Ureteric visualization before uterine artery clamping in Caesarean hysterectomy for morbidly adherent placenta; cohort study

Abstract

Background: Caesarean hysterectomy is considered the reference standard treatment for placenta accreta. In young women who want the option of future pregnancy and agree to close follow-up monitoring, conservative treatment is a valid option. Aim of the Work: to assess the safety and efficacy of early ureteric visualization in decreasing the incidence of urological injury in caesarean hysterectomy for morbidly adherent placenta in comparison with the standard approach. Patients and Methods: This cohort study was conducted on were 160 pregnant females who attended labor ward and underwent cesarean section for placenta accreta 142 ended with cesarean hysterectomy and 18 managed conservatively at department of obstetrics and gynecology at Maternity Hospital of Ain Shams University in the period between April 2019 and October 2020. They were divided into two groups: Cesarean hysterectomy was performed with the classic approach in 70 of them. Group A. Cesarean hysterectomy was performed with ureteric visualization in 72 patients (Group B) two of them were excluded from our study population as they have thrombocytopenia. Results: No statistical significance differences were found between two groups regarding demographic characteristics as age, BMI and gestational age. No differences were present regarding frequency of previous deliveries, abortions and indication for hysterectomies. No significant differences were found also regarding perioperative data as operative time (h), perioperative blood loss (ml), number of packed RBC units, plasma units, hospital length of stay (days), volume of blood loss in drains, drop in hemoglobin in both study groups (p=0.492 and 0.030) and incidence of adverse outcomes as bladder, ureteric or bowel injury, wound complications, ICU admission and maternal mortality. Although no statistically significant results but we recommend planned meticulous surgical approach for MAP with identification of the ureter before clamping the uterine artery and creation of bladder flap from lateral we assume this ensures best outcomes for those patients. More studies with larger sample size and more data particularly regard incidence of ureteric injury are needed for further evaluation. Conclusion: There were no statistical significance differences between early ureteric visualization and standard approach regarding safety and efficacy in decreasing the incidence of urologic injury in caesarean hysterectomy for morbidly adherent placenta