Conservative surgery vs hysterectomy for placenta accreta spectrum disorders: a systematic review and meta-analysis

Resection and reconstruction of the uterus may be an alternative to hysterectomy in placenta accreta spectrum disorders. We aimed to review whether surgical and maternal outcomes were comparable between these techniques.

Medline, Embase, and the Cochrane Library databases were searched until 1 January 2025. We included randomized controlled trials (RCT) and nonrandomized studies (NRSI) comparing conservative surgery, involving resection and reconstruction of the myometrium without placental removal, to hysterectomy in patients with placenta accreta, increta, or percreta. Two authors were responsible for independently screening the title and abstract, and the full texts of all identified records. We assessed the risk of bias with ROB-2 or ROBINS-I, and the quality of evidence with GRADE. The main analysis only included studies without a high risk of bias. A secondary non-inferiority Bayesian analysis was reported alongside the results.

We included one RCT and eleven nonrandomized studies (1586 women). Most women had FIGO PAS Grade 2 and 3a and with upper uterine segment involvement. Compared to hysterectomy, conservative surgery may result in a similar number of transfused packs of red blood cells (MD -0.70 packs, 95% CI -1.28 to -0.12; 1 RCT and 4 NRSI, 649 women; I2= 0%; low-certainty evidence), and a similar risk of bladder injury (RR 0.36, 95% CI 0.12 to 1.07; 1 RCT and 4 NRSI, 649 women; I2= 0%; low-certainty evidence). Excluding rare outcomes, the probability that conservative surgery is non-inferior to hysterectomy was greater than 90.0%.

On the basis of low evidence, conservative surgery may not increase the risk of clinically important harm compared to hysterectomy, with the benefit of uterus preservation. Further RCTs are needed to reach definitive conclusions.