Challenges in Diagnosis and Prevention of Iatrogenic Endometriosis as a Long-Term Surgical Complication after C-Section
Open accessAbstract
Endometriosis is a gynecological condition caused by the development of endometrial tissue outside the uterine cavity. Naturally, it commonly occurs at locations such as the ovaries and pelvic peritoneum. However, ectopic endometrial tissue may be discovered outside of the typical sites, suggesting the possibility of iatrogenic seeding after gynecological operations. Based on this hypothesis, we developed a study aiming to establish the root cause of atypical implantation of endometrial foci, as the main end point, and to determine diagnostic features and risk factors for this condition, as a secondary target. The research followed a retrospective design, including a total of 126 patients with endometriosis who met the inclusion criteria. A group of 71 patients with a history of c-section was compared with a control group of patients with endometriosis and no history of c-section. Endometriosis that developed inside or in close proximity to surgical incisions of asymptomatic patients before surgical intervention was defined as iatrogenic endometriosis. Compared with patients who did not have a c-section, the c-section group had significantly more minimally invasive pelvic procedures and multiple adhesions and endometriosis foci at intraoperative look (52.1% vs. 34.5%, respectively 52.1% vs. 29.1%). The most common location for endometriosis lesions in patients with prior c-section was the abdominal wall (42.2% vs. 5.4%), although the size of foci was significantly smaller by size and weight (32.2 mm vs. 34.8 mm, respectively 48.6 g vs. 53.1 g). The abdominal wall endometriosis was significantly associated with minimally invasive pelvic procedures (correlation coefficient = 0.469, p-value = 0.001) and c-section (correlation coefficient = 0.523, p-value = 0.001). A multivariate regression analysis identified prior c-section as an independent risk factor for abdominal wall endometriosis (OR = 1.85, p-value < 0.001). We advocate for strict protocols to be implemented and followed during c-section and minimally invasive procedures involving the pelvic region to ensure minimum spillage of endometrial cells. Further research should be developed to determine the method of abdominal and surgical site irrigation that can significantly reduce the risk of implantation of viable endometrial cells. Understanding all details of iatrogenic endometriosis will lead to the development of non-invasive disease diagnosis and minimally invasive procedures that have the potential to reduce postoperative complications.
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TL;DR
In a retrospective single-center study of 126 patients with endometriosis, prior cesarean section was associated with abdominal wall endometriosis and was an independent risk factor (OR = 1.85, p < 0.001). The authors conclude that c-section can seed endometrial tissue and call for strict surgical protocols and further research on prevention.
Key findings
- Among 71 patients with endometriosis after c-section, the most common lesion location was the abdominal wall (42.2% vs. 5.4% in the no-c-section group); c-section patients had smaller foci by size and weight (32.2 mm vs. 34.8 mm; 48.6 g vs. 53.1 g).
- The c-section group had significantly more minimally invasive pelvic procedures (52.1% vs. 34.5%, p = 0.049) and more multiple adhesions and endometriosis foci intraoperatively (52.1% vs. 29.1%, p = 0.017); 80% of patients without prior c-section had no adhesions vs. 53.6% in the c-section group (p = 0.002).
- Abdominal wall endometriosis correlated with minimally invasive pelvic procedures (rho = 0.469, p = 0.001) and c-section (rho = 0.523, p = 0.001); multivariate regression identified prior c-section (OR = 1.85, p < 0.001) and number of pregnancies (OR = 1.32, CI 1.01–1.64, p = 0.038) as significant risk factors.
- Baseline c-section group characteristics: mean age 33 years, mean age at surgery 28 years, latency 27.5 months from intervention to diagnosis, and >30 months from diagnosis to treatment; 59% had a single cesarean delivery, 87.3% had a Pfannenstiel incision, >80% had multiple endometriomas, and 42.2% had lesions at the incision site (fascia 56.3%, muscular layer 21.1%); cyclic pelvic/mid-abdominal pain was reported by 87.3%, dysmenorrhea by 69.1%, and abdominal mass by 61.9%.
Methods
- Retrospective observational single-center study using the database of the University Clinic of Obstetrics and Gynecology Bega, Timisoara, Romania, from January 2010 to November 2021; ethical approval was granted in November 2021 (A59). It included 126 patients with endometriosis: 71 with a history of c-section meeting criteria (at least one c-section, no pre-surgery endometriosis complaints, no macroscopic endometriosis during c-section, symptoms after delivery, surgically excised foci, and histopathological diagnosis of endometriosis) and 55 controls with endometriosis and no prior pelvic surgical interventions (abstract describes no history of c-section).
- Data were retrieved from hospital databases and paper records, including ICD-10 diagnoses and CPT procedures; variables included age, parity, abortion/delivery history, incision type, symptoms, mass size, latency period, imaging, operative findings, and histology. After clinical/imaging diagnosis, patients underwent laparoscopic or laparotomy excision and biopsy; tissue was fixed in 10% buffered formalin, paraffin embedded, and stained with hematoxylin-eosin.
