A Multidisciplinary Approach for Reducing Complications During Cesarean Sections for Placenta Accreta

A Multidisciplinary Approach for Reducing Complications During Cesarean Sections for Placenta Accreta | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A Multidisciplinary Approach for Reducing Complications During Cesarean Sections for Placenta Accreta Ari Avraham Luder This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6998116/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract BACKGROUND Placenta accreta spectrum (PAS) is a serious obstetric condition marked by abnormal placental adherence to the uterine wall, often leading to significant maternal and fetal complications. Women with a history of cesarean section (CS) are at increased risk. The standard treatment is CS, which carries high complication rates, including hemorrhage, urological injury, and the potential need for hysterectomy. Traditionally, these surgeries are performed solely by obstetricians. OBJECTIVES To evaluate whether a multidisciplinary team (MDT) approach improves surgical outcomes and reduces complications in women with PAS. STUDY DESIGN We retrospectively reviewed medical records of 417 women diagnosed with PAS between 2011 and 2022. In 2019, our institution adopted an MDT protocol that includes preoperative obstetric and urological evaluation, joint surgical planning, and the intraoperative insertion of bilateral ureteral catheters (UCs). Outcomes were compared between patients treated before and after MDT implementation. RESULTS Of 417 women, 108 (25.9%) were managed using the MDT protocol. Estimated blood loss was significantly lower in the MDT group (1297cc vs. 1586cc, P = .036), with fewer requiring transfusions (2.8% vs. 8.4%, P = .002). Hysterectomy rates were also reduced (0.9% vs. 7.4%, P = .04). Urological injury occurred in only 4.7% of MDT cases versus 13.9% in the non-MDT group (P = .027). The overall complication rate was significantly lower in the MDT group (5.6% vs. 15.6%, P = .007). CONCLUSION An MDT approach significantly reduces surgical complications in PAS, supporting its implementation as standard care. Obstetrics & Gynecology Urology & Nephrology Placenta accreta spectrum (PAS) Multidisciplinary Team (MDT) Cesarean section (CS) Urological injuries Preoperative evaluation Maternal outcomes Postoperative complications Figures Figure 1 A. Why was this study conducted? To evaluate the impact of a multidisciplinary team (MDT) approach on reducing urological and surgical complications in placenta accreta spectrum (PAS). B. What are the key findings? MDT care significantly reduced urological injuries, surgical complications, estimated blood loss, and hospital stays in PAS patients. C. What does this study add to what is already known? Provides evidence of the effectiveness of MDT protocols in PAS management, Demonstrating enhanced maternal outcomes and increased surgical safety. Brief summery A multidisciplinary surgical protocol significantly reduced urological injuries and complications in women undergoing cesarean section for placenta accreta spectrum. Introduction Placenta accreta spectrum (PAS) is characterized by abnormal placental implantation and represents a matter of growing concern in obstetrics attributed to rising incidence rates. According to (Wu,SK, et al. (2005 1 ) In the 1970s and 1980s, the prevalence was estimated at between 1 in 2,510 and 1 in 4,017, increasing to approximately 1 in 533 from 1982 to 2002. By 2016, data from the National Inpatient Sample in the United States indicated an even higher rate of 1 in 272 women discharged from birth-related hospitalizations. (Touhami O,et al 2022 2 ), Given that the risk of PAS is greater among women who had undergone a cesarean section (CS) delivery in the past, the increasing incidence of PAS over the past 4 decades is most likely linked to that rise in CS delivery rates. A CS is often closely associated with various degrees of invasion into the uterine wall, thereby posing considerable risks of injury to adjacent organs, such as the urinary bladder, especially for women with a history of multiple CSs (Alison G et al., 2021 3 ). The PAS includes 3 major types based upon the extent of placental invasion: placenta accreta, where the placenta adheres too deeply to the uterine wall without penetrating the muscle, placenta increta, where the placenta invades the uterine muscles, and placenta percreta, the most severe form, in which the placenta penetrates through the uterine wall and may attach to adjacent organs, such as the urinary bladder (Lucidi et al., 2023 4 ). (Mina A. et al., 2015 5 ) Placenta increta and placenta percreta comprise the advanced stages of PA, and they are associated with higher rates of complications that can be life-threatening for both mother and fetus. Urological complications are among the most significant surgical concerns due to the anatomical proximity of the bladder and ureters to the CS surgical site. (Lopez et.al, 2021 6 ) A meta-analysis of 56 studies involving 13,641 women undergoing surgery for PAS reported a urological complication rate of 15.2% that included cystotomy, ureteral injury, and vesicovaginal fistula observed in 13.5%, 2%, and 1.6% of cases, respectively. A comparison of planned with emergent surgeries for PAS revealed that urological complications occurred in 15.4% of elective surgeries versus 24.6% of emergency cases. (Lucidi et al, 2023 4 ) Traditional PAS management methods often necessitate aggressive surgical interventions, with emergency hysterectomy rates reaching up to 90%. (Lucidi et al, 2023 4 ) Alternative surgical approaches have been developed with the aim of mitigating such alarming rates. One small randomized trial that compared hysterectomy to conservative surgery, referred to as "one-step conservative surgery," involves the en bloc resection of the myometrium affected by placenta accreta spectrum (PAS) along with the placenta, followed by uterine reconstruction. however, demonstrated similar surgical outcomes (Nieto-Calvache. Et al 2024 7 ). A more integrative approach to PAS management described by (Stanleigh J et al 2019 8 ),involves a multidisciplinary team (MDT) protocol that encompasses the expertise of radiologists, gynecologists, urologists, and obstetricians. Those authors claimed that this collaborative model allows for early identification of PAS, clarifies preoperative risk factors, and reduces intraoperative and postoperative complication rates. Although retrospective cohorts indicated that this approach can decrease surgical estimated blood loss (EBL), transfusion rates, and the need for urgent hysterectomy, there is currently limited evidence of a reduction in overall and, specifically, urological complications. (Stanleigh J et al 2019 8 ). In this study, we identify factors influencing intra- and postoperative urological and surgical complications in women with PAS with the aim of contributing to evidence-based management strategies for optimizing outcomes for this complex patient population. Materials and Methods Study population After obtaining institutional board approval, we conducted a retrospective cohort study of all PAS patients treated at our institution between 2011 and 2022. The PAS cases were identified by a recorded database and ICD-9 codes. Methods We reviewed maternal medical histories, pre-surgical obstetric US and surgical reports and intra- and postoperative surgical complications. Those complications included bladder and ureteral injuries, hematuria, ileus, bacteremia or other postoperative