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Background Cesarean scar defects (CSD) are caused by cesarean sections and cause various symptoms. Although there has been no previous consensus on the name of this condition for a long time, it has been named cesarean scar disorder (CSDi). Methods This review summarizes the definition, prevalence, and etiology of CSD, as well as the pathophysiology and treatment of CSDi. We focused on surgical therapy and examined the effects and procedures of laparoscopy, hysteroscopy, and transvaginal surgery. Main findings The definition of CSD was proposed as an anechoic lesion with a depth of at least 2 mm because of the varied prevalence, owing to the lack of consensus. CSD incidence depends on the number of times, procedure, and situation of cesarean sections. Histopathological findings in CSD are fibrosis and adenomyosis, and chronic inflammation in the uterine and pelvic cavities decreases fertility in women with CSDi. Although the surgical procedures are not standardized, laparoscopic, hysteroscopic, and transvaginal surgeries are effective. Conclusion The cause and pathology of CSDi are becoming clear. However, there is variability in the prevalence and treatment strategies. Therefore, it is necessary to conduct further studies using the same definitions. The chronic inflammation that occurs in cesarean scar defect spreads into the uterine cavity and reduces fertility. Such secondary infertility has been termed cesarean scar disorder. This condition can be cured by endoscopic surgery.

Introduction A symptomatic uterine niche is a long‐term complication after a cesarean section (CS). A group of international niche experts reached consensus on a standardized definition of a disorder caused by a symptomatic niche, named cesarean scar disorder (CSDi). However, the prevalence of this disorder is unclear. The aim of this study was to assess the prevalence of CSDi in patients 3 years after a first CS. Material and Methods A secondary analysis was performed on the 3‐year follow‐up results of the 2Close study. The 2Close study was a multicenter randomized controlled trial that evaluated single‐ versus double‐layer uterine closure at CS in 32 hospitals in the Netherlands and included 2292 patients (registered in Dutch trial register: [NTR5480]). Patients, aged ≥18 years, undergoing a first CS were included. Three months after their CS, transvaginal ultrasonography was performed to evaluate the uterine scar for the presence of a niche. Three years after their CS, a digital questionnaire was sent to evaluate the primary and secondary symptoms of CSDi. For this secondary analysis, patients were excluded if they were pregnant, breastfeeding, or using hormonal contraception. The primary outcome of the study was the prevalence of CSDi. Results Of the 1648 participants who completed the 3‐year questionnaire, patients were excluded due to pregnancy or breastfeeding (n = 305), use of hormonal contraception (n = 509), missing ultrasound evaluations (n = 76), and incomplete responses (n = 88). Of the 670 patients included in this analysis, 543 (81.0%) had a uterine niche visible on ultrasound and 127 (19.0%) were without a niche. The prevalence of CSDi at 3 years following a first CS was 42.5% (285/670). Most reported symptoms were chronic pelvic pain (35.0%), postmenstrual spotting (32.8%), and abnormal vaginal discharge (23.2%). Conclusions Our study found a high prevalence of CSDi 3 years following their first CS. Symptoms were self‐reported and the exclusion criteria of pregnancy, breastfeeding, or hormonal contraception use could have introduced selection bias. Therefore, this percentage could be an overestimation of the actual prevalence. However, this high prevalence should be included in counseling patients with a scheduled CS. Three years following a first caesarean section 42.5% of all patients develop Caesarean Scar Disorder. Most reported symptoms within the Caesarean Scar Disorder are chronic pelvic pain, postmenstrual spotting and abnormal vaginal discharge. The long‐term consequences of a Caesarean Section on patients’ health should be structurally investigated.

Background Cesarean scar defects can lead to long-term complications, such as cesarean scar disorders, cesarean scar pregnancy, and the risk of uterine scar dehiscence and rupture in subsequent pregnancy. However, the optimal closure technique to prevent the development of cesarean scar defects (CSD) remains unclear. Therefore, this study aimed to explore whether two-layer interrupted versus two-layer continuous sutures could prevent the formation of CSD. Methods A randomized controlled trial was conducted in a single university hospital in Japan. We recruited pregnant women with ≥ 20 primary or previous cesarean sections. Participants were randomly assigned to either a two-layer interrupted or a two-layer continuous suture group. Residual myometrial thickness (RMT) and the depth of CSD were measured using sonohysterography, 6–8 months post-cesarean section. In addition, the rate of severe CSD, defined as a loss of over 50% of the myometrium, was examined. Results Of the 220 study participants, 43 dropped out; 89 in the interrupted group and 88 in the continuous group underwent sonohysterography. No significant difference in RMT was observed in the interrupted and continuous groups (median 8.1 [interquartile range, 6.2–9.9] mm and 7.9 [4.6–10.3] mm, respectively). However, the incidence of severe CSD in the interrupted group was significantly lower than that in the continuous group (2% versus 22%, p  < 0.0001). Multivariate logistic regression analysis revealed that the factors contributing to developing severe CSD were interrupted suture (odds ratio [OR]: 0.04, 95% confidence interval [95%CI]: 0.006–0.281, p  = 0.0011), the difference in myometrial thickness between the fundal and cervical sides at the center of the uterine wound before suturing (OR: 1.65, 95%CI: 1.144–2.367, p  = 0.0072), and retroversion of the uterus at 6–8 months after cesarean section (OR: 3.42, 95%CI: 1.074–10.946, p  = 0.0374). Conclusion This study suggested that two-layer interrupted sutures are superior to two-layer continuous sutures in preventing the development of severe CSD. Trial registration Clinical trial identification number: University Hospital Medical Information Network registration code, UMIN000040601. URL of the registration site: https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000046334 .