- Analysis used SPSS v26.0 and MedCalc v19; tests included Student’s t-test, Mann–Whitney U-test, Kruskal–Wallis test, chi-square/Fisher exact tests, Pearson/Spearman correlations, and multivariate regression for abdominal wall endometriosis, with alpha = 0.05.
Limitations
- The paper states the retrospective approach and the need to correlate rare findings with uterine surgical procedures; it also states that “a group of controls was not included to facilitate the statistical analysis, leaving the findings at an observational level,” despite describing a 55-patient comparison group.
- Evident from the text: the single-center retrospective design and reliance on existing records limit generalizability and causal inference; the control group is described inconsistently (abstract: no history of c-section; methods: no prior pelvic surgical interventions), and no long-term follow-up or prevention intervention is reported.
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Claims the paper makes
0 of 19 cited sources checked · 0 supported · 0 flagged
- Findingown data
In patients with endometriosis, those with a prior c-section had significantly more multiple adhesions and endometriosis foci at intraoperative look than those without a prior c-section (52.1% vs. 29.1%, p=0.017).
“Multiple adhesions and endometriosis foci were discovered intraoperatively in patients with previous c-sections (52.1%), while only 29.1% had multiple lesions in the group of patients without a history of c-section (p-value = 0.017) (Table 2).”
Quote in the paperSubstantial claim - Findingown data
In patients with endometriosis, those with a prior c-section had significantly more minimally invasive pelvic procedures than those without a prior c-section (52.1% vs. 34.5%, p=0.049).
“By comparing the group of patients with a positive history of cesarean section with the patients without previous c-sections, we observed a significant difference in the minimally invasive procedures, where the first group of patients had significantly more interventions (52.1% vs. 34.5%, p-value = 0.049).”
Quote in the paperNot a substantial claim - Findingown data
The most common location for endometriosis lesions in patients with prior c-section was the abdominal wall (42.2%), compared with 5.4% in patients without prior c-section.
“The most common location for endometriosis lesions in patients with prior c-section was the abdominal wall (42.2% vs. 5.4%)”
- Also stated in: § 4. Discussion · plain
“Although 42.2% of patients with a history of cesarean section were identified as having abdominal wall endometriosis, and although it is an insignificant percentage, it is worth mentioning that 5.4% of abdominal wall endometriosis was also found in patients with no history of cesarean section.”
Quote in the paperSubstantial claim - Also stated in: § 4. Discussion · plain
- Findingown data
Other variables that were significantly associated with abdominal wall location of endometriosis foci in the previous correlation analysis were not identified as significant risk factors.
“Other variables that were significantly associated with abdominal wall location of endometriosis foci in the previous correlation analysis were not identified as significant risk factors (Table 4).”
Quote in the paperNot a substantial claim - Findingown data
C-section was significantly positively associated with abdominal wall location of endometriosis (rho=0.523, p=0.001).
“Additionally, we observed a significant positive association between c-section and abdominal wall location of the endometriosis (rho value = 0.523, p-value = 0.001) and the number of endometriosis foci (rho value = 0.488, p-value = 0.001), while the correlation with foci size was significantly negative (rho value = −0.258, p-value = 0.003).”
Quote in the paperSubstantial claim
- Findingown data
Minimally invasive pelvic procedures were significantly positively associated with abdominal wall location of endometriosis (rho=0.469, p=0.001).
“The correlation analysis determined that there was a significant positive association between minimally invasive pelvic procedures and abdominal wall location of the endometriosis (rho value = 0.469, p-value = 0.001) and the number of endometriosis foci (rho value = 0.465, p-value = 0.001), while the correlation with foci weight and size was significantly negative (Table 3).”
Quote in the paperSubstantial claim - Findingown data
In patients without prior c-section, 80% had no adhesions, compared with 53.6% in patients with prior c-section (p=0.002).
“The intraoperative look accounted for multiple differences between groups, where 80% of patients with no history of c-sections did not have adhesions, compared with 53.6% in the other group (p-value = 0.002).”
Quote in the paperSubstantial claim - Findingown data
Minimally invasive pelvic procedures were significantly positively associated with the number of endometriosis foci (rho=0.465, p=0.001).
“The correlation analysis determined that there was a significant positive association between minimally invasive pelvic procedures and abdominal wall location of the endometriosis (rho value = 0.469, p-value = 0.001) and the number of endometriosis foci (rho value = 0.465, p-value = 0.001), while the correlation with foci weight and size was significantly negative (Table 3).”
Quote in the paperSubstantial claim - Findingown data
C-section was significantly positively associated with the number of endometriosis foci (rho=0.488, p=0.001).
