Up-front dissection of the uterovesical space or “bladder-first approach” reduces hemorrhage and bladder injury during hysterectomy for placenta accreta spectrum: reconfirmed in 78 more cases in a prospective single-center study

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BackgroundCaesarean hysterectomy (CH) for placenta accreta spectrum (PAS)may be associated with severe haemorrhage due to placental invasion of the myometrium and the uterovesical space or the parametrium. It leads to serious complications like massive haemorrhage requiring massive transfusion, coagulopathy, bladder & ureteric injuries, need for ICU admission and prolonged hospital stay.In order to reduce the complication of CH for PAS, on-goingefforts are being done to develop different surgical approaches.We have observed earlier in 12 cases that upfront dissection of uterovesical space (bladder-first approach) prior to delivery of the baby reduced haemorrhage arising from extensive neovasularization in this area, as well as bladder injury. ObjectiveObjective of this study was to assess the efficacy of Bladder- first approach in large sample in order to reduce the complication of CH for PAS disorder. MethodsWe present data of 78 more women (2017-2022) who underwent CH for PAS using the “bladder-first approach” from a tertiary care institute in Chandigarh, India.In this surgical approach, dissection of the Uterovesical fold from the lower uterine segment is done as much as possible or upto the cervix prior to making the uterine incision for delivery. During this dissection, vascular areas were isolated and coagulated with bipolar electrosurgery or ligated with silk suture and then divided ResultThe 78 women with PAS underwent CH under general anaesthesia. The mean gestational age was 35±2.5 weeks (range 25.4-38), mean blood loss was 1.56±1.06 L (range 0.4 -5 L) and mean number of blood transfusions was 2.08±2.1 units (range 0-9).Bladder injury occurred in 3/78(3.8%) and ICU admission (for ≤ 24 h) was needed by3/78(3.8%). Histology was available in 73/78 (percreta=19, increta=23 and accreta=31). There were 3/78 antenatal stillbirths. Seventy-five women had live born neonates including 2 pairs of twins. The APGAR score at 5 min ≤7 was seen in 6/77 neonates and 20/77 needed NICU care. There was one neonatal death on day 3 of life due to extreme prematurity and sepsis. Seventy-four women went home with babies including two pairs of twins. ConclusionThis data supportsUp-front dissection of the uterovesical spaceor“bladder-first approach” reduces haemorrhage and bladder injury during CH in PAS disorder, with no adverse effect on neonatal outcome. Achieving peripheral vascular control of the neovascularised uterovesical area prior to achieving control of central vascular supply (uterine arteries) reduced intra-operative haemorrhage. This approach needs no additional resources and can be practiced easily in developing countries.