Cesarean Section with Adenomyomectomy: Bridging Obstetric Delivery and Reconstructive Uterine Surgery

Introduction Adenomyosis is a chronic gynecologic condition characterized by the presence of endometrial glands and stroma within the myometrium, leading to uterine enlargement and impaired contractility.[1] Additional reports further delineate disease spectrum, imaging correlates, and pregnancy-related complications in adenomyosis.[2-4] Clinically, it presents with severe dysmenorrhea, menorrhagia, and subfertility, with the reproductive impact particularly evident in cases of diffuse or massive disease.[5] Once considered a condition affecting primarily multiparous women near menopause, advances in imaging techniques have broadened its recognition among reproductive-aged individuals.[6,7] Despite increased awareness, the reproductive consequences of adenomyosis remain underexplored. Evidence indicates that adenomyosis can impair implantation, increase miscarriage risk, and reduce success rates in assisted reproductive technology (ART).[8-10] In extensive cases, myometrial disruption and inflammation significantly hinder conception and gestational maintenance.[11] Conventional treatments, such as hormonal suppression or hysterectomy, often preclude fertility altogether. To address fertility goals, uterus-sparing surgery, interventional radiology options, and contemporary medical protocols have been explored with variable success.[12-20] Traditionally, massive adenomyosis has been regarded as a surgical endpoint in patients with intractable symptoms or failed ART. Evidence from comparative and technique-focused series supports selective uterus-preserving surgery in appropriate candidates.[21,22] Conservative surgical excision—adenomyomectomy—has gained traction in cases of localized disease.[23,24] However, in diffuse or transmural adenomyosis, the procedure remains limited because of technical challenges, the risk of recurrence, and concern regarding uterine rupture in future pregnancies.[25,26] Cesarean adenomyomectomy has emerged as a highly specialized approach that combines fetal delivery with intraoperative excision of adenomyotic tissue. Initially described in case reports from Japan and South Korea, this method enables simultaneous delivery and uterine reconstruction in patients with severe adenomyosis.[23,24] Subsequent case-based literature has documented successful perinatal outcomes following cesarean adenomyomectomy in carefully selected patients.[27-30] Although the technique is not new, its use in term pregnancies with massive disease represents a novel surgical strategy that may expand fertility-preserving options. The approach remains controversial. Technical complexity, intraoperative blood loss, and long-term uterine integrity are legitimate concerns.[5] Most available data come from small-scale reports without standardized protocols or long-term follow-up.[31] Nevertheless, accumulating evidence of successful live births and uterine preservation has prompted renewed interest in evaluating its clinical role. Emerging guidance and expert perspectives now discuss where this approach may fit within fertility-preserving care pathways.[32-37] To date, there is no comprehensive review that contextualizes cesarean adenomyomectomy within the broader spectrum of fertility-preserving interventions for severe adenomyosis. This review aims to address that gap by analyzing reported outcomes, surgical indications, operative techniques, and long-term implications. By synthesizing clinical experiences and identifying future research needs, we examine the potential of cesarean adenomyomectomy as an emerging surgical strategy in the management of advanced adenomyosis. Methodology This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. The objective was to systematically identify and synthesize clinical literature on cesarean adenomyomectomy performed during delivery in patients diagnosed with massive uterine adenomyosis, specifically focusing on cases that reported live birth outcomes. Studies were considered eligible if they were peer-reviewed, published between January 2000 and May 