infections, the need for blood transfusions, postpartum hemorrhage, re-laparotomy, intraoperative hysterectomy, and postoperative hematuria or hydronephrosis. Clinical follow-up data were also collected. The MDT protocol was implemented in January 2019. We have integrated 5 key elements in the management of PAS cases as follows: A dedicated obstetric ultrasound (US) protocol, including PAS staging, to ensure accurate diagnosis and to guide preoperative planning. Multidisciplinary discussions before surgery for comprehensive assessment and joint decision-making among the surgical team members. Bilateral ureteral stent insertion at the onset of surgery was performed to facilitate intraoperative identification of the ureters, a technique supported in complex obstetric procedures to minimize urological injury risks (D'Angelo et al., 2018 9 , Alfageme et al., 2017 10 ). A dedicated obstetric surgical team with expertise in PAS surgery, including conservative techniques to minimize the need for urgent hysterectomy while ensuring optimal patient safety. An on-site urological surgeon for expeditious specialized intervention. Surgical procedures The patient was positioned in the lithotomy position on the operating table at the beginning of each procedure. After general Anesthesia was induced, a 22-Fr rigid cystoscope was inserted into the bladder to visualize the bladder anatomy. Following this, a hydrophilic-coated guidewire was introduced into one of the ureteral orifices, and a 6-Fr open-ended ureteral catheter (UC) was advanced along the guide wire until it reached the renal pelvis. Proper positioning was confirmed before carefully removing the guidewire. The same steps were repeated for the contralateral ureter. The UCs were fixed to a urethral catheter. for the duration of the surgery. They were typically removed in the early postoperative period, usually between postoperative days 1 and 2. Statistical analysis Statistical analyses were conducted using the Statistical Package for Social Sciences (SPSS v23.0, SPSS Inc.) and Python's open-source statistical models. Follow-up time was calculated from the date of the index CS until an associated untoward event occurred or the last follow-up. The cohort was divided into 1 group of women who underwent a comprehensive MDT workup (since January 2019) and 1 group of women who were operated by means of an interdisciplinary approach by obstetricians/gynecologists and for whom UCs were not routinely used (from January 2011 to December 2018). The baseline characteristics and the rates of urological and other complications sustained by the women in the 2 groups were compared by means of the Student's t-test for the distribution of continuous variables, while the chi-square test was used to evaluate the distribution of binary variables. The data are presented as medians with interquartile ranges (IQR) unless otherwise specified. Ethical Compliance Statement This study was approved by the Institutional Review Board of Sheba Medical Center (SMC Ethics Committee Identifier 9269-22). All procedures were conducted in accordance with the ethical standards of the Declaration of Helsinki and its later amendments or comparable ethical standards. Comment This study provides comprehensive insights into the impact of a multidisciplinary team (MDT) approach on surgical outcomes for patients with placenta accreta spectrum (PAS). It highlights the effectiveness of the MDT protocol in reducing urological and other surgical complications, estimated blood loss (EBL), and length of hospital stay (LOS), with findings underscoring the value of interdisciplinary collaboration and the strategic use of ureteral catheterization (UC). Principal Findings This retrospective cohort study, involving 417 patients treated for PAS between 2011 and 2022, (Baseline characteristics are presented in Table 1) demonstrated significant benefits of an MDT approach compared to a non-MDT interdisciplinary approach. Key findings include: Baseline Characteristics: Both groups were similar in age, degree of PAS, and prevalence of placenta previa. However, the MDT group exhibited longer gestations (37 vs. 36 weeks, P = .044), lower gravidity (4.1 vs. 4.9, P = .001), and a higher rate of prior cesarean sections (100% vs. 79.9%, P = .001). Surgical outcomes and complication rates are detailed in Table 2. Estimated Blood Loss: The MDT group had significantly lower median EBL (1,290 ml vs. 1,500 ml, P = .036). Urological Complications: Urological injuries, the most common complications, were significantly lower in the MDT group (4.6% vs. 14%, P = .046). Specifically: Bladder Injury: Lower in the MDT group (2.77% vs. 9.06%, P = 0.05). Ureteral Injury: Reduced incidence in the MDT group (1.85% vs. 4.85%, P = 0.28). Other Surgical Complications: Reduced in the MDT group (5.6% vs. 15.6%, P = .027). Length of Hospital Stay: The MDT group experienced shorter LOS (4.8 vs. 5.7 days, P = .007). Data are expressed as means (standard deviation) unless otherwise stated. Urological complications: Bladder injury, Ureteral Injury Complete or partial damage. Surgical complications: intestinal injury, uterine rupture, postpartum hemorrhage, placenta rupture, ileus, sepsis. The P -values were derived from an independent t-test and a Chi-square test. TABLE 1 Demographics and clinical characteristics of the p lacenta accreta spectrum patients Variables Total (n = 417) Study Group P - value MDT Approach (n = 108) Non-MDT Approach (n = 309) Age >35, years 417 (100) 37.0 (5.04) 36.3 (5.11) .136 Gravidity 417 (100) 4.1 (1.5) 4.9 (1.5) .001 Length of gestation, weeks 417 (100) 37±2 (0.875) 36±2 (3.183) .044 Previous cesarean section, n (%) 355 (85.1) 108 (100.0) 247 (79.9) .001 Accreta degree, n (%) Placenta accreta 113(27.1) 28 (25.61) 85 (27.74) .523 Placenta increta 78 (18.9) 20 (19.3) 58 (19.0) Placenta percreta 226 (54.2) 59 (55.1) 167(54.1) Placenta previa, n % 216 (51.8) 61 (56.5) 155 (50.2) .330 TABLE 2 Length of stay, estimated blood loss, and urological and overall complication rate among the multidisciplinary team (MDT) protocol group and the non-MDT (interdisciplinary) group Variables Total (n = 417) Study Group P - value MDT approach (n=108) Non-MDT approach (n = 309) Estimated blood loss, ml 417 (100.0) 1297 (399) 1586 (1332) .036 Urgent hysterectomy rate (%) 24 (5.8%) 1 (0.9%) 23 (7.4%) .04 Urological complications, n (%) 48 ( 11.5) 5 (4.60) 43 (14.0) .046 Surgical complications, n (%) 56 (13.42) 6 (5.6) 50 (15.6) .027 Length of stay, days 417 (100.0) 4.8 5.7 .007 Results in Context These findings align with previous reports emphasizing the importance of MDT protocols in complex surgical scenarios. While prior studies have highlighted the benefits of MDTs, this study uniquely demonstrates the effectiveness of a structured protocol in reducing both urological injuries and other surgical complications during PAS-related surgeries. Previous research has not shown comparable reductions in urological injuries or urgent hysterectomies in such a context, establishing this study as a significant contribution to the literature. Clinical Implications This study underscores the importance of adopting multidisciplinary team (MDT) protocols for managing placenta accreta spectrum (PAS) to improve surgical outcomes. Key clinical benefits include: (1) Reduced urological injuries through enhanced intraoperative identification and protection of critical structures, aided by preoperative ureteral catheterization—an approach shown to reduce the risk of ureteral injuries (Sharma et al., 2019 11 ); (2) Decreased