Abstract / Summary
Background/Objectives: The escalating incidence of cesarean deliveries has driven an increase in cesarean scar pregnancy (CSP). Given the risks of hemorrhage and uterine rupture, surgical intervention is recommended; however, the optimal modality remains unclear. This systematic review and network meta-analysis (NMA) evaluated the efficacy and safety of surgical and combined techniques for CSP management. Methods: Following PRISMA guidelines and PROSPERO registration, electronic databases were searched from January 2010 onwards. Eligible studies included randomized controlled trials and cohort studies (≥5 patients) evaluating primary uterus-preserving surgical interventions for CSP. A frequentist NMA calculated pooled odds ratios (OR) and mean differences (MD), with treatments ranked via surface under the cumulative ranking (SUCRA) curves. Results: Sixty-four studies (8970 women; 63 non-randomized, one randomized) were included. Combined hysteroscopic-laparoscopic surgery (COMB_HL) ranked highest for initial treatment success (SUCRA = 93.5%; OR vs. dilation and curettage [DC] = 6.05, 95% CI: 2.50–14.65), followed by high-intensity focused ultrasound plus curettage (HIFU_C) (SUCRA = 79.1%), laparoscopic resection (70.6%), and ultrasound-guided sclerotherapy plus curettage (64.5%). Methotrexate plus curettage was not statistically distinguishable from DC (OR = 0.71, 95% CI: 0.35–1.46). Blood loss (MD = −39.92 mL) and hospital stay (MD = −1.00 day) favoured advanced modalities, but heterogeneity was very high (I2 = 95.0% and 96.7%) and both prediction intervals crossed the null. HIFU_C reduced overall complications versus DC (OR = 0.23, 95% CI: 0.07–0.72). Reproductive outcomes were too sparsely reported for synthesis. Evidence certainty was low for treatment success and very low for secondary safety endpoints. Conclusions: The available observational evidence suggests that visually guided and combined modalities are associated with a higher probability of success than blind DC. Rankings are hypothesis-generating rather than proof of superiority; treatment should be individualized to CSP type, residual myometrial thickness, gestational age, fertility wishes and local expertise.