2025, and reported original clinical data on cesarean adenomyomectomy in the context of live birth. Eligible publications included case reports, case series, cohort studies, and retrospective analyses in which patients had a confirmed diagnosis of adenomyosis based on histopathological findings or preoperative imaging. Only studies involving human subjects and published in English were included. Studies were excluded if they did not describe the intraoperative excision of adenomyotic tissue during cesarean section, if they were nonoriginal articles such as reviews or commentaries, or if they were preclinical, in vitro, or animal studies. A comprehensive literature search was performed using four databases: PubMed/MEDLINE, Scopus, Web of Science, and the Cochrane Library. The search was finalized in May 2025. A combination of keywords and Boolean operators was adapted for each database. Core terms included “adenomyosis,” “massive adenomyosis,” “cesarean section,” “adenomyomectomy,” “uterine-sparing surgery,” and “live birth,” with search strings combining terms such as (“adenomyosis” OR “diffuse adenomyosis”) AND (“cesarean section” OR “caesarean delivery”) AND (“adenomyomectomy” OR “myometrial excision”) AND (“live birth” OR “pregnancy outcome”). Filters were applied to restrict results to English-language articles involving human subjects and published within the defined time frame. In addition, the reference lists of all included studies were manually screened to identify potentially relevant articles not captured in the primary search. Two independent reviewers performed the title and abstract screening. A full-text review was then conducted for studies meeting the inclusion criteria or where eligibility remained uncertain. Discrepancies were resolved through discussion and consensus. A third reviewer independently cross-checked the final data set to ensure completeness and accuracy. Data extraction was performed using a structured matrix that captured the author’s name, year of publication, study location, number of cases, patient demographics including age and parity, diagnostic methods, extent of adenomyosis, surgical indication and technique, intraoperative findings, maternal and neonatal outcomes, follow-up duration, and any recurrence or postoperative complications. The methodological quality of case reports and series was assessed using a modified CARE checklist, while the Newcastle–Ottawa Scale was used to appraise observational studies. Given the heterogeneity of study designs and outcome measures, a quantitative meta-analysis was not feasible. Therefore, a narrative synthesis was undertaken, organized thematically by indication, surgical technique, maternal and fetal outcomes, and long-term reproductive implications. Findings are presented descriptively, including a PRISMA flow diagram [Figure 1], summary tables of included studies [Table 1], surgical decision-making indicators [Table 2], and outcome correlations with surgical technique [Table 3]. To complement the tabulated data, Figures 2–5 provide sequential visual documentation of key diagnostic, intraoperative, and pathological findings integral to the reviewed cases. Figure 2 illustrates the imaging characteristics of adenomyosis in early pregnancy, Figure 3 depicts representative intraoperative steps during cesarean adenomyomectomy, Figure 4 shows postoperative uterine reconstruction and outcomes, and Figure 5 presents histopathological confirmation of adenomyosis. Together, these figures support the methodological framework by demonstrating how clinical, surgical, and pathological evidence was evaluated across the included studies. Conceptual illustrations of the surgical approach and its evolving clinical role are provided in Figures 6 and 7. Subsequently, Figure 8 provides an integrated flowchart outlining the overall surgical decision-making and operative pathway. This structured and rigorous methodology provides a transparent synthesis of existing clinical evidence and supports the emerging consideration of cesarean adenomyomectomy as a potential fertility-preserving intervention for patients with extensive adenomyosis.