Background The increasing global rate of cesarean sections (CS) has raised concern about associated long-term complications, particularly uterine scar niches. A niche represents a localized myometrial defect at the hysterotomy site, which may lead to abnormal bleeding, pelvic pain, or subfertility. Objective to assess the scar area, niche formation and isolated myometrial defect creation after CS in women undergoing their 1st CS at various stages of 1st stage of labor, irrespective of gestational age. Methods This prospective observational cohort study was conducted at Ain Shams University Maternity Hospital between April 2024 and February 2025 and included 92 women who underwent their first CS for different obstetric indications at various stages of 1st stage of labor. Cervical changes were recorded just before the cesarean section, then all patients were recalled for TVUS three months postoperatively to evaluate scar location, the presence of a niche or isolated myometrial defect, and residual and total myometrial thickness. Results Among the 92 enrolled women, scar-related abnormalities were closely linked to cervical and fetal labor characteristics rather than general maternal or operative factors. While maternal age, BMI, gestational age, fetal weight, operation time, and blood loss showed no significant differences between women with and without niches or isolated myometrial defects ( p  > 0.05 for all comparisons), cervical dilation (6.0 ± 2.3 cm vs. 4.1 ± 1.9 cm), effacement (58.2 ± 24.4% vs. 36.6 ± 24.4%), and advanced fetal station (0 or + 1 in 67.6% of niche cases) were significantly associated with niche formation ( p  < 0.001 for all). Niche width and depth correlated positively with cervical dilation ( r  = 0.591, 0.385; respectively), effacement ( r  = 0.547, 0.381; respectively), and fetal descent ( r  = 0.766. 0.545; respectively) ( p  < 0.05 for all), Conversely, isolated myometrial defect were more frequent in CS performed at less progressive cervical changes and higher fetal head station. Anatomically, niches were more frequent in isthmic scars (55.9%), whereas isolated defects predominated in corpus scars (52.0%). Collectively, these findings suggest that advanced cervical changes contribute to wider and deeper niches, whereas insufficient cervical remodeling favors isolated defects development. Conclusion Advanced cervical changes contribute to wider and deeper niches, whereas insufficient cervical remolding favors isolated defect development. Therefore, labor dynamics represent a pivotal determinant of cesarean scar healing and postoperative uterine integrity.

Introduction Cesarean scar defect (CSD) is a long‐term outcome of cesarean section (CS) and associated with numerous gynecological and obstetric problems. Previous studies indicate that infection may be a risk factor for CSD. Adjunctive azithromycin was shown to reduce the risk of postoperative infection in patients undergoing non‐elective primary cesarean delivery in labor or after the rupture of membranes compared with standard antibiotic prophylaxis. This study investigated the protective effect of adjunctive azithromycin in combination with single‐dose cephalosporin against CSD in women undergoing non‐elective cesarean delivery. Material and methods A randomized, double‐blind, controlled clinical trial was conducted in a University hospital in Shanghai, China. A total of 242 women who underwent their first non‐elective CS were randomly assigned to receive 1500 mg cefuroxime sodium plus 500 mg intravenous azithromycin (n = 121; experimental group) or 1500 mg cefuroxime sodium plus a placebo (n = 121; placebo group). The primary outcome was CSD prevalence, as determined by transvaginal ultrasound and saline infusion sonohysterography within 6 months of delivery. Secondary outcomes were changes in infectious indicators (eg hypersensitive C‐reactive protein and procalcitonin), postoperative morbidity, and use of postoperative antibiotics. We also examined the operative procedure, pathogenic microorganism cultures, and fetal outcomes. Outcomes were compared between groups with the chi‐squared test, Fisher's exact test, or Student's t test. Results Between May 2018 and May 2021, 121 women were randomized to each arm. Because the sonographic follow up was disrupted by the coronavirus disease 2019 pandemic and strict management policies, we merged the follow‐up time points (6 weeks and 6 months) into a single time period (6 weeks to 6 months); 104 and 108 women in the experimental and placebo groups, respectively, completed the first sonographic follow up. CSD was diagnosed by sonography in 34/104 (32.7%) and 50/108 (46.3%) patients in the experimental and placebo groups, respectively (relative risk 0.71, 95% confidence interval 0.50–0.99; p = 0.043). Characteristics of CSD and short‐term infection outcomes did not differ between groups. Conclusions A single dose of intravenous 500 mg azithromycin adjunctive to single‐dose cefuroxime prophylaxis significantly reduced the incidence of CSD in women undergoing non‐elective CS.

