Exclusive hysteroscopic approach for the treatment of cesarean scar pregnancy: Systematic review of the literature

Background: The increase in cesarean section rates in developed countries over the past decades have led to several direct postoperative complications or long-term effects for subsequent pregnancies like cesarean scar pregnancy (CSP). Objective: Many therapies have been proposed for CSP treatment; however, there is no consensus on the best practice to adopt. Exclusive hysteroscopic treatment has been reported rarely but with good results. To understand the role, the safety, and effectiveness of this approach, we performed a systematic review of the literature. Design: This study is a systematic review. The literature review was performed according to the Preferred Reporting Items for Systematic Reviews. Data Sources and Methods: We searched in PubMed, Scopus, and Google Scholar databases until December 2024, with a combination of keywords: ectopic pregnancy, scar pregnancy, hysteroscopy, and treatment. Case reports of randomized controlled trials, prospective controlled studies, prospective cohort studies, retrospective studies, case series, and case reports were considered eligible. Results: We identified 265 manuscripts, but at the end of the screening process, we included a total of 8 manuscripts and 158 patients. We have analyzed for each study the age of the patients, pregnancy history, gestational age, presenting symptoms, Transvaginal ultrasound findings, basal beta human chorionic gonadotropin (beta-hCG), the type of hysteroscope used, complications and their management, and time of beta-hCG negativization. Conclusion: The hysteroscopic method represents a feasible and safe approach to the CSP treatment with good outcomes and reproducible even with high levels of beta-hCG and a gestational sac over the 3 cm. An initial gestational sac visualization with a diagnostic hysteroscope and the successive use of the resectoscope seems to be the most effective and safe method. Further multicentric studies and randomized clinical trials are needed to improve and standardize the technique.