blood loss and length of stay (LOS), reflecting improved hemostatic control and accelerated recovery; and (3) Effective interdisciplinary collaboration, integrating urological, gynecological, and obstetrical expertise to provide comprehensive, coordinated care. While prophylactic ureteral catheterization may not significantly reduce ureteral injury rates in all cases—as suggested in pelvic cancer surgeries (Koo et al., 2015 12 )—it consistently facilitates intraoperative identification and prompt repair, which is associated with improved outcomes. This is particularly relevant in complex or high-risk surgeries—such as PAS cases involving distorted anatomy or prior pelvic procedures—where early recognition of injury is critical. Although stenting may increase operative time and carries a modest risk of complications (e.g., hematuria or acute kidney injury), these are typically manageable. Therefore, most clinical guidelines recommend selective rather than routine use, emphasizing individualized decision-making based on patient risk. These findings support the integration of prophylactic stenting as a valuable tool within an MDT approach when used judiciously (Koo et al., 2015 12 ,Miller et al., 2018 13 ). Research Implications Future research should focus on: Multicenter Studies: To validate the findings across diverse settings. Cost-Effectiveness Analysis: Assessing the financial feasibility of implementing MDT protocols. Long-Term Outcomes: Evaluating patient recovery, recurrence, and quality of life. Training and Implementation: Investigating the scalability of MDT approaches in resource-limited settings. Strengths and Limitations Strengths: Large Cohort: The study analyzed 417 cases, one of the largest single-center studies on PAS management. Clear Separation of Groups: The MDT and non-MDT groups were distinctly defined, minimizing selection bias. Detailed Analysis: Complications, LOS, and EBL were comprehensively evaluated, adding robustness to the findings. Limitations: the retrospective design introduces the possibility of selection and reporting bias, inherent to this type of analysis. Second, the single-center nature of the study limits its generalizability, as the findings may not translate to other clinical environments with differing levels of expertise or resources. Third, the highly specialized surgical team involved in MDT implementation may not be replicable across all institutions, further restricting external applicability. Additionally, the small number of urgent hysterectomies and urological complications constrained the ability to perform more robust multivariate statistical analyses. Furthermore, while ureteral catheterization is a commonly used technique to prevent ureteral injury during complex pelvic surgeries, its routine use—particularly in unexperienced hands—remains controversial due to associated risks and potential complications (Higgins, 2016 14 , Van der Voet et al, 2019 15 ; Liu et al., 2020 16 ; Chong et al., 2018 17 ; Peng et al., 2021 18 ). These considerations reinforce the importance of careful patient selection and institutional preparedness when adopting such techniques as part of an MDT approach Conclusions The implementation of our MDT management protocol for PAS patients led to significant reductions in estimated blood loss (EBL), transfusion rates, urological complications, and overall complication rates, and subsequently to a decreased LOS. This study highlights the substantial advantages of an MDT approach in the surgical management of PAS. The collaboration between urologists and gynecologists significantly decreased the incidence of intraoperative and postoperative complications compared to an interdisciplinary approach. Declarations Ethics Approval and Consent to ParticipateThis study was approved by the Institutional Review Board of Sheba Medical Center (SMC Ethics Committee Identifier 9269-22). All procedures were conducted in accordance with the Declaration of Helsinki and its amendments. Consent for Publication Not applicable Availability of Data and Materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.Competing Interests The authors declare no competing interests. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Authors: Contributions AL leading author contributed to study design and manuscript drafting. NK, SM-T, HL-E, and AS contributed to patient care and data acquisition. ZAD supervised the project and critically revised the manuscript. All authors read and approved the final manuscript. Acknowledgements : Not applicable References Wu, S., Kocherginsky, M., & Hibbard, J.U. (2005). Abnormal placentation: Twenty-year analysis. American Journal of Obstetrics & Gynecology, 192, 1458–1461. Touhami O, Allen L, Flores Mendoza H, Murphy MA, Hobson SR. Placenta accreta spectrum: a non-oncologic challenge for gynecologic oncologists. International Journal of Gynecological Cancer, Apr. 2022 Alison G. Cahill, MD, MSCI; Richard Beigi, MD, MSc; R. Phillips Heine, MD; Robert M. Silver, MD; and Joseph R. Wax, MD. Placenta Accreta Spectrum ( 2021). American College of Obstetricians and Gynecologists and the Society for Maternal–Fetal Medicine. Number 7 (Replaces Committee Opinion No. 529, July 2012. Lucidi, A., Jauniaux, E., Hussein, A. M., Coutinho, C. M., Tinari, S., Khalil, A., Shamshirsaz, A., Palacios-Jaraquemada, J. M., & D'Antonio, F. (2023). Urological complications in women undergoing Cesarean section for placenta accreta spectrum disorders: systematic review and meta-analysis. Ultrasound in Obstetrics & Gynecology. Mina A. Ibrahim., Liu, A., Dalpiazza, A., Schwamb, R., Warren, K., & Khan, S.A. (2014). Urological manifestations of placenta percreta: A contemporary tertiary care institutional experience. Current Urology, 8, 57–65. doi:10.1159/000365691 López, J., Cín Santo, P., & Romero, R. (2021). Impact of Ureteral Catheterization on Postoperative Outcomes in Obstetric Surgery: A Systematic Review. Obstetrics & Gynecology International, 2021, Article ID 5894032 Nieto-Calvache, A. J., Palacios-Jaraquemada, J. M., Hussein, A. M., Jauniaux, E., Coutinho, C. M., & Rijken, M. (2024). Management of placenta accreta spectrum in low- and middle-income countries. Best Practice & Research Clinical Obstetrics & Gynaecology, 94, 102475. Stanleigh J, Michaeli J, Armon S, Khatib F, Zuckerman B, Shaya M, Ioscovitch A, Shenfeld O, Greenblat D, Farkash R, Tevet A, Samueloff A, Grisaru Granovsky S. Maternal and neonatal outcomes following a proactive peripartum multidisciplinary management protocol for placenta creta spectrum as compared to urgent delivery. Eur J Obstet Gynecol Reprod Biol . 