“Additionally, we observed a significant positive association between c-section and abdominal wall location of the endometriosis (rho value = 0.523, p-value = 0.001) and the number of endometriosis foci (rho value = 0.488, p-value = 0.001), while the correlation with foci size was significantly negative (rho value = −0.258, p-value = 0.003).”
Quote in the paperSubstantial claim - Findingown data
C-section was significantly negatively associated with foci size (rho=-0.258, p=0.003).
“Additionally, we observed a significant positive association between c-section and abdominal wall location of the endometriosis (rho value = 0.523, p-value = 0.001) and the number of endometriosis foci (rho value = 0.488, p-value = 0.001), while the correlation with foci size was significantly negative (rho value = −0.258, p-value = 0.003).”
Quote in the paperNot a substantial claim - Findingown data
Endometrial foci were significantly smaller and lighter in patients with prior c-section than in those without prior c-section (32.2 mm vs. 34.8 mm; 48.6 g vs. 53.1 g).
“although the size of foci was significantly smaller by size and weight (32.2 mm vs. 34.8 mm, respectively 48.6 g vs. 53.1 g).”
- Also stated in: § 3. Results · plain
“The size and weight of endometrial foci were significantly larger in patients without a history of c-sections, with an average of 34.8 mm in size and 53.1 g in weight.”
Quote in the paperNot a substantial claim - Also stated in: § 3. Results · plain
- Findingown data
Cesarean section was a statistically significant risk factor for abdominal wall endometriosis (OR=1.85, CI 1.34-2.26, p<0.001).
“The risk factor analysis determined that the number of pregnancies (OR = 1.32, CI (1.01–1.64), p = 0.038) and the cesarean section (OR = 1.85, CI [1.34–2.26], p <0.001) were statistically significant risk factors for abdominal wall endometriosis.”
- Also stated in: § Abstract · plain
“A multivariate regression analysis identified prior c-section as an independent risk factor for abdominal wall endometriosis (OR = 1.85, p-value < 0.001).”
Quote in the paperSubstantial claim - Also stated in: § Abstract · plain
- Findingown data
Minimally invasive pelvic procedures were significantly negatively associated with foci weight and size.
“The correlation analysis determined that there was a significant positive association between minimally invasive pelvic procedures and abdominal wall location of the endometriosis (rho value = 0.469, p-value = 0.001) and the number of endometriosis foci (rho value = 0.465, p-value = 0.001), while the correlation with foci weight and size was significantly negative (Table 3).”
Quote in the paperNot a substantial claim - Premisecitation
Amniotic fluid may facilitate the disconnection of active cells.
“The amniotic fluid may facilitate the disconnection of active cells [26].”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [26] Fatimah, 2018, Skin Endometriosis at the Caesarean Section Scar: A Case Report and Review of the Literature, Cureus
Not checked in the free run.
- Premisecitation
Existing evidence describes symptom onset of iatrogenic endometriosis after c-section occurring anytime between the first menstruation after surgery and seven years following surgery.
“The existing evidence describes patients with symptom onset of iatrogenic endometriosis after c-section occurring anytime between the first menstruation after surgery and seven years following surgery”
Quote in the paperNot a substantial claim0 of 2 sources checked- cites [13] Kill, 2011, Progression of pelvic implants to complex atypical endometrial hyperplasia after uterine morcellation, Obstet. Gynecol. source
Not checked in the free run.
- cites [14] Schuster, 2012, Endometriosis after laparoscopic supracervical hysterectomy with uterine morcellation: A case control study, J. Minim. Invasive Gynecol. source
Not checked in the free run.
- Premisecitation
There is scarce evidence that iatrogenic endometriosis behaves or develops differently from non-iatrogenic endometriosis.
“There is scarce evidence that iatrogenic endometriosis behaves or develops differently from non-iatrogenic endometriosis, since the general clinical presentation and patient complaints with endometriosis mostly include dysmenorrhea, dysuria, dyschezia, chronic pelvic pain, and infertility [11].”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [11] Kotowska, M., Urbaniak, J., Falęcki, W.J., Łazarewicz, P., Masiak, M., and Szymusik, I. (2021). Awareness of Endometriosis Symptoms—A Cross Sectional Survey among Polish Women. Int. J. Environ. Res. Public Health, 18. source
Not checked in the free run.
- Interpretationreasoning
The study connects the iatrogenic mechanism of endometrial cell spread to the peritoneal cavity and abdominal wall.
“Our research connects the iatrogenic mechanism of the endometrial cell spread to the peritoneal cavity and abdominal wall, and it raises awareness of the need for careful management of surgical interventions involving the uterus.”
Quote in the paperSubstantial claim- Rests on an assumption: Patients with prior c-section who developed endometriosis after surgery and had no documented endometriosis before or during c-section had iatrogenic endometriosis caused by the c-section.
