Urological complications in women undergoing Cesarean section for placenta accreta spectrum disorders: systematic review and meta‐analysis

Abstract

ObjectiveTo report the occurrence of urologic complications in women undergoing surgery for placenta accreta spectrum (PAS) disorders.MethodsMedline, Embase and Cochrane databases were searched electronically up to 1st of November 2022. Studies reporting cohort on surgical management and outcome of PAS. Two independent reviewers performed the data extraction using a predefined protocol and assessed the risk of bias using the Newcastle‐Ottawa scale for observational studies, with difference agreed by consensus. The primary outcome was the overall occurrence of urologic complications in women undergoing surgery for PAS. Secondary outcomes were overall cystotomy, intentional cystotomy, unintentional cystotomy, ureteral damage, ureteral fistula, vesicovaginal fistula. All these outcomes were explored in the overall population of patients undergoing hysterectomy for PAS disorders. In addition, we performed sub‐group analyses according to the severity of PAS at histopathology (placenta accreta/increta and percreta), type of intervention (planned vs emergency), ureteral stent placing and number of cases per year. Random‐effect meta‐analyses of proportions were used to analyze the data.ResultsSixty‐two studies were included. Urologic complications occurred in 15.29% (95% CI, 13.0‐17.2) of cases. Cystotomy complicated 13.02% (95% CI, 9.2‐17.3) of surgical operations. Intentional cystotomy was required in 5.58% (95% CI, 2.7‐9.3) of cases while damage to the bladder occurred in 7.40% (95% CI, 4.3‐11.2) of cases. Urologic complications occurred in 19.36% (95% CI, 16.3‐22.7) of cases undergoing hysterectomy and 12.22% (95% CI, 7.5‐17.8) of those having conservative treatment. In the sub‐group analyses, urologic complications occurred in 9.42% (95% CI, 5.4‐14.4) of women with placenta accreta‐increta and 38.52% (95% CI, 21.6‐57.0) of those described as placenta percreta and were mainly represented by cystotomy (5.53% (95% CI, 0.6‐15.1) in women with placenta accreta increta and 21.97% (95% CI, 15.4‐45.5) in the placenta percreta subgroup). Urologic complications occurred in 15.44% (95% CI, 8.1‐24.6) during planned procedures and in 24.61% (95% CI, 13.0‐38.5) during emergency intervention. The incidence of urologic complications was similar to that reported in the primary analysis in studies reporting >10 cases per year.ConclusionsPatients undergoing surgery for PAS disorders are at high‐risk of urologic complications, mainly cystotomy. The incidence of these complications is higher in patients described as having a placenta percreta at birth and in case of emergency surgical intervention. The high heterogeneity highlights the need to use standardized protocols for the diagnosis of PAS to identify prenatal imaging signs associated with a risk of urologic morbidity at delivery.This article is protected by copyright. All rights reserved.

Evaluation of preoperative ultrasound signs associated with bladder injury during complex Cesarean delivery: case–control study

“…The incidence of intraoperative urologic complication in the present study was lower than that reported in a recent systematic review and meta-analysis (9.4% vs 15.3%) 11 and involved only the upper part of the bladder. This can be explained by the high volume of cases and MDT expertise of nearly a decade in managing complex CDs 13 .…”

“…The use of three controls for each individual case, matched for the main risk factors of PAS in subsequent pregnancy, should limit the risk of bias in the present analysis of the data. Another limitation is the exclusion of cases requiring emergency delivery prior to planned surgery, which are known to be associated with a higher risk of intraoperative urologic complications 11 . The single-institution study design may also limit the generalizability of our results.…”

“…Multiple CDs are also associated with the development of thick pelvic adhesions, adding to the complexity of the surgical procedure in general and, in particular, separation of the bladder from the LUS 1 . A recent systematic review has shown that intraoperative urologic complication occurs in 15.3% of patients with PAS at birth 11 . The purpose of this preliminary study was to assess the role of ultrasound imaging in the preoperative evaluation of the risk of urologic injury in patients with a history of multiple CDs presenting with low placentation.…”

Addressing Diagnosis, Management, and Complication Challenges in Placenta Accreta Spectrum Disorder: A Descriptive Study

“…This will disproportionately impact rural and low-income patients, highlighting health disparities and barriers to accessing adequate healthcare for some patient populations. Considering that patients with placenta percreta and those undergoing emergency surgical intervention have a high risk of urological complications further displays the need of early diagnosis to allow the transfer of patients to medical centers equipped for such complications [ 35 ].…”

Vesicovaginal Fistulas: Prevalence, Impact, and Management Challenges

“…Pelvic radiotherapy for malignancy decreases the blood supply, leading to tissue necrosis, sloughing, and fistula formation, even after many years [34]. Intriguingly, due to the fact that the incidence of placenta accreta spectrum is increasing as a result of the rising Cesarean section rate, some research suggests that this may be a future risk factor for an increase in VVFs [35].…”