2019 Jun;237:139-144. D'Angelo, M., Cecchetto, G., Schettini, S., & Purgatorio, G. (2018). Ureteral Catheter Placement in Complex Obstetric Procedures. International Journal of Surgery Case Reports, 53, 62-65. Alfageme, A., Guerra, M., & Ramos, J. (2017). Urological Safety in Obstetric Surgical Procedures: The Benefits of Preoperative Ureteral Catheterization. European Urology Supplements, 16(6), 762-765. Sharma, P., Prakash, A., & Gupta, B. (2019). Intraoperative Identification of Ureteral Injuries: The Role of Ureteral Catheters. Journal of Surgical Research, 245, 131-138. Koo, Y. J., Jun, D. Y., & Kim, H. J. (2015). "The Effect of Prophylactic Ureteral Stenting in Pelvic Cancer Surgery: A Meta-Analysis." Journal of Urology, 193(5), 1704-1709. doi:10.1016/j.juro.2014.11.048 Miller, J. R., Baker, B. S., & Gray, J. A. (2018). "The Role of Ureteral Catheters in Complex Obstetric Surgery." Obstetrics and Gynecology, 132(3), 623-630. Higgins, C. C. (2016). Complications of peri-operative ureteral catheter placement in gynecologic and colorectal surgery. Urology, 94, 102475 Van der Voet, L. W., Bartels, H. C., & Timmermans, A. J. (2019). "Ureteral Catheters in Obstetric Surgery: Procedure and Complications." European Journal of Obstetrics & Gynecology and Reproductive Biology, 240, 213-218. Liu, Y., Chen, H., & Lin, J. (2020). "Bladder Perforation Due to Ureteral Catheter Placement: A Case Series and Literature Review." International Urogynecology Journal, 31(8), 1573-1579. Chong, J. T., Kan, K. M., Phillips, C. K., & Greenstein, A. (2018). Ureteral catheters for colorectal surgery: Influence on operative times and complication outcomes: An observational study. Investigative and Clinical Urology, 59(2), 119–125 Peng, Y. L., Ning, K., Wu, Z. S., Li, Z. Y., Deng, M. H., Xiong, L. B., Yu, C. P., Zhang, Z. L., Liu, Z. W., Lu, H. M., & Zhou, F. J. (2021). Ureteral stents cannot decrease the incidence of ureteroileal anastomotic stricture and leakage: A systematic review and meta-analysis. International Journal of Surgery, 93, 102975 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6998116","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":477748909,"identity":"78a8d0f6-2852-4aef-9aaf-8c4772988895","order_by":0,"name":"Ari Avraham Luder","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyUlEQVRIiWNgGAWjYFACxsYDDGwMDPwMIJJILQ1gLZINxGthYABrMThArBb+2YcbDvOU2eQb30h+9uBDBYM8v9gB/FokziUCtZxLs9x2I83ccMYZBsOZsxMIWHOGseEwb9thA7MbCWbSvG0MCQa3CWiRh2j5b2A8I/0bcVoMIFoOGBhI5BBpiyFQy8E555INJM68KZOccUaCsF/kzrA/fPCmzM6Avz19m8SHCht5fmkCWhBAAKxSgljlIMB/gBTVo2AUjIJRMJIAAI6HQz0dFoj0AAAAAElFTkSuQmCC","orcid":"","institution":"sheba medical center","correspondingAuthor":true,"prefix":"","firstName":"Ari","middleName":"Avraham","lastName":"Luder","suffix":""}],"badges":[],"createdAt":"2025-06-28 13:35:12","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":true,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":true},"doi":"10.21203/rs.3.rs-6998116/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6998116/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85924539,"identity":"34c9a0fd-d1c9-4ea4-a754-8e8c3efb7f20","added_by":"auto","created_at":"2025-07-03 08:26:55","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":50526,"visible":true,"origin":"","legend":"\u003cp\u003eUnnumbered image in the Materials \u0026amp; Methods section.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6998116/v1/8845ea333eb6fe35e45fe10c.png"},{"id":85926737,"identity":"1770fea6-36c5-4ffe-b305-eea08a94c467","added_by":"auto","created_at":"2025-07-03 08:43:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":624246,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6998116/v1/959c0096-cd3a-4ee0-84d2-a4ad0a02dc3b.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eA Multidisciplinary Approach for Reducing Complications During Cesarean Sections for Placenta Accreta\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"A. Why was this study conducted?","content":"\u003cp\u003eTo evaluate the impact of a multidisciplinary team (MDT) approach on reducing urological and surgical complications in placenta accreta spectrum (PAS).\u003c/p\u003e\n\u003cp\u003eB. What are the key findings?\u003c/p\u003e\n\u003cp\u003eMDT care significantly reduced urological injuries, surgical complications, estimated blood loss, and hospital stays in PAS patients.\u003c/p\u003e\n\u003cp\u003eC. What does this study add to what is already known?\u003c/p\u003e\n\u003cp\u003eProvides evidence of the effectiveness of MDT protocols in PAS management, Demonstrating enhanced maternal outcomes and increased surgical safety.\u003c/p\u003e"},{"header":"Brief summery","content":"\u003cp\u003eA multidisciplinary surgical protocol significantly reduced urological injuries and complications in women undergoing cesarean section for placenta accreta spectrum.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003ePlacenta accreta spectrum (PAS) is characterized by abnormal placental implantation and represents a matter of growing concern in obstetrics attributed to rising incidence rates.\u0026nbsp;According to (Wu,SK, et al. (2005\u003cstrong\u003e\u003csup\u003e1\u003c/sup\u003e\u003c/strong\u003e)\u0026nbsp;In the 1970s and 1980s, the prevalence was estimated at between 1 in 2,510 and 1 in 4,017, increasing to approximately 1 in 533 from 1982 to 2002. By 2016, data from the National Inpatient Sample in the United States indicated an even higher rate of 1 in 272 women discharged from birth-related hospitalizations. (Touhami O,et al 2022\u0026nbsp;\u003cstrong\u003e\u003csup\u003e2\u003c/sup\u003e\u003c/strong\u003e), Given that the risk of PAS is greater among women who had undergone a cesarean section (CS) delivery in the past, the increasing incidence of PAS over the past 4 decades is most likely linked to that rise in CS delivery rates. A CS is often closely associated with various degrees of invasion into the uterine wall, thereby posing considerable risks of injury to adjacent organs, such as the urinary bladder, especially for women with a history of multiple CSs (Alison G et al., 2021\u003cstrong\u003e\u003csup\u003e3\u003c/sup\u003e\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003eThe PAS includes 3 major types based upon the extent of placental invasion: placenta accreta, where the placenta adheres too deeply to the uterine wall without penetrating the muscle, placenta increta, where the placenta invades the uterine muscles, and placenta percreta, the most severe form, in which the placenta penetrates through the uterine wall and may attach to adjacent organs, such as the urinary bladder (Lucidi et al., 2023\u0026nbsp;\u003cstrong\u003e\u003csup\u003e4\u003c/sup\u003e\u003c/strong\u003e). (Mina A. et al., 2015\u0026nbsp;\u003cstrong\u003e\u003csup\u003e5\u003c/sup\u003e\u003c/strong\u003e) Placenta increta and placenta percreta comprise the advanced stages of PA, and they are associated with higher rates of complications that can be life-threatening for both mother and fetus.\u003c/p\u003e\n\u003cp\u003eUrological complications are among the most significant surgical concerns due to the anatomical proximity of the bladder and ureters to the CS surgical site. (Lopez et.al, 2021\u0026nbsp;\u003cstrong\u003e\u003csup\u003e6\u003c/sup\u003e\u003c/strong\u003e) A meta-analysis of 56 studies involving 13,641 women undergoing surgery for PAS reported a urological\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ecomplication rate of 15.2% that included cystotomy, ureteral injury, and vesicovaginal fistula observed in 13.5%, 2%, and 1.6% of cases, respectively. A comparison of planned with emergent surgeries for PAS revealed that urological complications occurred in 15.4% of elective surgeries versus 24.6% of emergency cases. (Lucidi et al, 2023\u0026nbsp;\u003cstrong\u003e\u003csup\u003e4\u003c/sup\u003e\u003c/strong\u003e)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTraditional PAS management methods often necessitate aggressive surgical interventions, with emergency hysterectomy rates reaching up to 90%. (Lucidi et al, 2023\u0026nbsp;\u003cstrong\u003e\u003csup\u003e4\u003c/sup\u003e\u003c/strong\u003e)\u0026nbsp; Alternative surgical approaches have been developed with the aim of mitigating such alarming rates. One small randomized trial that compared hysterectomy to conservative surgery, referred to as \"one-step conservative surgery,\" involves the en bloc resection of the myometrium affected by placenta accreta