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Cited by 7Endometriosis Research and TreatmentEctopic Pregnancy Diagnosis and ManagementGynecological conditions and treatments

Risk Factors for Postoperative Recurrence of Cesarean Scar Endometriosis

Open access
Zhong, Qiyu, Qin, Shuhang, Lai, Huiling, Yao, Shuzhong, Chen, Shuqin·2024·AJOG Global Reports
DOI 10.1016/j.xagr.2024.100349PMC PMC11077162
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Abstract

The increasing global prevalence of cesarean scar endometriosis (CSE) necessitates a thorough understanding of the risk factors for postoperative recurrence, as this is crucial for developing preventive strategies and informed decision-making. To obtain insight into the clinical risk factors for postoperative recurrence of CSE following open lesion resection. The cohort for this study comprised 272 women, including 26 patients with postoperative recurrence and 246 without recurrence. Various parameters, including baseline characteristics, preoperative, intraoperative, and postoperative conditions, as well as follow-up information, were analyzed. A comparison of these parameters was made between patients with and without postoperative recurrence. Time-to-recurrence analyses were conducted using Cox's univariate and multivariate proportional hazard analyses, the Kaplan-Meier method, and the log-rank test. The results revealed significant differences between patients with and without postoperative recurrence in terms of visual analogue scale (VAS) for abdominal pain (P = .008), method of surgery (P < .001), and incision length (P = .002). The Cox proportional hazard model identified VAS for abdominal pain ≥4 as a significant risk factor for postoperative recurrence (hazard ratio [HR], 3.72; 95% confidence interval [CI], 1.65-8.43, P = .002). Additionally, patients who received removal of scar + excision of mass + exploration underneath the scar (named as integrated excision) had a lower risk of recurrence compared to those who received local excision of mass (HR, 0.14; 95% CI, 0.04-0.48, P = .002). Furthermore, older patients (aged ≥35) years were found to have a lower risk of postoperative recurrence than those <35 years (HR, 0.35; 95% CI, 0.12-1.04, P = .058). The depth of involvement was also identified as a meaningful factor in postoperative recurrence for patients with local excision of mass, as determined by the log-rank test (P = .018). The study highlights that VAS for abdominal pain ≥4 is a risk factor for the recurrence of CSE after open lesion resection. Furthermore, the surgical method of integrated excision was identified as a protective factor.

AI snapshot

Written from the paper’s full text.

TL;DR

In 272 women with histopathologically confirmed cesarean scar endometriosis after open lesion resection, 26 had postoperative recurrence. VAS for abdominal pain ≥4 was a risk factor for recurrence, whereas integrated excision was protective.

Key findings

  • Among 272 women, 26 had recurrence and 246 did not; cumulative recurrence rates were 5.6% (15/268) at 12 months and 11.17% (21/188) at 36 months.
  • Multivariate Cox analysis found VAS for abdominal pain ≥4 was a significant risk factor for recurrence (HR, 3.72 [95% CI, 1.65–8.43]; P=.002), while integrated excision was protective compared with local excision of mass (HR, 0.14 [95% CI, 0.04–0.48]; P=.002); age ≥35 years had HR 0.35 (95% CI, 0.12–1.04; P=.058).
  • The recurrence group had higher rates of moderate/severe abdominal pain (VAS ≥4: 53.85% vs 28.46%; P=.008), more local excision of mass (80.77% vs 49.19%; P<.001), and shorter incision length (median 5 cm [IQR, 4–8] vs 10 cm [IQR, 5–12]; P=.002).
  • In the local excision of mass group, recurrence was higher for fascia/muscle and peritoneum involvement than for skin/subcutaneous/adipose involvement (P=.036; log-rank P=.018); no significant difference by infiltration depth was found in the integrated excision group.

Methods

  • Retrospective cohort of 272 women aged 20–45 years with histopathologically confirmed CSE who underwent open lesion resection at two Sun Yat-sen University affiliated hospitals from January 1, 2011 through October 31, 2021, with follow-up for 2–11 years until November 2022 or menopause.
  • Baseline, preoperative, intraoperative, postoperative, and follow-up data were compared between patients with and without recurrence; time-to-recurrence was analyzed using Cox univariate and multivariate proportional hazard analyses, Kaplan-Meier method, and log-rank test.
  • Two surgical methods were compared: integrated excision (removal of scar, excision of mass, and exploration underneath the scar) versus local excision of mass.