- Premisenone given
Available data regarding iatrogenic endometriosis after surgical intervention were sparse and derived from case reports and short case series.
“The available data regarding iatrogenic IE after surgical intervention were sparse and were derived from case reports and short case series, but this topic has recently sparked more interest.”
Quote in the paperSubstantial claim - Premisecitation
Cells can easily be transported into the pelvic floor through amniotic fluid and are carried onto the skin, subcutaneous tissues, or muscles near the surgical incision.
“Cells can easily be transported into the pelvic floor through the amniotic fluid and are carried onto the skin, subcutaneous tissues, or muscles near the surgical incision [25].”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [25] Scott, 1954, Clinical external endometriosis: Probable viability of menstrually shed fragments of endometrium, Obstet. Gynecol.
Not checked in the free run.
- Premisecitation
A variable amount of amniotic fluid containing active endometrial cells might flood and invade the abdominal wound because the hysterotomy is performed during cesarean section.
“Additionally, a variable amount of amniotic fluid containing active endometrial cells might flood and invade the abdominal wound because the hysterotomy is performed during cesarean section.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [25] Scott, 1954, Clinical external endometriosis: Probable viability of menstrually shed fragments of endometrium, Obstet. Gynecol.
Not checked in the free run.
- Classified as probably not a substantial claim. 8
- May combine two claims. 6
Probably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationPneumoperitoneum used in laparoscopic surgery was a major factor contributing to tumor cell implantation.
“It is also believed that pneumoperitoneum used in laparoscopic surgery was the major factor that contributed to tumor cell implantation [28,29].”
Quote in the paperNot a substantial claim0 of 2 sources checked- cites [28] Marras, 2019, Abdominal wall endometriosis: An 11-year retrospective observational cohort study, Eur. J. Obstet. Gynecol. Reprod. Biol. X
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- cites [29] Zayyan, 1998, Port site metastasis after laparoscopic assisted vaginal hysterectomy for endometrial cancer: Possible mechanism and prevention, Gynecol. Oncol. source
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationSome studies raise the hypothesis of post-cesarean scar endometriosis.
“with some of them raising the hypothesis of post-cesarean scar endometriosis [19].”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [19] Tatar, 2018, Post-cesarean scar endometriosis, Turk. J. Obstet. Gynecol. source
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationThe majority of research includes instances of gynecologic surgery for benign conditions such as adenomyosis, uterine leiomyomas, and fibroids.
“The majority of research includes instances of gynecologic surgery for benign conditions such as adenomyosis, uterine leiomyomas, and fibroids [17,18]”
Quote in the paperNot a substantial claim0 of 2 sources checked- cites [17] Rindos, 2017, Diagnosis and management of abdominal wall endometriosis: A systematic review and clinical recommendations, Obstet. Gynecol. Surv. source
Not checked in the free run.
- cites [18] Guo, S.-W. (2020). The Pathogenesis of Adenomyosis vis-à-vis Endometriosis. J. Clin. Med., 9. source
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May combine two claims.
InterpretationreasoningAbdominal wall endometriosis in patients without prior c-section can be explained by endometrial seeding from other invasive procedures identified in the study or by other causes not explained by the current evidence.
“This can be explained by endometrial seeding from other invasive procedures that were identified in this study or other causes that cannot be explained with the existing evidence presented by the current research.”
Quote in the paperNot a substantial claim- Rests on an assumption: Patients with prior c-section who developed endometriosis after surgery and had no documented endometriosis before or during c-section had iatrogenic endometriosis caused by the c-section.
Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
PremisecitationObesity can offer a wide surgical surface for the entrapment of endometrial cells and may impact iatrogenic endometriosis and its severity.
“Some studies suggest that obesity can offer a wide surgical surface for the entrapment of endometrial cells and may impact iatrogenic endometriosis and its severity [30].”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [30] Wang, 1997, Port site metastasis after laparoscopic-assisted vaginal hysterectomy for endometrial cancer: Possible mecanisms and prevention, Gynecol. Oncol. source
Not checked in the free run.
May combine two claims.
PremisecitationWomen with a record of laparoscopic supracervical hysterectomy might have a higher risk of scar endometriosis because the pelvic cavity can be exposed to endometrial cells, especially if morcellation is performed without a containment device.
“Even though, statistically speaking, scar endometriosis occurs most often after obstetric interventions; some studies suggest that women who have a record of laparoscopic supracervical hysterectomy might have a higher risk of advancing into scar endometriosis because the pelvic cavity can be exposed to endometrial cells, especially if morcellation is performed without a containment device [27].”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [27] Wang, 2003, Wound endometriosis: Risk factor evaluation and treatment, J. Chin. Med. Assoc.
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May combine two claims.
PremisecitationCesarean section can expose many endometrial cells during surgery, which can be caught in the freshly manipulated abdominal wound.