spectrum (PAS) along with the placenta, followed by uterine reconstruction. however, demonstrated similar surgical outcomes (Nieto-Calvache. Et al 2024\u0026nbsp;\u003cstrong\u003e\u003csup\u003e7\u003c/sup\u003e\u003c/strong\u003e). A more integrative approach to PAS management described by\u0026nbsp;(Stanleigh J et al 2019 \u003cstrong\u003e\u003csup\u003e8\u003c/sup\u003e\u003c/strong\u003e),involves a multidisciplinary team (MDT) protocol that encompasses the expertise of radiologists, gynecologists, urologists, and obstetricians. Those authors claimed that this collaborative model allows for early identification of PAS, clarifies preoperative risk factors, and reduces intraoperative and postoperative complication rates. Although retrospective cohorts indicated that this approach can decrease surgical estimated blood loss (EBL), transfusion rates, and the need for urgent hysterectomy, there is currently limited evidence of a reduction in overall and, specifically, urological complications. (Stanleigh J et al 2019 \u003cstrong\u003e\u003csup\u003e8\u003c/sup\u003e\u003c/strong\u003e). In this study, we identify factors influencing intra- and postoperative urological and surgical complications in women with PAS with the aim of contributing to evidence-based management strategies for optimizing outcomes for this complex patient population.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy population\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter obtaining institutional board approval, we conducted a retrospective cohort study of all PAS patients treated at our institution between 2011 and 2022. The PAS cases were identified by a recorded database and ICD-9 codes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe reviewed maternal medical histories, pre-surgical obstetric US and surgical reports and \u0026nbsp; intra- and postoperative surgical complications. Those complications included bladder and ureteral injuries, hematuria, ileus, bacteremia or other postoperative infections, the need for blood transfusions, postpartum hemorrhage, re-laparotomy, intraoperative hysterectomy, and postoperative hematuria or hydronephrosis. Clinical follow-up data were also collected.\u003c/p\u003e\n\u003cp\u003eThe MDT protocol was implemented in January 2019. We have integrated 5 key elements in the management of PAS cases as follows:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eA dedicated obstetric ultrasound (US) protocol, including PAS staging, to ensure accurate diagnosis and to guide preoperative planning.\u003c/li\u003e\n \u003cli\u003eMultidisciplinary discussions before surgery for comprehensive assessment and joint decision-making among the surgical team members.\u003c/li\u003e\n \u003cli\u003eBilateral ureteral stent insertion at the onset of surgery was performed to facilitate intraoperative identification of the ureters, a technique supported in complex obstetric procedures to minimize urological injury risks (D\u0026apos;Angelo et al., 2018 \u003cstrong\u003e\u003csup\u003e9\u003c/sup\u003e\u003c/strong\u003e, Alfageme et al., 2017 \u003cstrong\u003e\u003csup\u003e10\u003c/sup\u003e\u003c/strong\u003e).\u003c/li\u003e\n \u003cli\u003eA dedicated obstetric surgical team with expertise in PAS surgery, including conservative techniques to minimize the need for urgent hysterectomy while ensuring optimal patient safety.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAn on-site urological surgeon for expeditious specialized intervention. \u0026nbsp;\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical procedures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe patient was positioned in the lithotomy position on the operating table at the beginning of each procedure. After general Anesthesia was induced, a 22-Fr rigid cystoscope was inserted into the bladder to visualize the bladder anatomy. Following this, a hydrophilic-coated guidewire was introduced into one of the ureteral orifices, and a 6-Fr open-ended ureteral catheter (UC) was advanced along the guide wire until it reached the renal pelvis. Proper positioning was confirmed before carefully removing the guidewire. The same steps were repeated for the contralateral ureter. The UCs were fixed to a urethral catheter. for the duration of the surgery. They were typically removed in the early postoperative period, usually between postoperative days 1 and 2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStatistical analyses were conducted using the Statistical Package for Social Sciences (SPSS v23.0, SPSS Inc.) and Python\u0026apos;s open-source statistical models. Follow-up time was calculated from the date of the index CS until an associated untoward event occurred or the last follow-up. The cohort was divided into 1 group of women who underwent a comprehensive MDT workup (since January 2019) and 1 group of women who were operated by means of an interdisciplinary approach by obstetricians/gynecologists and for whom UCs were not routinely used (from January 2011 to December 2018). The baseline characteristics and the rates of urological and other complications sustained by the women in the 2 groups were compared by means of the Student\u0026apos;s t-test for the distribution of continuous variables, while the chi-square test was used to evaluate the distribution of binary variables. The data are presented as medians with interquartile ranges (IQR) unless otherwise specified.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Compliance Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Review Board of Sheba Medical Center (SMC Ethics Committee Identifier 9269-22). All procedures were conducted in accordance with the ethical standards of the Declaration of Helsinki and its later amendments or comparable ethical standards.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study provides comprehensive insights into the impact of a multidisciplinary team (MDT) approach on surgical outcomes for patients with placenta accreta spectrum (PAS). It highlights the effectiveness of the MDT protocol in reducing urological and other surgical complications, estimated blood loss (EBL), and length of hospital stay (LOS), with findings underscoring the value of interdisciplinary collaboration and the strategic use of ureteral catheterization (UC).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePrincipal Findings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective cohort study, involving 417 patients treated for PAS between 2011 and 2022, (Baseline characteristics are presented in Table 1)\u0026nbsp;demonstrated significant benefits of an MDT approach compared to a non-MDT interdisciplinary approach. Key findings include:\u003c/p\u003e\n\u003cp\u003eBaseline Characteristics: Both groups were similar in age, degree of PAS, and prevalence of placenta previa. However, the MDT group exhibited longer gestations (37 vs. 36 weeks, P = .044), lower gravidity (4.1 vs. 4.9, P = .001), and a higher rate of prior cesarean sections (100% vs. 79.9%, P = .001).\u0026nbsp;Surgical outcomes and complication rates are detailed in Table 2.\u003c/p\u003e\n\u003cp\u003eEstimated Blood Loss: The MDT group had significantly lower median EBL (1,290 ml vs. 1,500 ml, P = .036). Urological Complications: Urological injuries, the most common complications, were significantly lower in the MDT group (4.6% vs. 14%, P = .046). Specifically: Bladder Injury: Lower in the MDT group (2.77% vs. 9.06%, P = 0.05).