Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy.
EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK.
Ultrasound Obstet Gynecol. 2023 Nov;62(5):633-643. doi: 10.1002/uog.26299.
To report on the occurrence of urological complications in women undergoing Cesarean section for placenta accreta spectrum disorders (PAS).
MEDLINE, EMBASE and the Cochrane databases were searched electronically up to 1 November 2022. Studies reporting on the urological outcome of women undergoing Cesarean section for PAS were included. Two independent reviewers performed data extraction using a predefined protocol and assessed the risk of bias using the Newcastle-Ottawa scale for observational studies, with disagreements resolved by consensus.The primary outcome was the overall occurrence of urological complications. Secondary outcomes were the occurrence of any cystotomy, intentional cystotomy, unintentional cystotomy, ureteral damage, ureteral fistula and vesicovaginal fistula. All outcomes were explored in the overall population of women undergoing surgery for PAS. In addition, we performed subgroup analyses according to the type of surgery (Cesarean hysterectomy, or conservative surgery or management), severity of PAS at histopathology (placenta accreta/increta and placenta percreta), type of intervention (planned vs emergency) and number of cases per year. Random-effects meta-analyses of proportions were used to analyze the data.
There were 62 studies included in the systematic review and 56 were included in the meta-analysis. Urological complications occurred in 15.2% (95% CI, 12.9-17.7%) of cases. Cystotomy complicated 13.5% (95% CI, 9.7-17.9%) of surgical operations. Intentional cystotomy was required in 7.7% (95% CI, 6.5-9.1%) of cases, while unintentional cystotomy occurred in 7.2% (95% CI, 6.0-8.5%) of cases. Urological complications occurred in 19.4% (95% CI, 16.3-22.7%) of cases undergoing hysterectomy and 12.2% (95% CI, 7.5-17.8%) of those undergoing conservative treatment. In the subgroup analyses, urological complications occurred in 9.4% (95% CI, 5.4-14.4%) of women with placenta accreta/increta and 38.5% (95% CI, 21.6-57.0%) of those described as having placenta percreta, and included mainly cystotomy (5.5% (95% CI, 0.6-15.1%) and 22.0% (95% CI, 5.4-45.5%), respectively). Urological complications occurred in 15.4% (95% CI, 8.1-24.6%) of cases undergoing a planned procedure and 24.6% (95% CI, 13.0-38.5%) of those undergoing an emergency intervention. In subanalysis of studies reporting on ≥ 12 cases per year, the incidence of urological complication was similar to that reported in the primary analysis.
Women undergoing surgery for PAS are at high risk of urological complication, mainly cystotomy. The incidence of these complications was particularly high in women described as having placenta percreta at birth and in those undergoing emergency surgical intervention. The high heterogeneity between the included studies highlights the need for a standardized protocol for the diagnosis of PAS to identify prenatal imaging signs associated with the increased risk of urological morbidity at delivery. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
报告胎盘植入谱系疾病（PAS）行剖宫产术的女性发生泌尿系统并发症的情况。
电子检索 MEDLINE、EMBASE 和 Cochrane 数据库，截至 2022 年 11 月 1 日。纳入报告 PAS 行剖宫产术女性泌尿系统结局的研究。两名独立审查员使用预定义方案提取数据，并使用纽卡斯尔-渥太华量表评估观察性研究的偏倚风险，存在分歧时通过共识解决。主要结局为泌尿系统并发症的总体发生率。次要结局为任何膀胱切开术、有意膀胱切开术、无意膀胱切开术、输尿管损伤、输尿管瘘和膀胱阴道瘘的发生率。所有结局均在 PAS 手术的女性总体人群中进行探讨。此外，我们根据手术类型（剖宫产子宫切除术、保守性手术或管理）、组织学 PAS 严重程度（胎盘植入/胎盘粘连和胎盘穿透性）、干预类型（计划性 vs 紧急性）和每年病例数进行了亚组分析。使用随机效应荟萃分析比例来分析数据。
系统评价纳入 62 项研究，56 项研究纳入荟萃分析。泌尿系统并发症发生率为 15.2%（95%CI，12.9%-17.7%）。膀胱切开术使 13.5%（95%CI，9.7%-17.9%）的手术复杂化。7.7%（95%CI，6.5%-9.1%）的病例需要进行有意膀胱切开术，而 7.2%（95%CI，6.0%-8.5%）的病例发生无意膀胱切开术。行子宫切除术的患者中有 19.4%（95%CI，16.3%-22.7%）发生泌尿系统并发症，行保守治疗的患者中有 12.2%（95%CI，7.5%-17.8%）发生泌尿系统并发症。在亚组分析中，胎盘植入/胎盘粘连患者中泌尿系统并发症发生率为 9.4%（95%CI，5.4%-14.4%），胎盘穿透性患者中发生率为 38.5%（95%CI，21.6%-57.0%），主要为膀胱切开术（5.5%（95%CI，0.6%-15.1%）和 22.0%（95%CI，5.4%-45.5%））。计划性手术患者中有 15.4%（95%CI，8.1%-24.6%）发生泌尿系统并发症，紧急手术患者中有 24.6%（95%CI，13.0%-38.5%）发生泌尿系统并发症。对每年报告≥12 例病例的研究进行亚组分析，泌尿系统并发症发生率与主要分析结果相似。
行 PAS 手术的女性发生泌尿系统并发症的风险较高，主要为膀胱切开术。在描述为胎盘穿透性的女性和行紧急手术干预的女性中，这些并发症的发生率特别高。纳入研究之间的高度异质性突显了需要制定 PAS 的标准化诊断方案，以识别与分娩时泌尿系统发病率增加相关的产前影像学征象。© 2023 年国际妇产科超声学会。
