Surgical strategies for placenta percreta invading the bladder and review of literature

Major obstetric hemorrhage is the leading cause of maternal morbidity and mortality. In rare cases, life-threatening hematuria in pregnant women may result from invasion of the bladder by the placenta. We present our experience with 18 cases of placenta percreta with suspected bladder invasion. It is a retrospective single-center study conducted over a period of 3 years. Total 18 patients of radiologically diagnosed placenta percreta were included in the study. All patients who are at risk for placenta percreta underwent prenatal sonograms. Patients of Placenta Accreta Spectrum presenting electively also underwent MRI pelvis. Elective patients who were high risk of placenta percreta underwent bilateral placement of the balloon catheter in internal iliac artery. In case of doubt regarding bladder invasion, patient underwent anterior cystotomy and posterior wall of the bladder was examined and proximity of the ureteric orifice to the placenta and amount of involvement of bladder wall was assessed. Ureteric catheter placement was used as adjuncts depending on the proximity of placental invasion with ureteric orifice. Postoperative outcomes in the form of maternal morbidity, maternal mortality, fetal mortality, postoperative bleeding, bladder status, vesicovaginal fistula, bladder capacity were all evaluated. In our series, 17 cases all cases were diagnosed preoperatively by antenatal ultrasound and MRI. Only one patient presented with hematuria. Only in one patient, we attempted separation of placenta from bladder wall, and it resulted in profuse bleeding, and in rest, we excised the involved bladder. Partial cystectomy was done in 33.4% patients, 27% patients required bilateral placement of ureteric catheter due to proximity to the ureteric orifice. 33.4% patient underwent bilateral internal iliac artery ligation or balloon placement. Clot evaluation was needed in one patient. Intraoperatively—39% patients had uterus adhered to the bladder but no placental invasion into the bladder. One patient was managed with obstetric hysterectomy and methotrexate followed by clot evacuation and bilateral internal iliac artery ligation at a later date. One (5.6%) patient developed vesicovaginal fistula in postoperative period. There was one (5.6%) maternal mortality with no fetal mortality. On follow-up, patient had good bladder capacity, 3 weeks after the surgery. MRI done preoperatively can help us guide regarding the extent or severity of placental invasion. Intraoperatively, anterior cystostomy should be done in suspected placenta percreta. Grade I or II accrete/percreta patients can be managed conservatively. Partial cystectomy with placement of bilateral ureteric catheter is safer and less morbid approach in tackling placenta percreta invading the bladder with mucosal involvement.