Identifying risk factors for urologic complications in placenta accreta spectrum surgical management

To describe urologic complications associated with the surgical management of placenta accreta spectrum and determine their risk factors.

A retrospective study was conducted on all patients diagnosed with abnormal invasive placentation who underwent surgery and delivered between 2002 and 2023 at a single expert maternity centre. Intra-operative and post-operative complications were described, with a special focus on urologic intra-operative injuries, including vesical or ureteral injuries. Univariate and multivariate analyses were performed to determine risk factors of intra-operative urologic injuries associated with placenta accreta spectrum surgical management. Additionally, using the Clavien-Dindo classification, the effects of intra-operative urologic injury and ureteral stent placement on post-operative outcome were evaluated.

A total of 216 patients were included, of which 47 (21.48%) had an intra-operative bladder and/or ureteral injury. Placenta percreta was associated with a higher rate of intra-operative urologic injury than placenta accreta (72.34% vs. 6.38%, p < 0.001). Multivariate analyses showed that patients who had placenta percreta and bladder invasion or emergency hysterectomy were associated with more intra-operative urologic injuries (OR = 8.07, 95% CI [2.44-26.75] and OR = 3.87, 95% CI [1.09-13.72], respectively). Patients with intra-operative urologic injuries had significantly more severe post-operative complications, which corresponds to a Clavien-Dindo score of 3 or more, at 90 days (21.28% vs. 5.92%, p = 0.004).

Surgical management of placenta accreta spectrum is associated with significant urologic morbidity, with a major impact on post-operative outcomes. Urologic complications seem to be correlated with the depth of invasion and the emergency of the hysterectomy.