\u003c/p\u003e\n\u003cp\u003eUreteral Injury: Reduced incidence in the MDT group (1.85% vs. 4.85%, P = 0.28). Other Surgical Complications: Reduced in the MDT group (5.6% vs. 15.6%, P = .027). Length of Hospital Stay: The MDT group experienced shorter LOS (4.8 vs. 5.7 days, P = .007).\u003c/p\u003e\n\u003cp\u003eData are expressed as means (standard deviation) unless otherwise stated.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUrological complications: Bladder injury, Ureteral Injury Complete or partial damage.\u003c/p\u003e\n\u003cp\u003eSurgical complications: intestinal injury, uterine rupture, postpartum hemorrhage, placenta rupture, ileus, sepsis.\u003c/p\u003e\n\u003cp\u003eThe \u003cem\u003eP\u003c/em\u003e-values were derived from an independent t-test and a Chi-square test.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTABLE 1\u003c/strong\u003e \u003cstrong\u003eDemographics and clinical characteristics of the p\u003c/strong\u003e\u003cstrong\u003elacenta accreta spectrum\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003epatients\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"111%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 36px;\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 17px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003cp\u003e(n = 417)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 33px;\"\u003e\n \u003cp\u003eStudy Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e- value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003eMDT Approach\u003c/p\u003e\n \u003cp\u003e(n = 108)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003eNon-MDT Approach\u003c/p\u003e\n \u003cp\u003e(n = 309)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003eAge \u0026gt;35, years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17px;\"\u003e\n \u003cp\u003e417 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17px;\"\u003e\n \u003cp\u003e37.0 (5.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e36.3 (5.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e.136\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003eGravidity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17px;\"\u003e\n \u003cp\u003e417 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17px;\"\u003e\n \u003cp\u003e4.1 (1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e4.9 (1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003eLength of gestation, weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17px;\"\u003e\n \u003cp\u003e417 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17px;\"\u003e\n \u003cp\u003e37\u0026plusmn;2 (0.875)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e36\u0026plusmn;2 (3.183)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e.044\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003ePrevious cesarean section, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17px;\"\u003e\n \u003cp\u003e355 (85.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17px;\"\u003e\n \u003cp\u003e108 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e247 (79.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003eAccreta degree, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003ePlacenta accreta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17px;\"\u003e\n \u003cp\u003e113(27.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e28 (25.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e85 (27.74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 11px;\"\u003e\n \u003cp\u003e.523\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003ePlacenta increta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17px;\"\u003e\n \u003cp\u003e78 (18.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e20 (19.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e58 (19.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003ePlacenta percreta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17px;\"\u003e\n \u003cp\u003e226 (54.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e59 (55.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e167(54.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003ePlacenta previa, n %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17px;\"\u003e\n \u003cp\u003e216 (51.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17px;\"\u003e\n \u003cp\u003e61 (56.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e155 (50.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e.330\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTABLE 2\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eLength of stay, estimated blood loss, and urological and overall complication rate among the multidisciplinary team (MDT) protocol group and the non-MDT (interdisciplinary) group\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"115%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 34px;\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 14px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003cp\u003e(n = 417)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 40px;\"\u003e\n \u003cp\u003eStudy Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e- value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003eMDT approach\u003c/p\u003e\n \u003cp\u003e(n=108)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003eNon-MDT approach\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(n = 309)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eEstimated blood loss, ml\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e417 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17px;\"\u003e\n \u003cp\u003e1297 (399)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e1586 (1332)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e.036\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eUrgent hysterectomy rate (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e24 \u0026nbsp; \u0026nbsp; (5.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17px;\"\u003e\n \u003cp\u003e1 (0.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e23 (7.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eUrological complications, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e48 \u0026nbsp; \u0026nbsp; ( 11.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e5 (4.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e43 (14.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e.046\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eSurgical complications, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e56 \u0026nbsp; \u0026nbsp; (13.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17px;\"\u003e\n \u003cp\u003e6 (5.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e50 (15.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e.027\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eLength of stay, days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e417 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17px;\"\u003e\n \u003cp\u003e4.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e5.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e.007\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Results in Context","content":"\u003cp\u003eThese findings align with previous reports emphasizing the importance of MDT protocols in complex surgical scenarios. While prior studies have highlighted the benefits of MDTs, this study uniquely demonstrates the effectiveness of a structured protocol in reducing both urological injuries and other surgical complications during PAS-related surgeries. Previous research has not shown comparable reductions in urological injuries or urgent hysterectomies in such a context, establishing this study as a significant contribution to the literature.