Limitations

  • The paper states that the retrospective design is subject to information bias from missing or erroneous data; no clear criterion was initially determined for selecting the two surgical methods; the study cannot reveal the incidence of CSE; residual confounding may exist; and pathologic margin is not evaluated, so the division between recurrence and residual is flawed and may lead to a high recurrence rate in the evaluation.
  • Evident from the text: the observational retrospective design limits causal inference, and recurrence was defined as a postoperative painful mass found on physical and ultrasound examination rather than by routine histopathologic confirmation.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1016/j.xagr.2024.100349

Cites

40 of 40 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 6 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    In women with cesarean scar endometriosis who underwent open lesion resection, age ≥35 years was associated with a lower risk of postoperative recurrence than age <35 years (HR 0.35 [95% CI 0.12-1.04]; P=.058).

    “In addition, older patients (aged ≥35 years) had a lower risk of postoperative recurrence than those aged <35 years (HR, 0.35 [95% CI, 0.12–1.04]; P=.058).”
    • Also stated in: § RESULTS · plain
      “Furthermore, older patients (aged ≥35 years) were found to have a lower risk of postoperative recurrence than those <35 years (hazard ratio, 0.35 [95% confidence interval, 0.12–1.04]; P=.058).”
    Quote in the paperNot a substantial claim
  • Findingown data

    In women with cesarean scar endometriosis who underwent open lesion resection, the cumulative recurrence rates at 12 and 36 months were 5.6% (15/268) and 11.17% (21/188), respectively.

    “In this study, the cumulative recurrence rates at 12 and 36 months after open lesion resection of CSE were 5.6% (15/268) and 11.17% (21/188), respectively.”
    Quote in the paperSubstantial claim
  • Findingown data

    In women with cesarean scar endometriosis who underwent pelvic exploration, 45.1% (23/51) had concurrent pelvic endometriosis and/or adenomyosis.

    “Pelvic explorations in 51 CSE patients revealed that 45.1% (23/51) of the patients had concurrent pelvic endometriosis and/or adenomyosis.”
    Quote in the paperNot a substantial claim
  • Findingown data

    In women with cesarean scar endometriosis who underwent open lesion resection, the recurrence group had a shorter incision length than the nonrecurrence group (median 5 cm [IQR 4-8] vs 10 cm [IQR 5-12]; P=.002).

    “The incision length in the recurrence group (median, 5 cm; IQR, 4–8) was shorter than that in the nonrecurrence group (median, 10 cm; IQR, 5–12; P=.002).”
    Quote in the paperSubstantial claim
  • Findingown data

    In women with cesarean scar endometriosis who underwent open lesion resection, VAS for abdominal pain ≥4 was a significant independent risk factor for postoperative recurrence after adjustment (HR 3.72 [95% CI 1.65-8.43]; P=.002).

    “After adjusting for incision length, infiltrating depth, size of pathology specimen, and probability of abdominal wall drainage, the results indicated that VAS for abdominal pain ≥4 was a significant risk factor for postoperative recurrence (HR, 3.72 [95% CI, 1.65–8.43]; P=.002).”
    • Also stated in: § RESULTS · plain
      “The Cox proportional hazard model identified the visual analog scale for abdominal pain ≥4 as a significant risk factor for postoperative recurrence (hazard ratio, 3.72 [95% confidence interval, 1.65–8.43]; P=.002).”
    Quote in the paperSubstantial claim
  • May combine two claims. 12
  • The quote only partly states this claim. 7
  • Classified as probably not a substantial claim. 8

  • May combine two claims. The quote only partly states this claim.

    Findingown data

    In women with cesarean scar endometriosis who underwent open lesion resection, CSE was mainly characterized by cyclic abdominal pain (86.03%) and abdominal mass (100%).

    “In this study, CSE was mainly characterized by cyclic abdominal pain (86.03%) and abdominal mass (100%).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). The quote only partly states this claim.

    Findingown data

    In women with cesarean scar endometriosis who underwent open lesion resection, the median latency period from symptom onset to surgery was 3 years.

    “In this study, the median latency period was 3 years, which was consistent with previous literature reports.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    In women with cesarean scar endometriosis who underwent open lesion resection, both the diameter of mass and infiltrating depth had no significant differences between patients with and without recurrence disease.