“Cesarean section can expose many endometrial cells during the surgery, which can be caught in the freshly manipulated abdominal wound.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [25] Scott, 1954, Clinical external endometriosis: Probable viability of menstrually shed fragments of endometrium, Obstet. Gynecol.
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
PremisecitationEndometrial cells present in the wound healing process can benefit from nutrition and a protective barrier provided by clot formation, and growth can be sustained by secretion of growth factor α by suppression of local immune response.
“Previous research describes the hypothesis of endometrial cells being present in the wound healing process, and these newly implanted endometrial cells can benefit when it comes to the source of nutrition and protective barrier provided by clot formation; growth can be sustained by the secretion of growth factor α by suppression of local immune response.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [25] Scott, 1954, Clinical external endometriosis: Probable viability of menstrually shed fragments of endometrium, Obstet. Gynecol.
Not checked in the free run.
May combine two claims.
Interpretationown dataC-section is an important independent factor associated with abdominal wall endometriosis and can be regarded as a form of iatrogenic endometriosis.
“As the causality of endometriosis in the studied patients cannot be linked entirely to the cesarean section intervention, the significant correlation and risk factor analysis place c-sections as an important independent factor associated with this condition.”
- Also stated in: § 5. Conclusions · plain
“Cesarean sections are an independent risk factor for abdominal wall seeding of endometrial tissue, which can be regarded as a form of iatrogenic endometriosis.”
Quote in the paperSubstantial claim- Rests on an assumption: Patients with prior c-section who developed endometriosis after surgery and had no documented endometriosis before or during c-section had iatrogenic endometriosis caused by the c-section.
- Also stated in: § 5. Conclusions · plain
Probably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationMechanical transplantation is responsible for the evolution of iatrogenic endometriosis, according to two reports.
“However, according to two reports, it is believed that mechanical transplantation is responsible for the evolution of iatrogenic endometriosis as the great majority of the cases of iatrogenic endometriosis occur after the incision of the gravid uterus [24].”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [24] Gunes, 2005, Incisional endometriosis after Cesarean section, episiotomy, and other gynaecologic procedures, J. Obstet. Gynaecol. Res. source
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Probably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationEndometrium during pregnancy creates a favorable microenvironment that makes transplantation and implantation particularly successful.
“In addition, in an old case report, it has been suggested that endometrium during pregnancy creates a favorable microenvironment with certain characteristics that make transplantation and implantation particularly successful [24].”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [24] Gunes, 2005, Incisional endometriosis after Cesarean section, episiotomy, and other gynaecologic procedures, J. Obstet. Gynaecol. Res. source
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationAfter hysterectomy, iatrogenic endometriosis is reported to occur at an incidence of 1.4 percent.
“while after hysterectomy, IE is reported to occur at an incidence of 1.4 percent [13,14].”
Quote in the paperNot a substantial claim0 of 2 sources checked- cites [13] Kill, 2011, Progression of pelvic implants to complex atypical endometrial hyperplasia after uterine morcellation, Obstet. Gynecol. source
Not checked in the free run.
- cites [14] Schuster, 2012, Endometriosis after laparoscopic supracervical hysterectomy with uterine morcellation: A case control study, J. Minim. Invasive Gynecol. source
Not checked in the free run.
The paper relies on this without support.
Patients with prior c-section who developed endometriosis after surgery and had no documented endometriosis before or during c-section had iatrogenic endometriosis caused by the c-section.
“Endometriosis that developed inside or in close proximity to surgical incisions of asymptomatic patients before surgical intervention was defined as iatrogenic endometriosis.”
“As the causality of endometriosis in the studied patients cannot be linked entirely to the cesarean section intervention, the significant correlation and risk factor analysis place c-sections as an important independent factor associated with this condition.”
The paper relies on this without support.
The absence of endometriosis symptoms and macroscopic findings before or during c-section means no endometriosis was present before c-section.
“(2) the patient had no complains related to endometriosis before surgery; (3) no macroscopic findings of endometriosis were observed or documented by the gynecologist while the cesarean section was being performed;”
The paper relies on this without support.
The hospital database and paper records accurately and completely captured baseline characteristics, diagnoses, and procedures.
“All patients’ baseline characteristics and surgical procedures were documented in the hospital database in addition to paper patient records that were examined by qualified professionals participating in the present research.”
“We used a computerized database search to determine the exact diagnosis codified by the International Classification of Diseases (ICD-10), and procedures codified by the Current Procedural Terminology (CPT).”
The paper relies on this without support.
The control group of endometriosis patients without prior pelvic surgical interventions is comparable to the c-section group except for c-section history.
“a control group of patients with endometriosis and no history of pelvic surgical interventions.”