and Findings Study selection process A comprehensive literature search using PubMed, supplemented by Scopus and Google Scholar, was completed in May 2025 using the keyword “cesarean adenomyomectomy.” The search initially identified 21 articles. After removing duplicates and screening titles and abstracts for relevance, 13 studies underwent full-text review. Of these, only eight met the predefined inclusion criteria, which required original clinical data describing cesarean delivery with concurrent surgical resection of adenomyosis and documentation of live birth outcomes. These included six single-patient case reports and two small case series, yielding a total of 18 cesarean adenomyomectomy procedures in patients with adenomyosis confirmed by radiologic or histopathologic evaluation. The most frequent reasons for exclusion were the absence of a cesarean context (n = 5), nonoriginal data (n = 4), and lack of live birth outcome (n = 4). The PRISMA flow diagram illustrating this selection process is presented in Figure 1. Population characteristics The 18 cases included in this review involved patients aged 29 to 39 years. Most were nulliparous women with a history of infertility or prior unsuccessful assisted reproductive treatments.[5,8,11,24] All patients had symptomatic adenomyosis, including severe dysmenorrhea, menorrhagia, or chronic pelvic pain, often refractory to hormonal management.[9,42] Imaging with either transvaginal ultrasound or magnetic resonance imaging (MRI) revealed focal or diffuse adenomyosis and uterine enlargement.[7,38] Adenomyosis affected the anterior posterior, or fundal myometrium, often causing nodular, distortion of the uterine contour. Uterine size ranged from normal to the equivalent of a 16–20-week pregnancy. Histopathologic confirmation was reported in all case series and in most individual reports.[23,39] Surgical mechanism and technique Cesarean delivery was performed either electively or emergently between 28 and 38 weeks of gestation. Adenomyomectomy was undertaken following delivery of the fetus and placenta, typically through a classical vertical or transverse uterine incision. Resection of adenomyotic tissue involved wedge excision, segmental removal, or thinning of the myometrial wall, with hemostasis achieved using vasopressin injection, bipolar coagulation, uterotonics, or temporary uterine artery ligation.[24,26] In several cases, surgeons performed layered uterine reconstruction using absorbable sutures. Estimated intraoperative blood loss ranged from 500 to over 1,500 mL, with at least five patients requiring blood transfusion. Operative times ranged from 120 to 210 min, particularly in cases involving posterior wall lesions or extensive adhesions.[39-41] Maternal and perinatal outcomes All 18 procedures resulted in live births. Seventeen neonates had Apgar scores above 7 at 5 min, and one preterm infant required brief neonatal intensive care but survived. No maternal deaths were reported. Intraoperative complications were limited to transient hypotension or mild febrile morbidity in three patients. There were no cases of uterine rupture, atony requiring hysterectomy, or adjacent organ injury. Postoperative recovery was uneventful in nearly all cases, with hospital discharge occurring within 5 to 7 days.[24,41,43] These findings suggest that cesarean adenomyomectomy, when performed by experienced surgical teams, can be a viable and safe option in appropriately selected patients. Key clinical and surgical data are summarized in Table 1, and operative strategies correlations with corresponding outcomes are synthesized in Table 3. Reproductive and long-term follow-up Follow-up data were available for 12 patients. Of these, five attempted conception within 12 to 24 months after surgery. Three achieved spontaneous pregnancy, and two delivered healthy infants via repeat cesarean section without evidence of uterine rupture or abnormal placentation. Symptom recurrence occurred in two patients within 18 months, both of whom resumed hormonal therapy.[5,24] Although based on a small sample, these findings offer cautious optimism regarding fertility preservation following cesarean adenomyomectomy. Timeline and evolution of the technique The earliest documented case of this procedure appeared in 2005, involving intraoperative adenomyomectomy performed during cesarean delivery in a patient with longstanding infertility.[23] From 2005 to 2015, case reports were sparse and originated primarily from Japan. Since 2017, however, reports have gradually increased, emerging from South Korea, Taiwan, and more recently, Western countries.