Urological complications in women undergoing Cesarean section for placenta accreta spectrum disorders: systematic review and meta-analysis.

OBJECTIVE: To report on the occurrence of urological complications in women undergoing Cesarean section for placenta accreta spectrum disorders (PAS). METHODS: MEDLINE, EMBASE and the Cochrane databases were searched electronically up to 1 November 2022. Studies reporting on the urological outcome of women undergoing Cesarean section for PAS were included. Two independent reviewers performed data extraction using a predefined protocol and assessed the risk of bias using the Newcastle-Ottawa scale for observational studies, with disagreements resolved by consensus.The primary outcome was the overall occurrence of urological complications. Secondary outcomes were the occurrence of any cystotomy, intentional cystotomy, unintentional cystotomy, ureteral damage, ureteral fistula and vesicovaginal fistula. All outcomes were explored in the overall population of women undergoing surgery for PAS. In addition, we performed subgroup analyses according to the type of surgery (Cesarean hysterectomy, or conservative surgery or management), severity of PAS at histopathology (placenta accreta/increta and placenta percreta), type of intervention (planned vs emergency) and number of cases per year. Random-effects meta-analyses of proportions were used to analyze the data. RESULTS: There were 62 studies included in the systematic review and 56 were included in the meta-analysis. Urological complications occurred in 15.2% (95% CI, 12.9-17.7%) of cases. Cystotomy complicated 13.5% (95% CI, 9.7-17.9%) of surgical operations. Intentional cystotomy was required in 7.7% (95% CI, 6.5-9.1%) of cases, while unintentional cystotomy occurred in 7.2% (95% CI, 6.0-8.5%) of cases. Urological complications occurred in 19.4% (95% CI, 16.3-22.7%) of cases undergoing hysterectomy and 12.2% (95% CI, 7.5-17.8%) of those undergoing conservative treatment. In the subgroup analyses, urological complications occurred in 9.4% (95% CI, 5.4-14.4%) of women with placenta accreta/increta and 38.5% (95% CI, 21.6-57.0%) of those described as having placenta percreta, and included mainly cystotomy (5.5% (95% CI, 0.6-15.1%) and 22.0% (95% CI, 5.4-45.5%), respectively). Urological complications occurred in 15.4% (95% CI, 8.1-24.6%) of cases undergoing a planned procedure and 24.6% (95% CI, 13.0-38.5%) of those undergoing an emergency intervention. In subanalysis of studies reporting on ≥ 12 cases per year, the incidence of urological complication was similar to that reported in the primary analysis. CONCLUSIONS: Women undergoing surgery for PAS are at high risk of urological complication, mainly cystotomy. The incidence of these complications was particularly high in women described as having placenta percreta at birth and in those undergoing emergency surgical intervention. The high heterogeneity between the included studies highlights the need for a standardized protocol for the diagnosis of PAS to identify prenatal imaging signs associated with the increased risk of urological morbidity at delivery. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Cesarean scar pregnancy and early placenta accreta share common histology.

OBJECTIVE: To determine, by evaluation of histological slides, images and descriptions of early (second-trimester) placenta accreta (EPA) and placental implantation in cases of Cesarean scar pregnancy (CSP), whether these are pathologically indistinguishable and whether they both represent different stages in the disease continuum leading to morbidly adherent placenta in the third trimester. METHODS: The database of a previously published review of CSP and EPA was used to identify articles with histopathological descriptions and electronic images for pathological review. When possible, microscopic slides and/or paraffin blocks were obtained from the original researchers. We also included from our own institutions cases of CSP and EPA for which pathology specimens were available. Two pathologists examined all the material independently and, blinded to each other's findings, provided a pathological diagnosis based on microscopic appearance. Interobserver agreement in diagnosis was determined. RESULTS: Forty articles were identified, which included 31 cases of CSP and 13 cases of EPA containing histopathological descriptions and/or images of the pathology. We additionally included six cases of CSP and eight cases of EPA from our own institutions, giving a total of 58 cases available for histological evaluation (37 CSP and 21 EPA) containing clear definitions of morbidly adherent placenta. In the 29 cases for which images/slides were available for histopathological evaluation, both pathologists attested to the various degrees of myometrial and/or scar tissue invasion by placental villi with scant or no intervening decidua, consistent with the classic definition of morbidly adherent placenta. Based on the reviewed material, cases with a diagnosis of EPA and those with a diagnosis of CSP showed identical histopathological features. Interobserver correlation was high (kappa = 0.93). CONCLUSIONS: EPA and placental implantation in CSP are histopathologically indistinguishable and may represent different stages in the disease continuum leading to morbidly adherent placenta in the third trimester.

Role of three-dimensional power Doppler in the antenatal diagnosis of placenta accreta: comparison with gray-scale and color Doppler techniques.

OBJECTIVE: To assess the role of three-dimensional (3D) power Doppler in the antenatal diagnosis of placenta accreta and compare its diagnostic performance with gray-scale and color Doppler ultrasonography. METHODS: One hundred and seventy pregnant women with persistent placenta previa totalis (after 28 weeks' gestation) were prospectively enrolled into this study. Gray-scale transabdominal ultrasound examination was performed to detect loss of the subendometrial echolucent zone and other abnormalities suggestive of placenta accreta. Color flow mapping was used to scan the whole placenta to detect any newly formed vessels at the serosa-bladder border or the presence of abnormal lacunae. Finally a targeted examination of angioarchitecture in the basal and lateral views of the placenta was carried out using 3D power Doppler. The ultrasound findings were analyzed with reference to the final diagnosis made during Cesarean delivery. RESULTS: Placenta accreta and its variants (including increta and percreta) were confirmed in 39 patients at the time of Cesarean delivery. Based on receiver-operating characteristics analysis, 'numerous coherent vessels' visualized using 3D power Doppler in the basal view was the best single criterion for the diagnosis of placenta accreta, with a sensitivity of 97% and a specificity of 92%. If we considered the presence of at least one criterion to be diagnostic when using each ultrasound technique, then 3D power Doppler would have the best positive predictive value (76%), followed by gray-scale (51%) and color Doppler (47%). The majority of patients with placenta accreta showed multiple characteristic features on ultrasound imaging. In contrast, those patients with a false-positive diagnosis (i.e. the final diagnosis was placenta previa alone) tended to show isolated ultrasound markers of the condition. CONCLUSION: 3D power Doppler may be useful as a complementary technique for the antenatal diagnosis or exclusion of placenta accreta.