“By comparing the group of patients with a positive history of cesarean section with the patients without previous c-sections, we observed a significant difference in the minimally invasive procedures, where the first group of patients had significantly more interventions (52.1% vs. 34.5%, p-value = 0.049).”
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?
Some authors mentioned cases of AWE after supracervical hysterectomy, especially when no containment device was used.
“Some authors mentioned cases of AWE after supracervical hysterectomy, especially when no containment device was used [38].”
From Malignancy in Abdominal Wall Endometriosis: Is There a Way to Avoid It? A Systematic Review (2024) · cites this paper as [38]
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“After paraffin embedding, staining with hematoxylin-eosin was used to determine the major characteristics of endometrial tissue, as it is the most common method of diagnosis in surgical pathology [21].”
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“These factors serve as indicators for treatment [12]; thus, the care of iatrogenic endometriosis can significantly differ from that of non-iatrogenic endometriosis by the main medical or surgical approach.”
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“In addition, in an old case report, it has been suggested that endometrium during pregnancy creates a favorable microenvironment with certain characteristics that make transplantation and implantation particularly successful [24].”
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Guo, S.-W. (2020) · Journal of Clinical Medicine · doi:10.3390/jcm9020485 · Cited by 165 · cited 1× · see citing works
“The majority of research includes instances of gynecologic surgery for benign conditions such as adenomyosis, uterine leiomyomas, and fibroids [17,18], with some of them raising the hypothesis of post-cesarean scar endometriosis [19].”
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“Cesarean scars such as skin and uterine scars, trocar insertion sites, sigmoid colon, ovaries, bladder, vaginal vault, and parietal peritoneum are the most prevalent locations for IE [2,3].”
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“Cesarean scars such as skin and uterine scars, trocar insertion sites, sigmoid colon, ovaries, bladder, vaginal vault, and parietal peritoneum are the most prevalent locations for IE [2,3].”
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Iatrogenic endometriosis harbors somatic cancer-driver mutations
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“Women with endometriosis have a two- to four-fold increased chance of acquiring these tumors; in addition, mutational investigations have shown a clonal link between endometriosis-associated ovarian carcinomas and endometriotic lesions [16].”
BackgroundEndometriosis-associated Ovarian Cancers
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“Although endometriosis is believed to develop to cancer in less than 1% of instances, investigations have established it as a precursor to clear cell and endometrioid ovarian carcinomas [15].”
BackgroundRindos, N. B., & Mansuria, S. (2017) · Obstetrical & Gynecological Survey · doi:10.1097/ogx.0000000000000399 · Cited by 82 · cited 1× · see citing works
“The majority of research includes instances of gynecologic surgery for benign conditions such as adenomyosis, uterine leiomyomas, and fibroids [17,18], with some of them raising the hypothesis of post-cesarean scar endometriosis [19].”
BackgroundAbdominal wall endometriosis: An 11-year retrospective observational cohort study
Marras, S., Pluchino, N., Petignat, P., Wenger, J.-M., Ris, F., Buchs, N. C., & Dubuisson, J. (2019) · European Journal of Obstetrics & Gynecology and Reproductive Biology: X · doi:10.1016/j.eurox.2019.100096 · Cited by 63 · cited 1× · see citing works
“It is also believed that pneumoperitoneum used in laparoscopic surgery was the major factor that contributed to tumor cell implantation [28,29].”
BackgroundSchuster, M. W., Wheeler, T. L., & Richter, H. E. (2012) · Journal of Minimally Invasive Gynecology · doi:10.1016/j.jmig.2011.09.014 · Cited by 43 · see citing works
(2003) · PubMed · Cited by 39 · see citing works
Post-Cesarean scar endometriosis
Yıldırım, D., Tatar, C., Doğan, O., Hut, A., Dönmez, T., Akıncı, M., Toptaş, M., & Bayık, R. N. (2018) · Journal of Turkish Society of Obstetric and Gynecology · doi:10.4274/tjod.90922 · Cited by 39 · cited 2× · see citing works
“Until now, few previous studies and reviews have described cases of iatrogenic endometriosis developed after cesarean section [19], laparoscopic gastric bypass [22], and cholecystectomy [23].”
BackgroundResultKill, L. M., Kapetanakis, V., McCullough, A. E., & Magrina, J. F. (2011) · Obstetrics & Gynecology · doi:10.1097/aog.0b013e3181f2e0c6 · Cited by 38 · see citing works
Skin Endometriosis at the Caesarean Section Scar: A Case Report and Review of the Literature
Alnafisah, F., Dawa, S. K., & Alalfy, S. (2018) · Cureus · doi:10.7759/cureus.2063 · Cited by 37 · cited 1× · see citing works
“The amniotic fluid may facilitate the disconnection of active cells [26].”