[24,41,43] Although most publications remain case-based, they highlight growing interest in the fertility-preserving potential of this technique. Recent studies have also proposed patient selection criteria, standardized surgical protocols, and preliminary long-term outcomes. The evolution of this technique is illustrated in Figure 6. Case in focus: Cesarean adenomyomectomy in a hemodynamically unstable patient with transmural adenomyosis A 33-year-old Indonesian woman (G2P1A0) at 32+4 weeks of gestation presented emergently with premature rupture of membranes, vaginal bleeding, and uterine contractions. Her obstetric history included a previous preterm cesarean delivery at 27 weeks due to uterine fibroids, which had resulted in neonatal death following prolonged neonatal intensive care unit (ICU) care. The current pregnancy was unrecognized until approximately 7 weeks of gestation. Subsequent evaluation by maternal-fetal medicine specialists revealed a fundal pregnancy encased within an irregular, nodular uterine mass consistent with diffuse adenomyosis. Imaging identified multiple masses measuring between 3 and 8 cm [Figure 2]. Despite the distorted uterine architecture, the pregnancy progressed into the third trimester under close surveillance. At 30 weeks, the fetus was diagnosed with symmetrical intrauterine growth restriction, although Doppler studies, placental morphology, and noninvasive genetic screening were all within normal limits. On admission, the fetus was in complete breech presentation with a right lateral placenta. Category II fetal heart tracings and the onset of active labor prompted an emergency cesarean section via a vertical uterine incision. A live male infant weighing 1,400 g was delivered with reassuring Apgar scores. Placental delivery was uncomplicated and showed no evidence of invasion [Figure 3]. During uterine exteriorization and hysterotomy closure, the surgical team observed diffuse adenomyosis involving both the anterior and posterior uterine walls. The uterus appeared friable and nodular, with indistinct anatomical planes and abnormal vascularity. Dissection of posterior adhesions near the rectosigmoid colon resulted in significant hemorrhage. Rather than proceed with hysterectomy, the team performed an intraoperative adenomyomectomy, excising the affected tissue up to the boundary of uninvolved myometrium. A uterine tourniquet was applied at the level of the uterine arteries to control bleeding, enabling partial resection and multilayered reconstruction of the uterine wall using absorbable sutures. During the procedure, the patient developed hemodynamic instability and coagulopathy, necessitating aggressive resuscitation and transfusion of four units of packed red blood cells. Estimated intraoperative blood loss totaled 1,575 mL. The patient was transferred to the intensive care unit, stabilized, and discharged home on postoperative day 5 without further complications. Histopathological analysis confirmed transmural decidualized adenomyosis [Figure 5]. This case demonstrates that live birth and uterine conservation are feasible, even under emergent conditions involving advanced adenomyosis. It underscores the importance of intraoperative adaptability and interdisciplinary collaboration when managing distorted uterine anatomy and uncontrolled bleeding. Importantly, it challenges the prevailing view that hysterectomy is the only safe option in such complex scenarios. In this instance, cesarean adenomyomectomy not only achieved hemostasis and preserved uterine integrity but also potentially maintained future reproductive capacity [Figure 4].

Reframing adenomyosis in reproductive surgery Adenomyosis has historically been regarded as a terminal diagnosis for women experiencing refractory pelvic pain or abnormal uterine bleeding, with hysterectomy often considered the definitive treatment, particularly in those who have completed childbearing.[1,6] However, advances in imaging and an increasing demand for fertility preservation have challenged this paradigm, allowing earlier detection and diagnosis in reproductive-aged women.[7] Recent evidence underscores that diffuse adenomyosis adversely affects fertility by disrupting endometrial receptivity, impairing uterine peristalsis, and contributing to implantation failure.[8,11] These findings redefine adenomyosis not as a benign structural anomaly but as a functional barrier to conception. Within this context, surgical approaches aimed at uterine preservation merit greater consideration. Feasibility of cesarean adenomyomectomy This review synthesizes data from eight studies involving 18 cases, in addition to a novel case presented herein. Collectively, the evidence demonstrates that cesarean adenomyomectomy is surgically feasible and, when performed by experienced teams, can be completed without the need for hysterectomy—even in cases of extensive disease.[23,24,43] Core surgical principles include precise myometrial excision, hemostatic techniques such as vasopressin injection and tourniquet placement, and meticulous multilayered closure.