Background and Objectives: The isthmocele is a pouch-shaped defect in the anterior uterine wall, site of a previous cesarean section, due to a scar defect or dehiscence. The prevalence could be underestimated, but the rate of cesarean section is still high in the world. The preferable technique to correct this anomaly is not clearly indicated in the literature. Our objective is to evaluate the literature on the surgical treatment of isthmocele in pre-Cesarean women treated with minimally invasive technique. Our hypothesis is that robotic treatment is more effective than other procedures in women desirous of having children. Materials and Methods: The words “isthmocele”, “laparoscopy”, “robot” and “cesarean scar pregnancy” were searched on the main online scientific search sources (PubMed, Google Scholar, Scopus, WES, and Embase, etc.). We included articles in English and French, chosen for the relevance to the topic. We have decided to include also surgical corrections of isthmocele linked to pregnancies at the site of the defect, with particular attention to video training explanation. Results: We analyzed the literature about the minimally invasive surgery for the repair of an isthmocele, evaluating 20 articles. Comparing several surgical techniques, robotic-assisted laparoscopy could be an effective method to correct the defect, without high risk of intraoperative complications. Conclusions: As indicated in the literature, robotic tailored excision and repair of isthmocele (and of concomitant cesarean scar pregnancy) could be advantageous and safe, and it is necessary to promote video-training about this technique.

Cesarean section (CS) scar tissue fibrosis and decreased muscle density increase the risk of uterine rupture and placental implantation in subsequent pregnancies. Given the potent anti-fibrotic and regenerative properties of human amniotic mesenchymal stem cells (hAMSCs), this study investigated their therapeutic potential in repairing uterine scars in a rat model. A full-thickness uterine wall excision model was established to mimic CS scarring. hAMSCs were transplanted at the edge of the incision. Myometrial thickness and collagen deposition within the scar were assessed histologically using hematoxylin and eosin (H&E) and Masson’s staining. Immunohistochemistry evaluated the expression of MMP8, TGF-β1, VEGFA, and α-SMA within the scar region. mRNA transcriptome sequencing and quantitative real-time polymerase chain reaction (qRT-PCR) were employed to explore possible mechanisms. A total of 110 rats were used in the study, 30 in the sham group, 40 in the phosphate-buffered saline (PBS) control group and 40 in the hAMSCs treatment group. Compared with the PBS group, the hAMSCs group exhibited a 35% reduction in collagen fiber area and a 28% increase in smooth muscle cell density (P < 0.05). The MMP8, VEGFA, and α-SAM expressions in the uterine scar area of rats increased, whereas the TGF-β1 expression decreased (P < 0.05). Transcriptome sequencing and real-time fluorescence quantitative PCR results showed that the expression levels of Wnt4, Fzd5, Wnt5a, and PPARD genes were lower in the uterine scar region of rats in the hAMSCs group compared with those in the PBS group. Transplantation of hAMSCs inhibits scar formation in uterine wounds and promotes regeneration of smooth muscle tissue and neovascularization, which in turn promotes uterine wound repair. This effect may be related to the activation of Wnt pathway and the inhibition of PPARD gene expression. Graphical Abstract