BackgroundCLINICAL EXTERNAL ENDOMETRIOSIS
Scott, R. B., & LINDE, R. W. T. (1955) · Obstetrical & Gynecological Survey · doi:10.1097/00006254-195506000-00021 · Cited by 30 · cited 1× · see citing works
“Cells can easily be transported into the pelvic floor through the amniotic fluid and are carried onto the skin, subcutaneous tissues, or muscles near the surgical incision [25].”
BackgroundAwareness of Endometriosis Symptoms—A Cross Sectional Survey among Polish Women
Kotowska, M., Urbaniak, J., Falęcki, W. J., Łazarewicz, P., Masiak, M., & Szymusik, I. (2021) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph18189919 · Cited by 26 · cited 1× · see citing works
“There is scarce evidence that iatrogenic endometriosis behaves or develops differently from non-iatrogenic endometriosis, since the general clinical presentation and patient complaints with endometriosis mostly include dysmenorrhea, dysuria, dyschezia, chronic pelvic pain, and infertility [11].”
BackgroundKawahara, N., Miyake, R., Yamanaka, S., & Kobayashi, H. (2021) · Cancers · doi:10.3390/cancers13153829 · Cited by 18 · cited 1× · see citing works
“Biochemical diagnostics may involve the determination of the levels of CA125, a highly sensitive but imprecise marker [9].”
BackgroundNawrocka-Rutkowska, J., Szydłowska, I., Rył, A., Ciećwież, S. M., Ptak, M., & Starczewski, A. (2021) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph18126606 · Cited by 17 · cited 1× · see citing works
“It is, however, ineffective for identifying peritoneal endometriosis and foci less than 3 mm in diameter [7].”
BackgroundAbdominal wall endometrioma found during abdominoplasty.
Ostric, S. A., Martin, W. J., & Kouris, G. J. (2006) · Aesthetic Plastic Surgery · doi:10.1007/s00266-005-0099-8 · Cited by 15 · cited 1× · see citing works
“Until now, few previous studies and reviews have described cases of iatrogenic endometriosis developed after cesarean section [19], laparoscopic gastric bypass [22], and cholecystectomy [23].”
Result(2005) · PubMed · Cited by 12 · see citing works
Zayyan, K. S., & Kazmi, N. T. (1998) · Gynecologic Oncology · doi:10.1006/gyno.1998.5027 · Cited by 9 · see citing works
Advances of Laparoscopy for the Diagnosis of Pelvic Congestion Syndrome
Arnaoutoglou, C., Variawa, R., Zarogoulidis, P., et al. (2021) · Medicina · doi:10.3390/medicina57101041 · Cited by 9 · cited 1× · see citing works
“Laparoscopy or laparotomy is the gold standard for diagnosing pelvic endometriosis [10], since the operation enables the assessment of the uterus, appendages, peritoneum, adhesions, and the size and number of foci, hence determining the degree of endometriosis.”
BackgroundIatrogenic endometriosis following apical pelvic organ prolapse surgery: a case report
Çubuk, A., Özkaptan, O., & Neymeyer, J. (2020) · Journal of Medical Case Reports · doi:10.1186/s13256-019-2327-x · Cited by 5 · cited 1× · see citing works
“Introduction Iatrogenic endometriosis (IE) is defined by the appearance of endometrial glands and stroma outside the uterus following certain surgical procedures, including complete or supracervical hysterectomy, myomectomy, cesarean section, and the endometrial tissue seeding of surgical scars during these operations…”
BackgroundTransvaginal Ultrasound as a First-Line Approach in Deep Endometriosis: A Pictorial Essay
Doroftei, B., Maftei, R., Ilie, O., et al. (2021) · Diagnostics · doi:10.3390/diagnostics11030444 · Cited by 5 · cited 1× · see citing works
“The transvaginal ultrasound examination is the first step in detecting endometriosis, since it is readily accessible, non-invasive, and reasonably inexpensive [4].”
Background
Flagged first, then by citations
2 of the 30 references couldn’t be matched to a known paper.
Research works printed but not linked: 1
- Brandt, W.E., and Helms, C.A. (2007). Genital tract: Radiographic imaging and MR. Fundamentals of Diagnostic Radiology, Lippincott Williams and Wilkins. Chapter 35.
Cited by
Sorted by citations
Gunther, K., Fisher, T., Liu, D., Abbott, J. A., & Ford, C. E. (2025) · eLife · doi:10.7554/elife.103825 · Cited by 13 · see citing works
Malignancy in Abdominal Wall Endometriosis: Is There a Way to Avoid It? A Systematic Review
Alaert, J., Lancelle, M., Timmermans, M., Tanos, P., Nisolle, M., & Karampelas, S. (2024) · Journal of Clinical Medicine · doi:10.3390/jcm13082282 · Cited by 9 · see citing works
“Some authors mentioned cases of AWE after supracervical hysterectomy, especially when no containment device was used [38].”
