113 patients with a diagnosis of significant USD after CS who were interested in repeat pregnancies. All the patients underwent laparoscopic metroplasty. In group 1 (n=61), patients underwent standard laparoscopy, and in group 2 (n=52), laparoscopy was performed using a technique with shortening and plication of the uterine round ligament. Baseline clinical evaluation included clinical data and medical history, index of undifferentiated connective tissue dysplasia (uCTD), preoperative and postoperative scar condition according to expert ultrasound, and analysis of reproductive outcomes. A comparative analysis of the results of two methods of surgical treatment was performed.

Results: In USD patients after CS, the most common complaints were menstrual cycle disorders, including postmenstrual bleeding (70.8%), intermenstrual bleeding (12.4%), heavy menstrual bleeding (3.5%), painful menstrual bleeding (8%), pain syndrome (16.8%), and secondary infertility (31%). There was a high incidence of two or more previous CS (36.3%) and the emergency nature of the previous CS (68.1%). Clinical features of USD included retroflexio uteri (75.2%) and concomitant uCTD (46%). As a result of standard laparoscopic metroplasty, clinical manifestations disappeared in 90.2% of patients and the mean minimal scar thickness (mST) increased significantly to 4.8 (1.8) mm (p=0.00001). The use of round ligament shortening and plication as an additional stage allowed the elimination of clinical manifestations in 100% of cases, and the mean mST as a result of the operation significantly increased and amounted to 5.3 (1.2) mm (p=0.00001). In addition, the increase in mST was significantly greater in the round ligament shortening group than in the standard technique group (3.16 (1.21) and 2.5 (2.07) mm, respectively) (p=0.049). In addition, there were no unsatisfactory results in the round ligament shortening group, while the incidence of unsatisfactory results in the metroplasty without round ligament shortening group was 6/61 (9.8%) (p=0.036). According to the statistical analysis, the main risk factors for unsatisfactory results of metroplasty were three or more previous CS and the presence of uCTD with a diagnostic coefficient (DC) ≥17 points.

Conclusion: Shortening and plication of the round ligament can improve the results of laparoscopic metroplasty. The risk factors for unsatisfactory results of metroplasty are the presence of three or more CS in the past history and uCTD (DC uCTD ≥17 points).

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Sobre autores

Sergey Martynov

Academician V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology, Ministry of Health of the Russian Federation

Autor responsável pela correspondência
Email: s_martynov@oparina4.ru
ORCID ID: 0000-0002-6795-1033

Dr. Med. Sci., Leading Researcher at the Gynecological Department

Rússia, Moscow

Tatyana Sukhareva

Academician V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology, Ministry of Health of the Russian Federation

Email: t_sidorova@oparina4.ru
ORCID ID: 0000-0002-5508-3611

Graduate Student at the Gynecological Department

Rússia, Moscow

Leyla Adamyan

Academician V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology, Ministry of Health of the Russian Federation

Email: l_adamyan@oparina4.ru
ORCID ID: 0000-0002-3253-4512

Dr. Med. Sci., Professor, Academician of RAS, Deputy Director for Science, Head of the Gynecological Department

Rússia, Moscow

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2. Fig. 1. a - uterine scar, adhesions in the area of the vesicoureteral fold; b - opening of the vesicoureteral fold; c - bladder relegation; d - excision of the uterine scar with a monopolar hook; e - scar excised, Gegar dilator in the cervical canal; f - 1st row of sutures (separate vicryl muscular-muscular-mucosal-muscular sutures); g - 2nd row of muscular-muscular-serosal sutures; h - peritonization of the peritoneum with the peritoneal vesicoureteral fold; i - view after plication and shortening of the round ligaments on both sides

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3. Fig. 2. a - scheme of scar excision; b - scheme of the 2nd row of sutures (separate vicryl muscle-muscle-serous sutures)

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4. Fig. 3. Distribution of patients according to the nDST diagnostic coefficient in the studied groups

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5. Fig. 4. Uterine position in groups 1 and 2 (according to laparoscopy after separation of adhesions)

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