Purpose The surgical technique for uterine closure following cesarean section influences the healing of the cesarean scar; however, there is still no consensus on the optimal technique regarding the closure of the endometrium layer. The aim of this study was to compare the effect of closure versus non-closure of the endometrium during cesarean section on the risk to develop uterine scar defect and associated symptoms. Methods A randomized prospective study was conducted of women undergoing first elective cesarean section at a single tertiary medical center. Exclusion criteria included previous uterine scar, preterm delivery and dysmorphic uterus. Women were randomized for endometrial layer closure versus non-closure. Six months following surgery, women were invited to the ambulatory gynecological clinic for follow-up visit. 2-D transvaginal ultrasound examination was performed to evaluate the cesarean scar characteristics. In addition, women were evaluated for symptoms that might be associated with uterine scar defect. Primary outcome was defined as the residual myometrial thickness (RMT) at the uterine cesarean scar. Data are presented as median and interquartile range. Results 130 women were recruited to the study, of them follow-up was achieved in 113 (86.9%). 61 (54%) vs. 52 (46%) of the women were included in the endometrial closure vs. non-closure groups, respectively. Groups were comparable for patient's demographic, clinical characteristics and follow-up time for postoperative evaluation. Median RMT was 5.3 (3.0–7.7) vs. 4.6 (3.0–6.5) mm for the endometrial closure and non-closure groups, respectively ( p  = 0.38). Substantially low RMT (< 2.5 mm) was measured in four (6.6%) women in the endometrial closure group and three (5.8%) of the women in the non-closure group ( p  = 0.86). All other uterine scar sonographic measurements, as well as dysmenorrhea, pelvic pain and intermenstrual bleeding rates were comparable between the groups. Conclusion Closure versus non-closure of the endometrial layer during cesarean uterine incision repair has no significant difference in cesarean scar characteristics and symptom rates at 6 months follow-up.

Objective To evaluate the clinical effectiveness and pregnancy rate after hysteroscopic resection (HR) and/or vaginal repair (VR) in patients with cesarean scar defect (CSD). Methods This prospective observational study enrolled 191 patients who received CSD surgery in the First affiliated hospital of Sun Yat-sen University between September 2019 to February 2022 (96 in HR and 95 in VR, respectively). Patient follow-up were performed three months after surgery in both groups by transvaginal ultrasound to confirm the presence of fluid in the niche, along with the resolution of prolonged menses at the same time. The primary outcome was the clinical effectiveness between HR and VR, identified by the resolution of prolonged menses. Results The rates of niche-fluid disappearance (70.1% vs 60.2%, P  = 0.176) and prolonged menses resolution (74.8% vs 80.0%, P  = 0.341) were comparable for HR and VR. A subgroup analysis for niche size revealed that HR provides patients with small niche a more favorable rate of menstrual resolution compared to VR (size of niche ≤ 15 mm 2 , a OR = 3.423, 95% confidence interval [CI] 1.073–10.918), but patients with large niche experience a lower rate of resolution compared to VR (size of niche > 25 mm 2 , a OR = 0.286, 95% CI 0.087- 0.938). During follow-up, 41 patients who wanted to conceive became pregnant. Kaplan–Meier estimates of the cumulative probability of pregnancy at 12 months and 24 months were 47.1% (95% CI: 34.5%, 58.8%) and 63.8% (95% CI: 52.5%, 72.9%), respectively. The median pregnancy time was 22 months (95% CI: 14.2, 29.8) after VR and 12 months (95% CI: 8.3, 15.7, Gehan-Breslow-Wilcoxon P  = 0.021) after HR. Among patients with subsequent infertility, 31.6% achieved pregnancy by unassisted mode and 29.8% by IVF/ICSI. Moreover, among patients with previously failed IVF/ICSI treatment, 60% (12/20) obtained pregnancy, including 71.4% (10/14) after HR and 33.3% (2/6) after VR. Conclusions Hysteroscopic resection is as effective as vaginal repair at relieving symptoms of CSD-associated prolonged menses. Hysteroscopic resection is the modality of choice with an improvement in prolonged menses for small niche, while vaginal might be considered for a large niche. Furthermore, surgical intervention could improve the clinical pregnancy rate of CSD patients. All of these provide evidence for the individualized management of CSD.

Cesarean wound healing is influenced by surgeon experience, suture type, and technique. This study utilized a simulation model to quantify these effects. Obstetricians–gynecologists and junior residents performed two-layer continuous suturing on uterine models, forming eight groups based on experience level (expert, novice), suture type (conventional, barbed), and technique (Albert–Lembert, layer-to-layer). The ideal wound condition was defined as that achieved by an expert using barbed sutures and the layer-to-layer technique. Wound characteristics were quantified and compared to this ideal. Experts using barbed sutures in Albert–Lembert suturing showed higher wound density but greater deformation and larger endometrial openings (both P < 0.01). Novices using barbed sutures in Albert–Lembert suturing showed similar wound density but significantly greater deformation and opening (both P < 0.01). Novices using conventional sutures in layer-to-layer suturing showed the lowest wound density and longest suturing time (both P < 0.01). Notably, novices using barbed sutures achieved wound characteristics comparable to experts using conventional sutures in Albert–Lembert suturing and results closer to the ideal in layer-to-layer suturing. These findings establish a quantifiable standard for cesarean suturing and suggest that optimizing suture types and techniques may help compensate for differences in surgical expertise.