Laparoscopic-Assisted Vaginal Hysterectomy in a Patient with Placenta Percreta

Abstract

Delayed minimally invasive hysterectomy should be considered in women with placenta percreta in order to lessen morbidity and speed postoperative recovery.

FIGO consensus guidelines on placenta accreta spectrum disorders: Nonconservative surgical management,

“…In the systematic review of urinary tract injury rates with PAS disorders, there were no reported unintentional urologic complications in nine cases of delayed hysterectomy; however, this was not statistically significant when compared with immediate management.Intentional cystotomy and partial cystectomy were still required in three of the second surgeries (33% of the cases) 33. While traditionally these second surgeries involve a laparotomy, minimally invasive surgical approaches including robotics have been reported 92,[94][95][96]. This approach requires advanced skills but may have enhanced visualization compared with laparotomy, along with shorter recovery, although surgical times are quite prolonged (up to 286-330 minutes) [92][93][94][95][96].…”

“…While traditionally these second surgeries involve a laparotomy, minimally invasive surgical approaches including robotics have been reported 92,[94][95][96]. This approach requires advanced skills but may have enhanced visualization compared with laparotomy, along with shorter recovery, although surgical times are quite prolonged (up to 286-330 minutes) [92][93][94][95][96]. These techniques require care in CoE with both advanced surgical programs and the capacity to manage emergent massive obstetric hemorrhage.…”

Urological Manifestations of Placenta Percreta

“…The extirpative approach is another method that is seldom administered with placenta percreta [42,43]. The conservative approach does not remove the placenta with an aim towards preventing further hemorrhaging [19].…”

“…Most case reports that applied the conservative method have detailed that a postpartum hysterectomy was performed [43]. With placenta percreta cases, using laparoscopic hysterectomy over laparotomy is recommended as it improves visualization allowing for more dissection precision decreasing the risk of hemorrhage [43]. …”

“…The placenta is left in situ post-delivery and adjunct therapy is administered such as methotrexate, angiography guided balloon occlusion, uterine artery embolization, internal iliac artery ligation/embolization, dilatation and curettage, and/or hysteroscopic loop resection [42,44]. The extirpative approach removes the placenta, leaving the uterine cavity empty at the time of delivery and is theorized to elevate the risk of postpartum hemorrhage [42,43]. Adopting a urological perspective to this obstetrical condition, we emphasize the importance of maintaining the integrity of a bladder if a hysterectomy is performed.…”