title: Minimally invasive therapy for gynaecological symptoms related to a niche in the caesarean scar: a systematic review.
abstract: BACKGROUND
  Various therapies are currently used to treat symptoms related to the niche (an anechoic area) in the caesarean scar, in particular to treat abnormal uterine bleeding (AUB).
  
  
  OBJECTIVE
  To systematically review the available literature reporting on the effect of various therapies on niche-related symptoms.
  
  
  METHODS
  A systematic search of MEDLINE, Embase, Cochrane, trial registers and congress abstracts from AAGL and ESGE was performed.
  
  
  METHODS
  Articles reporting on the effectiveness of therapies other than hysterectomy in women with niche-related symptoms were included. Studies were included if they reported one of the following outcomes: effect on AUB, pain relief, sexual function, quality of life (QOL), and surgical, anatomic, fertility, or pregnancy outcome.
  
  
  METHODS
  Two authors independently selected the articles to be included. The Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines were followed. A standardised checklist was used to score the methodological quality of the included studies.
  
  
  RESULTS
  Twelve studies were included, reporting on hysteroscopic niche resection (eight studies, 384 patients), laparoscopic repair (one study, 13 patients), (laparoscopic assisted) vaginal repair (two studies, 47 patients), and oral contraceptives (OCs) (one study, 11 patients). Reported AUB improved in the vast majority of the patients after these interventions, ranging from 87 to 100%. The rate of complications was low. Pregnancies were reported after therapy; however, sample sizes and follow-up were insufficient to study fertility or pregnancy outcome. The methodological quality of the selected papers was considered to be moderate to poor, and was therefore insufficient to make solid conclusions.
  
  
  CONCLUSIONS
  More evidence is needed before (surgical) niche interventions are implemented in daily practice.
authors.affiliation: Department of Obstetrics and Gynaecology, Deventer Hospital, Deventer, The Netherlands.
authors.forename: L F
authors.initials: LF
authors.lastname: van der Voet
authors.forename: A J
authors.initials: AJ
authors.lastname: Vervoort
authors.forename: S
authors.initials: S
authors.lastname: Veersema
authors.forename: A J
authors.initials: AJ
authors.lastname: BijdeVaate
authors.forename: H A M
authors.initials: HA
authors.lastname: Brölmann
authors.forename: J A F
authors.initials: JA
authors.lastname: Huirne
mesh_terms: D002585:Cesarean Section; D002921:Cicatrix / Q000150:complications*; D003278:Contraceptives, Oral, Hormonal / Q000627:therapeutic use; D003952:Diagnostic Imaging; D005260:Female; D005298:Fertility; D006801:Humans; D015907:Hysteroscopy; D010535:Laparoscopy; D008796:Metrorrhagia / Q000209:etiology* / Q000628:therapy*; D010146:Pain / Q000209:etiology / Q000601:surgery; D017060:Patient Satisfaction; D011247:Pregnancy; D011256:Pregnancy Outcome; D011788:Quality of Life; D019529:Sexuality
chemical_list: D003278:Contraceptives, Oral, Hormonal
keywords: Caesarean section scar; hysteroscopic resection; laparoscopy; niche; postmenstrual spotting; systematic review; vaginal repair