Comparisons between laparoscopic and laparotomic surgery for CSP have not been reported. Laparotomic resection has many advantages, such as completely removing pregnancy tissue implanted in the scar, repairing scar defects and reducing the risk of recurrence, but it leaves large surgical wounds . Laparoscopy has been widely used in gynaecology. Likewise, laparoscopic surgery has many advantages in the treatment of CSP. In the present study, 278 cases met the inclusion criteria. These patients were treated with laparoscopic surgery or transabdominal surgery. The hysterotomy rate was 30.68%, which reflects the proportion of high-risk CSP patients admitted to our centre. Moreover, few studies have focused on exploring the best treatment strategy in high-risk CSP, and there are no similar reports in the available literature. Hysterotomy with laparoscopy in the treatment of high-risk CSP resulted in fewer complications than laparotomy in this work.
In this study, more patients underwent laparoscopic surgery than laparotomy after other treatments failed. In addition, laparoscopy involved less bleeding and fewer blood transfusions than laparotomy. At the same time, we also observed that the total number of days of hospitalization and postoperative hospitalization were better in the laparoscopic group than in the laparotomic surgery group. In summary, we have shown that laparoscopic surgery is superior to laparotomic surgery in the treatment of high-risk CSP. Hysterotomy with laparoscopy in the treatment of high-risk CSP resulted in fewer complications than laparotomy in this work.
To reduce the risk of bleeding during or after the operation, some surgeons try to pretreat blood vessels in various ways. UAE is currently accepted as a treatment or pretreatment for CSP. However, UAE may affect the blood supply of the uterus and ovaries and cause pelvic pain, pulmonary embolism and endometrial atrophy . Bilateral uterine artery (or internal iliac artery) ligation or temporary arterial occlusion has been used for vascular pretreatment in CSP . In our retrospective analysis, the residual tissue, reoperation and intraoperative blood transfusion rates in patients treated with temporary vascular occlusion were better than those in patients treated with permanent vascular occlusion. Therefore, patients benefitted more from temporary arterial occlusion in both groups.
In some of the retrospective studies, laparoscopic or open surgery was used as a remedy after other treatments were ineffective or after massive bleeding. Therefore, there is the possibility of underestimation of the severity of the disease before the operation. This leads to a potential increase in risk and an increased burden on patients [16–18]. In other studies, laparoscopic or open surgery was used. However, there was no explanation for the use of these treatments or for the inability to compare laparoscopic with open surgery [19–22]. In a prospective study, all patients underwent MTX embolization under UAE, followed by D&C or hysteroscopy combined with laparoscopy. As a remedial measure after D&C, laparotomy was performed in 21.2% of patients and even led to hysterectomy in a patient . In the case of high-risk CSP, D&C may not be appropriate.
More importantly, we cannot go to the other extreme and must carefully choose medical treatment or D&C under hysteroscopy or ultrasound monitoring for the most dangerous type of CSP. For type II CSP, fatal intraoperative and/or postoperative bleeding, tardive intermittent massive vaginal bleeding, residual tissue, a slow decrease or even an increase in the serum β-hCG level and intrauterine infection were likely to occur following treatment by the above methods. In addition, CSDs are often deep or irregular, making it difficult for the instrument to reach the deepest part and inevitably resulting in residual tissue. Furthermore, intraoperative bleeding, perforation of the uterus, bladder injury and other serious complications could occur . Therefore, timely hysterotomy may avoid the above situations given a definite diagnosis.
In the present study, 278 cases met the inclusion criteria. These patients were treated with laparoscopic surgery or transabdominal surgery. The hysterotomy rate was 30.68%, which reflects the proportion of high-risk CSP patients admitted to our centre. Of course, as one of the major tertiary referral hospitals in China, these data also indicate that doctors must pay proper attention to CSP. However, we found that the CSP classification as determined either by the Vial criteria or by Chinese experts could not truly reflect the seriousness of the CSP we observed, which was inconsistent with our clinical practice. Hysterotomy was performed for most type II CSP (according to the Chinese expert consensus) patients who underwent laparoscopy or laparotomy. This may lead to an overemphasis on excessive surgical treatment, which increases patient pain, hospitalization costs and length of stay. Is this true outside of our own observations? Previous studies have shown that either laparoscopy or laparotomy was performed mainly for type II CSP (Val et al).
Our research aimed to explore a suitable, effective and safe surgical approach for the treatment of high-risk CSP. To better guide clinical practice, we propose a new method for the classification of CSP, which could improve the awareness and identification of high-risk CSP. We also suggest that a comprehensive assessment be made of the probability of recurrent CSP or CSD after hysterotomy. It is not clear whether blocking the arteries will affect the function of the female reproductive system. When subsequent follow-up data become available, there will be a new evaluation.
Our study still has some shortcomings. It is limited by its retrospective nature, the heterogeneity of the data and the reliance on clinical CSP data not originally collected for research purposes. Additionally, it was limited by being a single-centre experience and having potential selection bias, which may limit its external validity. Our results may not represent the findings of other hospitals. Another limitation of our study is the incomplete follow-up, which makes it difficult to conduct a comprehensive analysis of the follow-up parameters, such as menstruation, ovarian function and fertility.