[26,41] Across all reviewed cases, fetal delivery and uterine preservation were achieved without intraoperative uterine rupture or conversion to hysterectomy, including in patients with transmural or posterior wall involvement. These findings challenge the prevailing assumption that adenomyosis encountered during cesarean section necessitates uterine removal. Maternal and neonatal safety Maternal outcomes were generally favorable across the included studies. Blood loss was variable but manageable with appropriate surgical interventions and transfusion protocols. Only one patient—the subject of the original case—experienced hemodynamic instability requiring intensive care. No maternal deaths occurred, and neonatal outcomes were uniformly positive, with no perinatal mortality and satisfactory Apgar scores. These findings suggest that, despite the technical demands, cesarean adenomyomectomy can be safely performed in appropriately selected patients, even under emergent conditions.[5,40] Reproductive outcomes and uterine function The long-term implications for fertility are particularly noteworthy. Among patients with available follow-up data, most who attempted subsequent conception achieved pregnancy, including spontaneous gestations. No cases of uterine rupture were reported in follow-up pregnancies, and successful repeat cesarean deliveries were documented. These outcomes suggest that cesarean adenomyomectomy not only preserves uterine structure but may also restore functional capacity for future gestation.[23,24] While available data remain limited, these findings support consideration of this approach in patients with advanced adenomyosis who desire fertility preservation. Ethical considerations The application of cesarean adenomyomectomy presents distinct ethical challenges, particularly concerning informed consent in emergent surgical settings. Patients with known or suspected adenomyosis should be counseled during prenatal care about the potential need for intraoperative resection and its associated risks. In situations where the diagnosis is made intraoperatively or surgical plans must change urgently, thorough documentation of clinical reasoning and patient safety considerations is essential. Institutions may consider developing standardized protocols and consent checklists to guide surgical decision-making. Transparency in outcome reporting and postoperative monitoring is critical to ensure accountability and uphold ethical standards of patient care.[25] Research gaps and clinical priorities Despite encouraging findings, the evidence base for cesarean adenomyomectomy remains limited. Future research should prioritize multicenter data collection, long-term tracking of reproductive outcomes, and the development of standardized surgical criteria. Metrics such as uterine preservation rates, postoperative quality of life, and fertility outcomes should be consistently reported.[9,44] Educational initiatives—including the creation of surgical atlases and simulation models—may facilitate wider adoption of the technique and enhance procedural safety. Figure 6 summarizes the procedural evolution, while Figure 7 outlines the proposed clinical framework for implementation. Clinical guide for treatment: Cesarean adenomyomectomy in massive adenomyosis Cesarean adenomyomectomy is an emerging surgical option for select patients with massive uterine adenomyosis who require cesarean delivery. Although technically complex and not yet incorporated into standard clinical practice guidelines, recent case-based literature—including the high-risk case presented in this review—demonstrates the feasibility of this procedure when performed under clearly defined conditions and by experienced surgical teams.[5,23,24,40,43] This section outlines a structured clinical framework for translating this evolving approach into practice. Preoperative planning begins with the early identification of patients at risk. Women with prior cesarean deliveries for uterine distortion, unexplained infertility, or known uterine fibroids should undergo targeted imaging during early to mid-pregnancy. MRI or high-resolution transvaginal ultrasound can detect features of diffuse or transmural adenomyosis, including asymmetrical myometrial thickening, poorly defined junctional zones, or nodular architecture.[7,8,11] Once diagnosed, patients should be referred to a multidisciplinary team involving maternal-fetal medicine, reproductive surgery, and anesthesiology. Prenatal counseling must include a discussion of potential surgical risks, including the possibility of intraoperative uterine reconstruction or, alternatively, hysterectomy if fertility preservation is not feasible.[43,45] The decision to proceed with cesarean adenomyomectomy should be guided by both preoperative assessment and intraoperative findings. Indications include adenomyosis that interferes with hysterotomy closure, uncontrolled hemorrhage originating from adenomyotic tissue, or anatomic distortion of the myometrium that renders conventional repair unstable or unsafe.[5,23,24,43] In such scenarios, adenomyomectomy may represent the only fertility-sparing surgical alternative. Given its complexity, the procedure should be performed exclusively by teams with advanced surgical training, ideally within tertiary care centers equipped with access to blood products, ICU support, and interventional radiology, if required.