    “In our study, both the diameter of mass and infiltrating depth had no significant differences between patients with or without recurrence disease.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    In women with cesarean scar endometriosis who underwent open lesion resection, univariate analysis showed age at surgery, VAS for abdominal pain, type of surgery, and incision length were risk factors for CSE recurrence.

    “Univariate analysis of risk factors for recurrent CSE revealed statistically significant factors; age at surgery, VAS for abdominal pain, type of surgery, and incision length were risk factors for CSE recurrence.”
    Quote in the paperSubstantial claim

  • May combine two claims. The quote only partly states this claim.

    Findingown data

    In women with cesarean scar endometriosis who underwent open lesion resection, the number of lesions, infiltrating depth, concomitant pelvic endometriosis and/or adenomyosis, stitching approach, size of pathology specimen, intraoperative bleeding, duration of surgery, catheterization and antibiotic use, probability of abdominal compression, abdominal wall drainage, and postoperative medication did

    “However, the number of lesions, infiltrating depth, concomitant pelvic endometriosis and/or adenomyosis, stitching approach, size of pathology specimen, intraoperative bleeding, duration of surgery, catheterization and antibiotic use, probability of abdominal compression, abdominal wall drainage, and postoperative medication showed no significant differences between patients with or without”
    Quote in the paperNot a substantial claim

  • The quote only partly states this claim.

    Findingown data

    In women with cesarean scar endometriosis who underwent open lesion resection, the recurrence rate in this study was 9.85%.

    “which was similar to our study (9.85%)”
    Quote in the paperNot a substantial claim

  • May combine two claims. The quote only partly states this claim.

    Findingown data

    In women with cesarean scar endometriosis who underwent open lesion resection, a minority had noncyclic (7.35%) or no abdominal pain (3.68%).

    “A minority of the patients had noncyclic (7.35%) or no abdominal pain (3.68%).”
    Quote in the paperNot a substantial claim

  • The quote only partly states this claim.

    Findingown data

    In women with cesarean scar endometriosis who underwent open lesion resection, local excision of mass was associated with a higher postoperative recurrence rate than integrated excision (P<.001).

    “Patients with local excision of mass (P<.001) had higher recurrence rates.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    In prior work, risk factors for recurrence after surgical treatment of abdominal wall endometriosis were the size of the lesion and mass involving the muscle or peritoneum.

    “A retrospective study by Zhao et al21 revealed that the risk factors for recurrence after surgical treatment were the size of the lesion and mass involving the muscle or peritoneum.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [21] Zhao, 2005, Abdominal wall endometriomas, Int J Gynaecol Obstet source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    The margin of the lesion is not evaluated in pathologic examination, and the division between recurrence and residual is flawed, which may lead to a high recurrence rate in the evaluation.

    “At present, the margin of the lesion is not evaluated in the pathologic examination via a pathologist, and the division between recurrence and residual is still flawed, which may lead to a high recurrence rate in the evaluation.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    In women with cesarean scar endometriosis who underwent local excision of mass, local excision may not completely remove deep lesions, resulting in partial residual lesions, or some deeper lesions may be missed.

    “suggesting that local excision of mass may not completely remove deep lesions, resulting in partial residual lesions, or some deeper lesions may be missed.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductown data

    There were no significant differences between recurrence and nonrecurrence groups in age at surgery, BMI, parity, number of CD, history of dysmenorrhea, preoperative medication, previous surgery for CSE, characteristics of abdominal wall pain, maximum diameter of mass, original CD incision type, latency period, preoperative CA125, and CA199 (P>.05).

    “There were no significant differences between the 2 groups in terms of age at surgery, BMI, parity, number of CD, history of dysmenorrhea, preoperative medication, previous surgery for CSE, characteristics of abdominal wall pain, the maximum diameter of the mass during physical examination, original CD incision type, latency period, preoperative cancer antigen (CA) 125, and CA199 (P>.05) (Table 1)”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductreasoning

    The study is retrospective and subject to information bias from missing or erroneous data acquisition.

    “The limitations of our study are those inherent to a retrospective review. Retrospective reviews are subject to information bias in terms of missing or errors in data acquisition.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    Because the study is retrospective, a clear criterion for selection of the two surgical methods was not initially determined.

    “Because this study is retrospective, a clear criterion for the selection of the 2 surgical methods was not initially determined.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    Wide surgical resection is the standard treatment for CSE.

