Hysteroscopy versus laparoscopy and transvaginal approach for treating cesarean scar defect: a systematic review and meta-analysis

Background Cesarean scar defect (CSD) is increasingly recognized as a cause of postmenstrual abnormal uterine bleeding, pelvic symptoms, and potentially impaired fertility. Several surgical approaches are available, but their comparative effectiveness and perioperative outcomes remain uncertain. Objective To compare the efficacy and safety of hysteroscopic, laparoscopic, and transvaginal surgical treatment of CSD. Methods A systematic review and meta-analysis were conducted according to PRISMA guidance and registered in PROSPERO (CRD420251000047). PubMed, Web of Science, Scopus, Cochrane Library, and clinical trial registries were searched from inception to September 2026. Randomized and observational comparative studies and single-arm studies were eligible. Comparative outcomes were pooled as odds ratios (ORs) or mean differences (MDs), while single-arm outcomes were summarized as pooled proportions or mean changes. Results Forty-two studies involving 2822 participants were included. Compared with laparoscopy, hysteroscopy was associated with shorter operative time (MD − 50.28 min, 95% CI − 78.79 to − 21.77), lower blood loss (MD − 33.33 mL, 95% CI − 41.42 to − 25.24), shorter hospital stay (MD − 2.85 days, 95% CI − 3.78 to − 1.91), and fewer complications (OR 0.24, 95% CI 0.07–0.81). Similar perioperative advantages were observed compared with transvaginal surgery. No significant differences were found between approaches in pregnancy outcomes, overall treatment response, cure, or partial improvement. Heterogeneity was substantial for many perioperative and anatomical outcomes. Conclusion Hysteroscopic treatment demonstrated favorable perioperative outcomes compared with laparoscopic and transvaginal approaches, while comparative evidence did not establish a consistent difference in reproductive or overall clinical effectiveness. Interpretation is limited by substantial heterogeneity, predominantly observational evidence, and potential selection bias. Interpretation of reproductive outcomes is limited by substantial heterogeneity, predominantly observational evidence, potential selection bias, and lack of adjustment for fertility related confounders. Trial registration Registration number CRD420251000047.