Abdominal wall endometriosis after cesarean section: a systematic review of clinical presentation, timing, and outcomes

Objective: To synthesize the available evidence on abdominal wall endometriosis (AWE) after cesarean section (CS) by characterizing its clinical features and timing of presentation, and to determine how often prior or concomitant endometriosis is present, in order to explore whether AWE can develop independently of individual predisposition. Data sources: Systematic search up to September 22nd, 2025. Methods of study selection: Eligibility was defined using the following framework: Population: women with histologically confirmed AWE following CS; Intervention: diagnostic evaluation and surgical excision with histological confirmation; Comparator: no comparator group was required, though exploratory comparisons were performed between women with and without other forms of endometriosis; Outcomes: clinical, diagnostic, and surgical timelines; Study type: case reports or series. The review followed PRISMA 2020 guidelines. Tabulation, integration, and results: 158 studies met inclusion criteria, accounting for 484 cases across all world regions. Median age at diagnosis was 33 years (IQR 29-36). Median time from CS to symptoms was 26 months (IQR 12-48), and from CS to diagnosis 48 months (IQR 36-72). Abdominal pain (96%, 95% CI 93.7-97.6) and a palpable mass (94.1%, 95% CI 91.6-96.1) were the most frequent symptoms. Subfascial involvement was most common (52.8%, 95% CI 45.2-60.4). Recurrence occurred in 5.3% (95% CI 2.8-8.8). Prior endometriosis was reported in 9.4% (95% CI 5.1-15.5), and concomitant disease in 8.1% (95% CI 3.7-14.8). Exploratory comparisons of clinical timelines revealed no significant differences between women with and without other forms of endometriosis. Conclusion: AWE after CS is uncommon but expected to rise as CS rates increase. The rarity of coexisting endometriosis supports iatrogenic implantation per se as a sufficient initiating event. Its extrapelvic location and the well-defined timing of tissue dissemination make AWE an especially informative in-vivo model for studying early mechanisms of endometriosis pathogenesis.