Surgical Techniques for the Management of Placenta Accreta Spectrum

Local Resection After Cesarean Delivery for Placenta Accreta Spectrum Disorder: A Systematic Review and Meta-analysis

OBJECTIVE

To compare maternal and surgical outcomes between local resection and immediate hysterectomy after cesarean delivery in patients with placenta accreta spectrum (PAS).

DATA SOURCES

Four public databases (PubMed, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials) were systematically searched for relevant publications up to July 31, 2024. Because the Cochrane Library included all the identified clinical trials, it was unnecessary to search ClinicalTrials.gov . The search strategy included the terms "placenta accreta" or "placenta accreta spectrum" and "pregnancy outcomes" and related key words about local resection and cesarean hysterectomy.

METHODS OF STUDY SELECTION

With the use of established inclusion criteria, 4,889 studies were reviewed. The included studies evaluated surgical and maternal outcomes associated with immediate hysterectomy compared with local resection.

TABULATION, INTEGRATION, AND RESULTS

Data extraction was conducted with the Patient/Population, Intervention, Comparison, Outcome, and Study design framework. Both fixed-effects and random-effects models were used to synthesize the findings. A total of 11 studies published between 2018 and 2024 were analyzed (nine retrospective studies, one randomized controlled trial, and one prospective cohort study). The quality of the included studies was globally low, and 7 of 11 studies had severe bias. The immediate hysterectomy group had a significantly higher prevalence of placenta percreta compared with the local resection group (69.4% vs 44.3%, P <.01). In contrast to immediate hysterectomy, local resection yielded improved surgical outcomes, demonstrated by the following metrics: transfusion rate (six studies, 375 vs 205 patients, odds ratio [OR] 0.47, 95% CI, 0.29-0.75), estimated blood loss (seven studies, 416 vs 246 patients, mean difference -396 mL, 95% CI, -534 to -257), urologic complications (seven studies, 408 vs 241 patients, OR 0.18, 95% CI, 0.10-0.33), and intensive care unit admission (three studies, 87 vs 79 patients, OR 0.19, 95% CI, 0.07-0.53). One study recorded three maternal deaths: two in the immediate hysterectomy group and one in the local resection group. The results of subgroup analyses focused on patients with severe forms of PAS (placenta increta and percreta) were similar in the overall analysis.

CONCLUSION

In this systematic review and meta-analysis, eligible studies comparing the local resection with immediate hysterectomy at cesarean hysterectomy for PAS were overall low quality because of the lack of intention-to-treat information. Despite these limitations, local resection for PAS may possibly be an option for appropriately selected patients to reduce surgical morbidity. Because the indication criteria, safety, surgical techniques, and necessity of adjunctive therapies for local resection remain understudied, further prospective studies are warranted.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42024594315.

Comparison of Maylard and Cherney incisions' outcomes in hysterectomy surgery for benign indications: a double-blind randomized controlled trial

OBJECTIVES

Choosing the incision for surgery depends on a variety of factors, including the surgeon's preference, patient preference, surgical indications, the patient's systemic issues, previous surgical scars, and other considerations. This trial aimed to evaluate and compare the surgical outcomes of two techniques-Maylard and Cherney incisions-in benign hysterectomy procedures for women.

MATERIALS AND METHODS

A randomized controlled trial was conducted in Al-Zahra Women's Tertiary Referral University Hospital. A total of 60 patients undergoing benign hysterectomy were randomly allocated to two groups, with one group undergoing surgery with a Maylard incision and the other with a Cherney incision. Surgeries in both groups were performed by a gynecologist oncologist who was a member of the university faculty, accompanied by an Obstetrics and Gynecology Resident.

RESULTS

There were no significant differences in hemoglobin levels or clinical or obstetric characteristics before surgery between the two study groups (p > 0.05). The mean time from skin incision to entering the abdominal cavity was 14.23 min for Maylard and 13.6 min for Cherney (p = 0.091). The average blood loss was 506.6 mL in the Maylard group and 429.3 mL in the Cherney group, which was statistically significant (p = 0.031). Postoperative hemoglobin levels were 11.68 g/dL in the Maylard group and 12.07 g/dL in the Cherney group (p = 0.133). Pain scores were higher in the Cherney group than in the Maylard group (p = 0.041). There were no surgical complications after 1 and 3 months in the study groups.

CONCLUSIONS

No complications were observed in any of the patients following the surgery. The Mylard incision showed a higher level of bleeding in comparison with the Cherney incision, which was linked to more noticeable pain. Nevertheless, both incisions are deemed as effective options for gynecological surgeries, offering superb visibility to the pelvis.

Risk factors for intensive care unit admission after cesarean hysterectomy for placenta accreta spectrum

OBJECTIVE

Placenta accreta spectrum (PAS) is a complex disorder of uterine wall disruption with significant morbidity and mortality, particularly at time of delivery. Both physician and physical hospital resource allocation/utilization remains a challenge in PAS cases including intensive care unit (ICU) beds. The primary objective of the present study was to identify preoperative risk factors for ICU admission and create an ICU admission prediction model for patient counseling and resource utilization decision making in an evidence-based manner.