    “Wide surgical resection is the standard treatment for CSE,3,14 and pathologic diagnosis is the basic criteria for confirmation.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [3] Carsote, 2020, Abdominal wall endometriosis (a narrative review), Int J Med Sci source

      Not checked in the free run.

    • cites [14] Mao, 2020, Post-cesarean section abdominal wall endometrioma, Cureus

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    In a prior retrospective study, mass size was not a risk factor for postoperative recurrence.

    “Interestingly, mass size was not a risk factor for postoperative recurrence in the retrospective study by Kim et al.17”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [17] Kim, 2022, Cumulative recurrence rate and risk factors for recurrent abdominal wall endometriosis after surgical treatment in a single institution, Yonsei Med J source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    In women with cesarean scar endometriosis who underwent open lesion resection, the local microenvironment of CSE lesions may lead to changes in hormones, enzymes, and various factors, resulting in poor drug response; therefore, routine drug use after surgery does not guarantee benefits to clinical outcomes.

    “The local microenvironment of CSE lesions may lead to some changes in hormones, enzymes, and various factors, resulting in poor drug response; therefore, routine drug use after surgery does not guarantee benefits to clinical outcomes.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Study design and conductreasoning

    Although various approaches were employed to avoid confounding, residual confounding may exist.

    “Although various approaches were employed to avoid confounding, residual confounding may exist.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    The medical records were reviewed by 1 researcher, and 2 other researchers validated the information to confirm accuracy.

    “The medical records were reviewed by 1 researcher, and 2 other researchers validated the information to confirm accuracy.”
    Quote in the paperNot a substantial claim

  • May combine two claims. The quote only partly states this claim.

    Study design and conductown data

    The final analysis included 272 women with pathologically confirmed CSE who underwent open excision, of whom 26 had recurrent symptoms and 246 did not.

    “Ultimately, 272 patients who underwent the open excision of pathologically confirmed CSE were reviewed systematically, of whom 26 had recurrent symptoms, and 246 did not (nonrecurrent) (Figure 2).”
    Quote in the paperSubstantial claim
20 of 20

  • The paper relies on this without support.

    The risk factors affecting recurrence of cesarean scar endometriosis after surgical resection are rarely elucidated.

    “However, the risk factors affecting the recurrence of CSE after surgical resection are rarely elucidated.”
1 of 1

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Correct demolitive and reconstructive surgery is essential to mitigate incisional hernia risk.

    “Therefore, correct demolitive and reconstructive surgery is essential to mitigate this risk [31].”

    From Surgical Reconstruction of Abdominal Wall Endometriosis Post-Cesarean Section: A Monocentric Experience of a Rare Pathology (2025) · cites this paper as [31]

    The Materials and Methods (Patients; page unavailable) describe excision and possible mesh or flap repair for large tissue defects. The Results address recurrence of cesarean scar endometriosis, not incisional hernia. A search for incisional hernia found it only in a reference title, so our copy does not establish that these surgical measures mitigate hernia risk. (LLM, conf=0.76)

    Experimental — accuracy not yet measured

Cites

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1 of the 41 references couldn’t be matched to a known paper.

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Related

Authors
Zhong, Q., Qin, S., Lai, H., Yao, S., & Chen, S.
Affiliations
Sun Yat-sen University (CN)
Corresponding author
  • Yao, Shuzhong
  • Chen, Shuqin
ORCID
Venue
AJOG Global Reports
Publisher
Elsevier BV
Published
2024-05
Volume
4
Issue
2
Pages
100349
ISSN
2666-5778 (ISSN-L)
DOI
10.1016/j.xagr.2024.100349
PMC
PMC11077162
OpenAlex
W4393969694
Semantic Scholar
74d0531e9551c6463f3b9c97687a80466971b452
Cited by
7
References
41
Citations by year
2026: 4 · 2025: 3
FWCI
2.74
Type
journal article
Language
en
Open access
Licence
Locations
  • AJOG Global Reports (publishedVersion, cc-by-nc-nd)
  • PubMed Central (publishedVersion, cc-by-nc-nd)
  • PubMed (publishedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
Funders
Sun Yat-Sen University
Topics
  • Health Sciences › Medicine › Reproductive Medicine › Endometriosis Research and Treatment
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Ectopic Pregnancy Diagnosis and Management
  • Health Sciences › Medicine › Obstetrics and Gynecology › Gynecological conditions and treatments
Keywords
postoperative recurrence, risk factors, abdominal pain, surgical technique, incision length, age

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