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Implications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study underscores the importance of adopting multidisciplinary team (MDT) protocols for managing placenta accreta spectrum (PAS) to improve surgical outcomes. Key clinical benefits include: (1) Reduced urological injuries through enhanced intraoperative identification and protection of critical structures, aided by preoperative ureteral catheterization\u0026mdash;an approach shown to reduce the risk of ureteral injuries (Sharma et al., 2019\u0026nbsp;\u003cstrong\u003e\u003csup\u003e11\u003c/sup\u003e\u003c/strong\u003e); (2) Decreased blood loss and length of stay (LOS), reflecting improved hemostatic control and accelerated recovery; and (3) Effective interdisciplinary collaboration, integrating urological, gynecological, and obstetrical expertise to provide comprehensive, coordinated care.\u003c/p\u003e\n\u003cp\u003eWhile prophylactic ureteral catheterization may not significantly reduce ureteral injury rates in all cases\u0026mdash;as suggested in pelvic cancer surgeries (Koo et al., 2015 \u003cstrong\u003e\u003csup\u003e12\u003c/sup\u003e\u003c/strong\u003e)\u0026mdash;it consistently facilitates intraoperative identification and prompt repair, which is associated with improved outcomes. This is particularly relevant in complex or high-risk surgeries\u0026mdash;such as PAS cases involving distorted anatomy or prior pelvic procedures\u0026mdash;where early recognition of injury is critical. Although stenting may increase operative time and carries a modest risk of complications (e.g., hematuria or acute kidney injury), these are typically manageable. Therefore, most clinical guidelines recommend selective rather than routine use, emphasizing individualized decision-making based on patient risk. These findings support the integration of prophylactic stenting as a valuable tool within an MDT approach when used judiciously (Koo et al., 2015 \u003cstrong\u003e\u003csup\u003e12\u0026nbsp;\u003c/sup\u003e\u003c/strong\u003e,Miller et al., 2018 \u003cstrong\u003e\u003csup\u003e13\u003c/sup\u003e\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResearch Implications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFuture research should focus on:\u003c/p\u003e\n\u003cp\u003eMulticenter Studies: To validate the findings across diverse settings.\u003c/p\u003e\n\u003cp\u003eCost-Effectiveness Analysis: Assessing the financial feasibility of implementing MDT protocols.\u003c/p\u003e\n\u003cp\u003eLong-Term Outcomes: Evaluating patient recovery, recurrence, and quality of life.\u003c/p\u003e\n\u003cp\u003eTraining and Implementation: Investigating the scalability of MDT approaches in resource-limited settings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrengths and Limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStrengths:\u003c/p\u003e\n\u003cp\u003eLarge Cohort: The study analyzed 417 cases, one of the largest single-center studies on PAS management.\u003c/p\u003e\n\u003cp\u003eClear Separation of Groups: The MDT and non-MDT groups were distinctly defined, minimizing selection bias.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDetailed Analysis: Complications, LOS, and EBL were comprehensively evaluated, adding robustness to the findings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ethe retrospective design introduces the possibility of selection and reporting bias, inherent to this type of analysis.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Second, the single-center nature of the study limits its generalizability, as the findings may not translate to other clinical environments with differing levels of expertise or resources.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThird, the highly specialized surgical team involved in MDT implementation may not be replicable across all institutions, further restricting external applicability. Additionally, the small number of urgent hysterectomies and urological complications constrained the ability to perform more robust multivariate statistical analyses.\u003c/p\u003e\n\u003cp\u003eFurthermore, while ureteral catheterization is a commonly used technique to prevent ureteral injury during complex pelvic surgeries, its routine use\u0026mdash;particularly in unexperienced hands\u0026mdash;remains controversial due to associated risks and potential complications (Higgins, 2016\u0026nbsp;\u003cstrong\u003e\u003csup\u003e14\u003c/sup\u003e\u003c/strong\u003e, Van der Voet et al, 2019\u0026nbsp;\u003cstrong\u003e\u003csup\u003e15\u003c/sup\u003e\u003c/strong\u003e; Liu et al., 2020\u0026nbsp;\u003cstrong\u003e\u003csup\u003e16\u003c/sup\u003e\u003c/strong\u003e; Chong et al., 2018\u0026nbsp;\u003cstrong\u003e\u003csup\u003e17\u003c/sup\u003e\u003c/strong\u003e; Peng et al., 2021\u0026nbsp;\u003cstrong\u003e\u003csup\u003e18\u003c/sup\u003e\u003c/strong\u003e). These considerations reinforce the importance of careful patient selection and institutional preparedness when adopting such techniques as part of an MDT approach\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe implementation of our MDT management protocol for PAS patients led to significant reductions in estimated blood loss (EBL), transfusion rates, urological complications, and overall complication rates, and subsequently to a decreased LOS. This study highlights the substantial advantages of an MDT approach in the surgical management of PAS. The collaboration between urologists and gynecologists significantly decreased the incidence of intraoperative and postoperative complications compared to an interdisciplinary approach.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics Approval and Consent to ParticipateThis study was approved by the Institutional Review Board of Sheba Medical Center (SMC Ethics Committee Identifier 9269-22). All procedures were conducted in accordance with the Declaration of Helsinki and its amendments.\u003c/p\u003e\n\u003cp\u003eConsent for Publication Not applicable\u003c/p\u003e\n\u003cp\u003eAvailability of Data and Materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.Competing Interests The authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003eAuthors: Contributions AL leading author \u0026nbsp;contributed to study design and manuscript drafting. NK, SM-T, HL-E, and AS contributed to patient care and data acquisition. ZAD supervised the project and critically revised the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements :\u003c/p\u003e\n\u003cp\u003eNot applicable\u003cbr\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eWu, S., Kocherginsky, M., \u0026amp; Hibbard, J.U. (2005). Abnormal placentation: Twenty-year analysis. American Journal of Obstetrics \u0026amp; Gynecology, 192, 1458\u0026ndash;1461.\u003c/li\u003e\n \u003cli\u003eTouhami O, Allen L, Flores Mendoza H, Murphy MA, Hobson SR. Placenta accreta spectrum: a non-oncologic challenge for gynecologic oncologists. International Journal of Gynecological Cancer, Apr. 2022\u003c/li\u003e\n \u003cli\u003eAlison G. Cahill, MD, MSCI; Richard Beigi, MD, MSc; R. Phillips Heine, MD; Robert M. Silver, MD; and Joseph R. Wax, MD. Placenta Accreta Spectrum ( 2021). American College of Obstetricians and Gynecologists and the Society for Maternal\u0026ndash;Fetal Medicine. Number 7 (Replaces Committee Opinion No. 529, July 2012.