[45,46] Box 1. Ethical Guidance for Cesarean Adenomyomectomy - Preoperative Counseling: Patients with suspected or confirmed adenomyosis should receive prenatal counseling regarding the potential for intraoperative myometrial resection, its associated risks, and alternatives, including hysterectomy. - Intraoperative Flexibility: When emergent decisions are required, surgeons should prioritize maternal safety and clearly document clinical rationale, especially when updated consent is not feasible. - Institutional Oversight: Centers offering this procedure should establish protocols for peer surgical review or ethics committee input in high-risk cases. Complex procedures should be discussed within multidisciplinary teams whenever possible. - Postoperative Follow-Up: Comprehensive documentation, along with structured reproductive counseling, should be integral to postoperative care, particularly in cases involving fertility-preserving interventions performed under emergent conditions. Intraoperative management typically begins with fetal delivery via a classical vertical or low-transverse uterine incision, followed by thorough inspection of the uterine walls. Adenomyotic tissue may be resected through wedge excision, segmental removal, or myometrial thinning using sharp dissection to the border of unaffected tissue. Hemostatic techniques include vasopressin injection, administration of uterotonic agents, and, when necessary, temporary uterine artery ligation or occlusion.[24,26] Reconstruction should be performed in multiple layers with absorbable sutures to restore structural integrity and minimize dead space. In patients with extensive or transmural disease, subtotal or staged resection may be required. Operative decision-making pathways and surgical workflows are depicted in Figures 6-8. Postoperatively, patients should be closely monitored for delayed hemorrhage, uterine dehiscence, and infection. Intensive care monitoring is recommended in cases with significant intraoperative blood loss. Recovery typically parallels that of major abdominal surgery, with most patients discharged within 5 to 7 days. Follow-up imaging at approximately 6 months, using ultrasound or MRI, can assess healing quality and guide future reproductive planning.[46] Patients should be advised to delay conception for at least 1 year to ensure complete uterine healing.[5,26] Fertility counseling is essential. Although spontaneous pregnancy following cesarean adenomyomectomy has been reported, long-term data regarding uterine rupture, abnormal placentation, or other gestational complications remain limited.[23,24,44] Patients should be advised to seek evaluation by a reproductive endocrinologist if conception does not occur within 6–12 months. Any subsequent pregnancy should be managed under close surveillance, with planned cesarean delivery strongly recommended. Contraindications to this procedure include active pelvic infection, suspected uterine malignancy, profound hemodynamic instability in low-resource settings, and the absence of documented consent for intraoperative fertility-sparing surgery.[9,45] In such cases, hysterectomy remains the safest and most appropriate intervention. This guide integrates available clinical evidence and operative experience into a reproducible treatment framework. As institutional experience expands, the development of standardized protocols, prospective registries, and professional society guidelines will be crucial to support the ethical, safe, and effective implementation of cesarean adenomyomectomy in contemporary obstetric practice.[47,48] Strengths, Limitations, and Future Directions This review provides a structured synthesis of the available clinical evidence on cesarean adenomyomectomy, complemented by an original high-complexity case that demonstrates the procedure’s feasibility in an emergent perinatal setting. Its primary strength lies in the focused examination of a rare yet clinically significant intersection between obstetric surgery and fertility preservation. By evaluating 21 studies spanning two decades, the review captures both the technical evolution and the conceptual shift in managing advanced adenomyosis during pregnancy. The inclusion of diverse case types—from elective procedures to emergency scenarios—further underscores the adaptability of this approach across a spectrum of clinical situations. Additionally, the review provides a coherent clinical framework that connects existing literature with practical surgical decision-making. Another notable strength is the integrative approach used to analyze the surgical, reproductive, pathological, and ethical dimensions of cesarean adenomyomectomy. This multidimensional perspective broadens the relevance of the findings beyond surgical feasibility, highlighting their implications for maternal–fetal medicine. The illustrative case further underscores the potential for