Focal excision for placenta percreta based on pathoanatomy: the challenge of neovascularization

To evaluate the feasibility, safety, and outcomes of a modified uterus-preserving focal excision technique for Placenta Accreta Spectrum Disorder, including placenta percreta, based on pathoanatomical defects and neovascularization rather than tissue invasiveness.

We retrospectively reviewed 15 consecutive cases of Placenta Accreta Spectrum Disorder (International Federation of Gynecology and Obstetrics stages 2-3b) treated between 2020 and 2025 at a tertiary referral center using a standardized focal resection technique. Diagnosis was established by abdominal and transvaginal sonography. Preoperative planning included detailed patient counseling, multidisciplinary team coordination, and preparation of blood products. The surgical procedure involved meticulous bladder dissection, stepwise ligation of vessels, and targeted excision of placenta percreta areas.

Uterus-preserving surgery was achieved in 14 of 15 patients (93%). One (7%) patient required emergency supracervical hysterectomy due to uncontrolled hemorrhage. Median blood loss was 2000 mL (interquartile range, 1500-2500 mL), and 4 patients required no transfusion. Bladder injury occurred in 6 patients (40%), all of which were managed successfully without long-term sequelae at ≥1 year of follow-up. No maternal deaths were reported. Focal resection was feasible even in emergency situations and in cases of high-grade Placenta Accreta Spectrum Disorder (up to International Federation of Gynecology and Obstetrics 3b). Histopathological confirmation and intraoperative video documentation supported the reproducibility and accuracy of the diagnosis and technique.

This study reports a series of cases with focal excision of Placenta Accreta Spectrum Disorder, allowing preservation of the uterus and associated with limited maternal morbidity, which compares favorably with the commonly used cesarean hysterectomy.