BackgroundRisk Factors for Postoperative Recurrence of Cesarean Scar Endometriosis
Zhong, Q., Qin, S., Lai, H., Yao, S., & Chen, S. (2024) · AJOG Global Reports · doi:10.1016/j.xagr.2024.100349 · Cited by 7 · see citing works
Chen, Y., Dong, Y., Hu, H., Zhou, Y., Xue, M., Li, D., & Sun, L. (2025) · BMC Women s Health · doi:10.1186/s12905-025-03984-w · Cited by 6 · see citing works
“At present, many studies have reported that the increase in the number of cesarean sections is a risk factor for AWE, but no study has reported whether the number of cesarean sections before the onset is related to the recurrence of AWE [17, 18].”
Current Understanding of Endometriosis Pathophysiology and Future Perspectives
Falsetta, M. L., & Chrysilla, E. (2025) · Seminars in Reproductive Medicine · doi:10.1055/s-0045-1810431 · Cited by 3 · see citing works
Iatrogenic Endometriosis of the Breast Mimicking Fat Necrosis: A Case Report
Riva-Morales, I. D. L., Umeres-Francia, G. E., & Novo, J. E. (2023) · International Journal of Surgical Pathology · doi:10.1177/10668969231201416 · Cited by 1 · see citing works
Endometriosis de pared abdominal: serie clínica de 11 casos
Luco-Korn, M. M., Merino, C., Saffie, M. B., & Jorge Carvajal, C. (2024) · Revista chilena de obstetricia y ginecología · doi:10.24875/rechog.24000016
Extrapelvic Endometriosis of the Rectus Abdominis Muscle After Cesarean Section: A Case Report
Atay, A. O., & Yilmaz, D. (2025) · ASIDE Case Reports · doi:10.71079/aside.cr.112125316
Endometriosis During Pregnancy: Maternal and Fetal Considerations
Çopuroğlu, M. (2026) · Obstetrics and gynecology. · doi:10.5772/intechopen.1015030
Bladder Endometriosis: An Updated Narrative Review with Three Surgical Cases
Ramírez, J. C., Gómez, D. T., Cepeda, K. D., & Trujillo, C. G. (2026) · International Urogynecology Journal · doi:10.1007/s00192-026-06689-2
Catamenial pneumothorax presenting as tension pneumothorax: a case report
Olukorode, J., Nwachukwu, N., Popoola, A., Kristilere, H., Oladipupo, Y., Akin-Adewale, R., Oluwagbemi, A., Fafiola, O., Ogidan, L., & Omiko, R. (2026) · Frontiers in Reproductive Health · doi:10.3389/frph.2026.1871134
Dual-site concurrent abdominal wall and lower uterine cesarean scar endometriosis: a case report
Lacsamana, J. M., Genobaga, S., & Genobaga, C. (2026) · Case Reports in Women s Health · doi:10.1016/j.crwh.2026.e00864
- Authors
- Neamtu, R., Dahma, G., Mocanu, A. G., Bernad, E., Silaghi, C.-I., Stelea, L., Citu, C., Dobrescu, A., Bratosin, F., Grigoras, M. L., Motoc, A., Dema, S., Craina, M., Chiriac, V. D., & Gluhovschi, A.
- Affiliations
- Discipline of Obstetrics and Gynecology, “Victor Babes” University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania
- Victor Babeș University of Medicine and Pharmacy Timișoara (RO)
- Discipline of Anatomy and Embryology, “Victor Babes” University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania
- ORCID
- Venue
- International Journal of Environmental Research and Public Health
- Publisher
- MDPI AG
- Published
- 2022-02-27
- Volume
- 19
- Issue
- 5
- Pages
- 2791
- ISSN
- 1660-4601 (ISSN-L)
- PMC
- PMC8910041
- OpenAlex
- W4214758826
- Semantic Scholar
- 9dbf557ab25bcfc7d53d5d2e91341e828504157e
- Cited by
- 12
- References
- 30
- Citations by year
- 2026: 4 · 2025: 4 · 2024: 3 · 2023: 1
- FWCI
- 1.69
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- International Journal of Environmental Research and Public Health (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- RePEc: Research Papers in Economics (submittedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Topics
- Health Sciences › Medicine › Reproductive Medicine › Endometriosis Research and Treatment
- Health Sciences › Medicine › Surgery › Intestinal and Peritoneal Adhesions
- Health Sciences › Medicine › Obstetrics and Gynecology › Gynecological conditions and treatments
- Keywords
- iatrogenic endometriosis, cesarean section, abdominal wall endometriosis, postoperative adhesions, risk factors, surgical irrigation, endometriosis prevention, endometriosis diagnosis
- MeSH terms
- Cesarean Section, Endometriosis, Female, Humans, Iatrogenic Disease, Pregnancy, Retrospective Studies, Gynecologic Surgical Procedures
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-10.
Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-10.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
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