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Resective-reconstructive surgery versus hysterectomy for placenta accreta spectrum: a histopathologically stratified
Firat Okmen1, Huseyin Ekici2, Ali Akdemir1
1Department of Obstetrics and Gynecology, Ege University School of Medicine, İzmir, Türkiye.
Objective:
To compare maternal surgical and postoperative outcomes between resective-reconstructive surgery and cesarean hysterectomy in histopathologically confirmed placenta accreta spectrum, analysing patients by the initially intended surgical strategy.
Methods:
We retrospectively reviewed 141 consecutive, histopathologically confirmed placenta accreta spectrum cases managed at a tertiary centre over approximately nine years (January 2017-January 2026). The primary analysis classified patients by the initially planned strategy (planned resective-reconstructive surgery, n = 84; planned hysterectomy, n = 57); six women converted to hysterectomy were analysed within the planned resective-reconstructive surgery group, and an as-treated analysis (resective-reconstructive surgery, n = 78; hysterectomy, n = 63) was pre-specified as secondary. The primary outcome was intraoperative bladder injury; estimates were adjusted for age, gravidity and depth of invasion and verified with Cochran-Mantel-Haenszel stratification.
Results:
Hysterectomy was associated with more frequent intraoperative bladder injury (24.6% versus 8.3%; adjusted odds ratio 3.16, 95% confidence interval 1.16-8.64) and with greater transfusion requirements, longer operative time and longer postoperative stay (all p < 0.05). The bladder-injury association was consistent across accreta, increta and percreta strata (common odds ratio 3.24, 95% confidence interval 1.20-8.74). The as-treated analysis showed the same associations with larger effect sizes.
Conclusion:
In histopathologically confirmed placenta accreta spectrum, resective-reconstructive surgery was associated with lower measured maternal morbidity than hysterectomy; the association persisted, though attenuated, under the initially intended strategy and across depth-of-invasion strata. Because treatment was not randomized, these associations cannot establish superiority, and management should be individualized through multidisciplinary evaluation at experienced centres.
