Background
Hysterectomy for placenta accreta spectrum may be associated with urologic morbidity, including intentional or unintentional cystostomy, ureteral injury, and bladder fistula. Although previous retrospective studies have shown an association between placenta accreta spectrum and urologic morbidities, there is still a paucity of literature addressing these urologic complications.
Objective
We sought to report a systematic description of such morbidity and associated factors.
Study Design
This was a retrospective study of all histology-proven placenta accreta spectrum deliveries in an academic center between 2011 and 2020. Urologic morbidity was defined as the presence of at least one of the following: cystotomy, ureteral injury, or bladder fistula. Variables were reported as median (interquartile range) or number (percentage). Analyses were made using appropriate parametric and nonparametric tests. Multinomial regression analysis was performed to assess the association of adverse urologic events with the depth of placental invasion.
Results
In this study, 58 of 292 patients (19.9%) experienced urologic morbidity. Patients with urologic morbidity had a higher rate of placenta percreta (compared with placenta accreta and placenta increta) than those without such injuries. Preoperative ureteral stents were placed in 54 patients (93.1%) with and 146 patients (62.4%) without urologic injury ( P =.003). After adjusting for confounding variables, multinomial regression analysis revealed that the odds of having adverse urologic events was 6.5 times higher in patients with placenta percreta than in patients with placenta accreta.
Conclusion
Greater depth of invasion in placenta accreta spectrum was associated with more frequent and severe adverse urologic events. Whether stent placement confers any protective benefit requires further investigation.
Introduction
Placenta accreta spectrum (PAS) disorder is known to be associated with significant maternal morbidity and mortality because of hemorrhage and an emergent need for blood product transfusion. In addition, PAS may extend beyond the uterus and involve other organs, most commonly the bladder. Although direct ureteral invasion is uncommon, surgical extirpation of invasive retroperitoneal placental tissue may result in ureteral injury.
Although urologic complications associated with cesarean deliveries have previously been comprehensively described, similar data regarding urologic injury associated with PAS are lacking. , In a retrospective study of 49 women with PAS in 2015, Norris et al concluded that patients with PAS frequently required urologic intervention to prevent or repair injury to the urinary tract. Another retrospective study by Woldu et al reported rates of 27% and 4% of cystostomy and ureteral injury in patients with PAS, respectively. In addition, they found that the degree of placental invasion, number of previous cesarean deliveries, and intraoperative blood loss were associated with a higher likelihood of urologic injury.
We sought to describe the clinical characteristics and outcomes of patients with PAS with urologic complications.
Why was this study conducted?
Despite the significant urologic morbidity during hysterectomy for placenta accreta spectrum (PAS), there is limited literature reporting on this issue.
Key findings
Urologic complications are common in the setting of complex hysterectomies because of PAS. Deep placental invasion is associated with a higher rate of surgical urologic complications and general surgical complications.
What does this add to what is known?
Despite the concern for urologic morbidity and common occurrence, urogenital fistula formation is a rare finding. It is important to have surgeons with urologic expertise involved in the multidisciplinary care of PAS. Moreover, it is important to counsel patients about urologic morbidities ahead of time.
Materials and Methods
This was a retrospective analysis of all patients with histopathology-confirmed PAS, treated at Baylor College of Medicine–affiliated hospitals between January 1, 2011, and June 30, 2020. All cases had histology-confirmed PAS. Medical records were reviewed retrospectively by experienced senior physicians, and demographics, clinical characteristics, and outcomes were recorded. In 2011, we introduced a multidisciplinary approach for the management of known PAS in our center, the details of which have been previously published. The study was approved by our institutional review board (H-28609).
Urologic morbidity was defined as the presence of cystotomy (whether intentional or unintentional), ureteral injury, or bladder fistula. The depth of invasion was reported in terms of accreta, increta, or percreta based on the pathology report. Descriptive urologic variables examined included the performance of cystoscopy, cystoscopy time, and ureteral stent placement. The primary outcomes were indices of urologic morbidity as detailed above. Secondary urologic outcomes were postoperative days with a Foley catheter in place and hospital discharge with the Foley catheter. Nonurologic outcomes included estimated blood loss, number of blood products transfused, and length of hospital stay.
All continuous variables were tested for normality using descriptive statistics for skewness and kurtosis, visual evaluation of histograms, and the Kolmogorov-Smirnov test. Continuous data were reported as median (interquartile range [IQR]). Categorical data were reported as proportions and percentages. Comparisons between study groups were made using the Mann-Whitney U test and the chi-square or the Fisher exact test, as appropriate. Multinomial regression analysis was performed to assess the association of adverse urologic events with depth of placental invasion adjusted for race and ethnicity, gestational age at delivery, number of previous cesarean deliveries, depth of invasion, and multidisciplinary management status. Statistical analysis was done using the SPSS software (version 23.0; SPSS Inc, Chicago, IL). The level of significance was set at P <.05.
Results
In this study, 58 of 292 patients (19.9%) experienced urologic injury. These women had a higher rate of placenta percreta (compared with accreta and increta) than those without injury. The baseline clinical characteristics in each group have been presented in Table 1 . Preoperative temporary ureteral catheters were placed in 54 (93.1%) and 146 (62.4%) of women with and without injuries, respectively ( P =.003). Patients with injury had more complex intraoperative courses, experiencing a median of 1 more liter of blood loss and remained in the hospital for a median of 2.5 more postoperative days compared with patients without urologic injury ( P <.001 for both). Details of the urologic and nonurologic outcomes of these patients are provided in Tables 2 and 3 .
| Characteristic | Urologic injury, n=58 | No urologic injury, n=234 | P value |
|---|---|---|---|
| Age (y) | 33 (30–38) | 34 (30–38) | .60 |
| BMI (kg/m 2 ) | 31 (26–38) | 31 (27–37) | .96 |
| Gravidity | 4 (3–6) | 4 (3–5) | .65 |
| Race and ethnicity | .04 | ||
| Hispanic | 32 (55.2) | 95 (40.6) | |
| Non-Hispanic White | 20 (34.5) | 75 (32.1) | |
| Non-Hispanic Black | 5 (8.6) | 50 (21.4) | |
| Others | 1 (1.7) | 14 (6.0) | |
| GA at delivery (wk) | 33 (30–34) | 34 (31–35) | .03 |
| Mode of delivery | .51 | ||
| Vaginal | 1 (1.7) | 7 (3.0) | |
| Planned CD | 24 (41.4) | 116 (49.6) | |
| Emergency CD | 33 (56.9) | 111 (47.4) | |
| Placenta previa | 51 (87.9) | 199 (85.0) | .57 |
| Number of previous CDs | 2.5 (2–3) | 2 (2–3) | .04 |
| In vitro fertilization | 2 (3.4) | 21 (9.0) | .27 |
| Depth of invasion | <.001 | ||
| Accreta | 6 (10.3) | 83 (35.5) | |
| Increta | 6 (10.3) | 70 (29.9) | |
| Percreta | 46 (79.3) | 81 (34.6) | |
| Antenatal diagnosis | 50 (86.2) | 164 (66.7) | .003 |
| Multidisciplinary approach | 50 (86.2) | 160 (65.0) | .002 |
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