METHODS

This was a case-control study of 145 patients at our PAS referral center undergoing cesarean hysterectomy for PAS. Final confirmation by histopathology was required for inclusion. Patient disposition after surgery (ICU vs post-anesthesia care unit) was our primary outcome and pre-/intra-/postoperative variables were obtained via electronic medical records with an emphasis on the predictive capabilities of the preoperative variables. Uni- and multivariate analysis was performed to identify independent predictive factors for ICU admission.

RESULTS

In this large cohort of 145 patients who underwent cesarean hysterectomy for PAS, with histopathologic confirmation, 63 (43%) were admitted to the ICU following delivery. These patients were more likely to be delivered at an earlier gestational age (34 vs 35 weeks, P < 0.001), have had >2 episodes of vaginal bleeding and emergent delivery compared to patients admitted to patients with routine recovery care (44% vs 18.3%, P = 0.009). Uni- and multivariate logistic regression showed an area under the curve of 0.73 (95% CI: [0.63, 0.81], P < 0.001) for prediction of ICU admission with these three variables. Patients with all three predictors had 100% ICU admission rate.

CONCLUSION

Resource prediction, utilization and allocation remains a challenge in PAS management. By identifying patients with preoperative risk factors for ICU admission, not only can patients be counseled but this resource can be requested preoperatively for staffing and utilization purposes.

Complex obstetrical surgery: building a team and defining roles

As the number of placenta accreta spectrum cases continues to rise, the gap in surgical skills in labor and delivery units becomes more apparent. Recent scholarly work has highlighted the diminishing advanced surgical skills among obstetrician-gynecologists, particularly among new graduates. Therefore, it has become a practice in many institutions to refer complex cesarean deliveries and obstetrical hysterectomies to subspecialists, specifically gynecologic oncologists. Hence, in this commentary, we propose a process through which key personnel within departments of obstetrics and gynecology are identified and their appropriate level of involvement in cases of complex obstetrical surgery is delineated. In doing so, we describe the surgical skills expected from each provider level so that the cesarean delivery complexity level can be matched with specific surgical expertise. Through this process, an obstetrician-led complex obstetrical surgery team is formed. Ultimately, the goal of this process is 2-fold; first, to return cases with higher levels of surgical complexity back to obstetricians and, second, to reduce the surgical back-up burden from gynecology subspecialists such as gynecologic oncologists.

Cesarean hysterectomy for placenta accreta spectrum: Surgeon specialty-specific assessment

OBJECTIVE

To assess (i) clinical and pregnancy characteristics, (ii) patterns of surgical procedures, and (iii) surgical morbidity associated with cesarean hysterectomy for placenta accreta spectrum based on the specialty of the attending surgeon.

METHODS

The Premier Healthcare Database was queried retrospectively to study patients with placenta accreta spectrum who underwent cesarean delivery and concurrent hysterectomy from 2016 to 2020. Surgical morbidity was assessed with propensity score inverse probability of treatment weighting based on surgeon specialty for hysterectomy: general obstetrician-gynecologists, maternal-fetal medicine specialists, and gynecologic oncologists.

RESULTS

A total of 2240 cesarean hysterectomies were studies. The most common surgeon type was general obstetrician-gynecologist (n = 1534, 68.5%), followed by gynecologic oncologist (n = 532, 23.8%) and maternal-fetal medicine specialist (n = 174, 7.8%). Patients in the gynecologic oncologist group had the highest rate of placenta increta or percreta, followed by the maternal-fetal medicine specialist and general obstetrician-gynecologist groups (43.4%, 39.6%, and 30.6%, P < .001). In a propensity score-weighted model, measured surgical morbidity was similar across the three subspecialty groups, including hemorrhage / blood transfusion (59.4-63.7%), bladder injury (18.3-24.0%), ureteral injury (2.2-4.3%), shock (8.6-10.5%), and coagulopathy (3.3-7.4%) (all, P > .05). Among the cesarean hysterectomy performed by gynecologic oncologist, hemorrhage / transfusion rates remained substantial despite additional surgical procedures: tranexamic acid / ureteral stent (60.4%), tranexamic acid / endo-arterial procedure (76.2%), ureteral stent / endo-arterial procedure (51.6%), and all three procedures (55.4%). Tranexamic acid administration with ureteral stent placement was associated with decreased bladder injury (12.8% vs 23.8-32.2%, P < .001).

CONCLUSION

These data suggest that patient characteristics and surgical procedures related to cesarean hysterectomy for placenta accreta spectrum differ based on surgeon specialty. Gynecologic oncologists appear to manage more severe forms of placenta accreta spectrum. Regardless of surgeon's specialty, surgical morbidity of cesarean hysterectomy for placenta accreta spectrum is significant.