Perioperative Complications of Hysterectomy After a Previous Cesarean Section: A Systematic Review and Meta-Analysis

Figures & data

Figure 1 PRISMA flow diagram.

Figure 2 Risk of bias assessment using the Newcastle-Ottawa Scale for cohort (left; 24 studies) and case-control studies (right; two studies).

Figure 3 Meta-analysis of associations between previous cesarean delivery and perioperative complications in subsequent hysterectomy.

Abbreviations: k, number of studies; n, number reported outcomes; OR, odds ratio; previous CS, previous cesarean section; , sampling variance; , variance between reported outcomes from the same study; , variance between studies; NA, not applicable.

Figure 4 Meta-analysis of associations between previous cesarean delivery and perioperative complications in subsequent hysterectomy according to the study design.

Abbreviations: k, number of studies; n, number reported outcomes; OR, odds ratio; previous CS, previous cesarean section; , sampling variance; , variance between reported outcomes from the same study; , variance between studies; NA, not applicable.

Table 1 Subgroup Analysis According to Routes of Operation

Outcomes	Route of Operation
	Vaginal (n=5)		Minimal Invasive (n=10)		Mix (n=11)
	k (n)	OR (95% CI)	k (n)	OR (95% CI)	k (n)	OR (95% CI)
Crude Analysis
Urinary tract injury	2 (2)	2.96 (0.37–23.40)	6 (8)	6.85 (3.41–13.73)	7 (10)	1.98 (1.43–2.74)
Wound complications	1 (1)	0.20 (0.02–1.60)	1 (1)	0.29 (0.01–5.66)	7 (9)	2.27 (1.97–2.61)
Gastrointestinal injury	1 (1)	9.56 (0.59–154.47)	2 (2)	1.64 (0.26-10.50)	4 (4)	1.68 (1.14–2.48)
Fistula formation	2 (2)	0.87 (0.18–4.17)	0 (0)	NA	2 (2)	2.34 (0.57–9.64)
Reoperation	0 (0)	NA	0 (0)	NA	2 (2)	1.46 (1.19–1.78)
Postoperative infections	3 (7)	1.25 (0.91–1.72)	0 (0)	NA	3 (5)	1.55 (1.23–1.95)
Blood transfusion	3 (3)	0.96 (0.30–3.06)	1 (1)	0.93 (0.42–2.05)	3 (3)	1.46 (1.01–2.10)
Postoperative febrile	1 (1)	0.91 (0.50–1.64)	0 (0)	NA	1 (1)	1.21 (0.86–1.70)
Readmission	0 (0)	NA	0 (0)	NA	3 (3)	1.01 (0.86–1.19)
Death	1 (1)	0.50 (0.02–12.42)	0 (0)	NA	1 (1)	0.97 (0.05–18.79)
Adjusted Analysis
Urinary tract injury	0 (0)	NA	0 (0)	NA	3 (4)	2.21 (1.46–3.34)
Gastrointestinal injury	0 (0)	NA	0 (0)	NA	1 (1)	1.83 (1.11–3.03)
Readmission	0 (0)	NA	0 (0)	NA	1 (1)	0.88 (0.72–1.08)

Abbreviations: n, number of studies; k, number of studies for each outcome; (n), number of reported outcomes; OR, Odds ratio; CI, confidence interval; NA, not applicable.

Table 2 Sensitivity Analysis by Excluded High Risk of Bias Studies

Outcomes	Original Analysis Results		Sensitivity Analysis Results
	k (n)	OR (95% CI)	k (n)	OR (95% CI)
Crude Analysis
Urinary tract injury	15 (20)	3.15 (2.01–4.94)	2 (3)	1.80 (1.47–2.20)
Wound complications	9 (11)	2.24 (1.94–2.57)	1 (1)	2.21 (1.90–2.57)
Gastrointestinal injury	7 (7)	1.73 (1.19–2.53)	1 (1)	1.90 (1.21–2.98)
Fistula formation	4 (4)	1.50 (0.53–4.29)	0 (0)	NA
Reoperation	2 (2)	1.46 (1.19–1.78)	0 (0)	NA
Postoperative infections	6 (12)	1.44 (1.22–1.71)	1 (3)	1.53 (1.10–2.15)
Blood transfusion	7 (7)	1.35 (1.03-1.76)	1 (1)	0.14 (0.01–2.35)
Postoperative febrile	2 (2)	1.13 (0.84–1.51)	0 (0)	NA
Death	2 (2)	0.72 (0.08–6.31)	0 (0)	NA
Readmission	3 (3)	1.01 (0.85-1.26)	1 (1)	0.95 (0.79–1.14)
Adjusted Analysis
Urinary tract injury	3 (4)	2.21 (1.46–3.34)	3 (4)	2.21 (1.46–3.34)
Gastrointestinal injury	1 (1)	1.83 (1.11–3.03)	1 (1)	1.83 (1.11–3.03)
Readmission	1 (1)	0.88 (0.72–1.08)	1 (1)	0.88 (0.72–1.08)

Abbreviations: k, number of studies for each outcome; (n), number of reported outcomes; OR, Odds ratio; CI, confidence interval; NA, not applicable.