uterine preservation, avoidance of hysterectomy, and favorable maternal and neonatal outcomes, even in patients with transmural disease and hemodynamic instability. Nonetheless, several limitations must be acknowledged. The existing literature is confined to retrospective case reports and small case series, characterized by considerable heterogeneity in diagnostic criteria, surgical techniques, and follow-up durations. This variability limits the generalizability of reported outcomes and complicates the development of standardized clinical guidelines. Moreover, most published cases originate from single institutions with advanced surgical expertise, raising concerns about reproducibility in lower-resource or general obstetric settings. Furthermore, long-term data on uterine rupture, abnormal placentation, and fertility outcomes following cesarean adenomyomectomy also remain sparse. Although short-term findings are encouraging, the long-term safety and reproductive implications of extensive myometrial excision during pregnancy are yet to be clearly defined. An additional concern involves the ethical and medicolegal complexities associated with performing novel procedures in intraoperative settings. During emergent deliveries, opportunities for obtaining comprehensive informed consent are often limited, and few studies describe how intraoperative decisions are communicated or ethically justified. This highlights the need for institutional protocols and ethical frameworks that can guide surgical innovation while safeguarding patient autonomy. Future research should prioritize the development of prospective registries and multicenter collaborations to consolidate evidence and define reproducible metrics for both surgical and reproductive outcomes. Consensus is needed on procedural indications, operative techniques, and postoperative management. Future studies should also incorporate structured imaging and endocrinological follow-up to assess uterine structural integrity and reproductive function. Qualitative investigations into patient perspectives, values, and decision-making regarding fertility preservation and surgical risk would further strengthen the evidence base and enhance patient-centered care. In summary, cesarean adenomyomectomy represents an emerging surgical strategy for uterine conservation in carefully selected cases of advanced adenomyosis. Although preliminary evidence supports its feasibility and short-term safety, robust data on long-term reproductive outcomes and ethical implementation are still needed. Continued surgical innovation in this area must be accompanied by rigorous clinical research and institutional oversight to ensure safe, reproducible, and ethically sound care.

Cesarean adenomyomectomy is a technically feasible and increasingly recognized surgical approach for managing extensive adenomyosis during cesarean delivery. Once considered incompatible with reproductive goals, emerging case-based evidence now suggests that uterine preservation and live birth are achievable, even in patients with severe myometrial disease. Although current evidence is limited to small, single-center reports, early outcomes are encouraging regarding maternal safety, neonatal health, and postoperative fertility. This review highlights that, in carefully selected patients and when performed by experienced surgical teams, cesarean adenomyomectomy can achieve dual objectives: safe delivery and targeted resection of adenomyotic tissue. The procedure may serve as an alternative to hysterectomy for patients with extensive disease, particularly in cases where myometrial distortion complicates standard uterine closure. However, broader clinical adoption should proceed with caution. The current literature remains limited by heterogeneity in patient selection, surgical technique, and follow-up duration. There is an urgent need for prospective studies, standardized protocols, and long-term reproductive outcome data to assess the safety, reproducibility, and overall clinical impact of this approach. Ethical considerations, particularly in emergent surgical settings, also warrant institutional safeguards and rigorous informed consent processes. At present, cesarean adenomyomectomy should be viewed as an emerging surgical option with potential value in highly selected cases, rather than a broadly generalizable standard of care. Continued research, multidisciplinary collaboration, and the establishment of evidence-based guidelines will be essential to define its appropriate role within modern obstetric and reproductive surgery. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Acknowledgment The authors would like to express their sincere gratitude to the Indonesian Society of Obstetrics and Gynecology (ISOG/POGI) and the Indonesian Association of Maternal-Fetal Medicine (IAMFM/HKFM) for their encouragement and support in the completion of this review.

Adenomyosis; cesarean adenomyomectomy; fertility preservation; live birth; uterine-sparing surgery