\u003c/li\u003e\n \u003cli\u003eLucidi, A., Jauniaux, E., Hussein, A. M., Coutinho, C. M., Tinari, S., Khalil, A., Shamshirsaz, A., Palacios-Jaraquemada, J. M., \u0026amp; D\u0026apos;Antonio, F. (2023). Urological complications in women undergoing Cesarean section for placenta accreta spectrum disorders: systematic review and meta-analysis. Ultrasound in Obstetrics \u0026amp; Gynecology.\u003c/li\u003e\n \u003cli\u003eMina A. Ibrahim., Liu, A., Dalpiazza, A., Schwamb, R., Warren, K., \u0026amp; Khan, S.A. (2014). Urological manifestations of placenta percreta: A contemporary tertiary care institutional experience. Current Urology, 8, 57\u0026ndash;65. doi:10.1159/000365691\u003c/li\u003e\n \u003cli\u003eL\u0026oacute;pez, J., C\u0026iacute;n Santo, P., \u0026amp; Romero, R. (2021). Impact of Ureteral Catheterization on Postoperative Outcomes in Obstetric Surgery: A Systematic Review. Obstetrics \u0026amp; Gynecology International, 2021, Article ID 5894032\u003c/li\u003e\n \u003cli\u003eNieto-Calvache, A. J., Palacios-Jaraquemada, J. M., Hussein, A. M., Jauniaux, E., Coutinho, C. M., \u0026amp; Rijken, M. (2024). Management of placenta accreta spectrum in low- and middle-income countries. Best Practice \u0026amp; Research Clinical Obstetrics \u0026amp; Gynaecology, 94, 102475.\u003c/li\u003e\n \u003cli\u003eStanleigh J, Michaeli J, Armon S, Khatib F, Zuckerman B, Shaya M, Ioscovitch A, Shenfeld O, Greenblat D, Farkash R, Tevet A, Samueloff A, Grisaru Granovsky S. Maternal and neonatal outcomes following a proactive peripartum multidisciplinary management protocol for placenta creta spectrum as compared to urgent delivery.\u0026nbsp;\u003cem\u003eEur J Obstet Gynecol Reprod Biol\u003c/em\u003e. 2019 Jun;237:139-144.\u003c/li\u003e\n \u003cli\u003eD\u0026apos;Angelo, M., Cecchetto, G., Schettini, S., \u0026amp; Purgatorio, G. (2018). Ureteral Catheter Placement in Complex Obstetric Procedures. International Journal of Surgery Case Reports, 53, 62-65.\u003c/li\u003e\n \u003cli\u003eAlfageme, A., Guerra, M., \u0026amp; Ramos, J. (2017). Urological Safety in Obstetric Surgical Procedures: The Benefits of Preoperative Ureteral Catheterization. European Urology Supplements, 16(6), 762-765.\u003c/li\u003e\n \u003cli\u003eSharma, P., Prakash, A., \u0026amp; Gupta, B. (2019). Intraoperative Identification of Ureteral Injuries: The Role of Ureteral Catheters. Journal of Surgical Research, 245, 131-138.\u003c/li\u003e\n \u003cli\u003eKoo, Y. J., Jun, D. Y., \u0026amp; Kim, H. J. (2015). \u0026quot;The Effect of Prophylactic Ureteral Stenting in Pelvic Cancer Surgery: A Meta-Analysis.\u0026quot; Journal of Urology, 193(5), 1704-1709. doi:10.1016/j.juro.2014.11.048\u003c/li\u003e\n \u003cli\u003eMiller, J. R., Baker, B. S., \u0026amp; Gray, J. A. (2018). \u0026quot;The Role of Ureteral Catheters in Complex Obstetric Surgery.\u0026quot; Obstetrics and Gynecology, 132(3), 623-630.\u003c/li\u003e\n \u003cli\u003eHiggins, C. C. (2016). Complications of peri-operative ureteral catheter placement in gynecologic and colorectal surgery. Urology, 94, 102475\u003c/li\u003e\n \u003cli\u003eVan der Voet, L. W., Bartels, H. C., \u0026amp; Timmermans, A. J. (2019). \u0026quot;Ureteral Catheters in Obstetric Surgery: Procedure and Complications.\u0026quot; European Journal of Obstetrics \u0026amp; Gynecology and Reproductive Biology, 240, 213-218.\u003c/li\u003e\n \u003cli\u003eLiu, Y., Chen, H., \u0026amp; Lin, J. (2020). \u0026quot;Bladder Perforation Due to Ureteral Catheter Placement: A Case Series and Literature Review.\u0026quot; International Urogynecology Journal, 31(8), 1573-1579.\u003c/li\u003e\n \u003cli\u003eChong, J. T., Kan, K. M., Phillips, C. K., \u0026amp; Greenstein, A. (2018). Ureteral catheters for colorectal surgery: Influence on operative times and complication outcomes: An observational study. Investigative and Clinical Urology, 59(2), 119\u0026ndash;125\u003c/li\u003e\n \u003cli\u003ePeng, Y. L., Ning, K., Wu, Z. S., Li, Z. Y., Deng, M. H., Xiong, L. B., Yu, C. P., Zhang, Z. L., Liu, Z. W., Lu, H. M., \u0026amp; Zhou, F. J. (2021). Ureteral stents cannot decrease the incidence of ureteroileal anastomotic stricture and leakage: A systematic review and meta-analysis. International Journal of Surgery, 93, 102975\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Sheba Medical Center","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Placenta accreta spectrum (PAS), Multidisciplinary Team (MDT), Cesarean section (CS), Urological injuries, Preoperative evaluation, Maternal outcomes, Postoperative complications","lastPublishedDoi":"10.21203/rs.3.rs-6998116/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6998116/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBACKGROUND\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePlacenta accreta spectrum (PAS) is a serious obstetric condition marked by abnormal placental adherence to the uterine wall, often leading to significant maternal and fetal complications. Women with a history of cesarean section (CS) are at increased risk. The standard treatment is CS, which carries high complication rates, including hemorrhage, urological injury, and the potential need for hysterectomy. Traditionally, these surgeries are performed solely by obstetricians.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOBJECTIVES\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo evaluate whether a multidisciplinary team (MDT) approach improves surgical outcomes and reduces complications in women with PAS.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSTUDY DESIGN\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe retrospectively reviewed medical records of 417 women diagnosed with PAS between 2011 and 2022. In 2019, our institution adopted an MDT protocol that includes preoperative obstetric and urological evaluation, joint surgical planning, and the intraoperative insertion of bilateral ureteral catheters (UCs). Outcomes were compared between patients treated before and after MDT implementation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRESULTS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOf 417 women, 108 (25.9%) were managed using the MDT protocol. Estimated blood loss was significantly lower in the MDT group (1297cc vs. 1586cc, P = .036), with fewer requiring transfusions (2.8% vs. 8.4%, P = .002). Hysterectomy rates were also reduced (0.9% vs. 7.4%, P = .04). Urological injury occurred in only 4.7% of MDT cases versus 13.9% in the non-MDT group (P = .027). The overall complication rate was significantly lower in the MDT group (5.6% vs. 15.6%, P = .007).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONCLUSION\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAn MDT approach significantly reduces surgical complications in PAS, supporting its implementation as standard care.\u003c/p\u003e","manuscriptTitle":"A Multidisciplinary Approach for Reducing Complications During Cesarean Sections for Placenta Accreta","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-03 08:26:51","doi":"10.21203/rs.3.rs-6998116/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c1ed308a-9663-4e26-a802-844f54ee541d","owner":[],"postedDate":"July 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":50730551,"name":"Obstetrics \u0026 Gynecology"},{"id":50730552,"name":"Urology \u0026 Nephrology"}],"tags":[],"updatedAt":"2025-10-13T08:14:08+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-03 08:26:51","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6998116","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6998116","identity":"rs-6998116","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}