Vesicouterine adherence is independent of the degree of villi implantation: A retrospective case-control study

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None of the existing histological classification criteria are based on and correlate with surgical difficulty, morbidity risk, or maternal outcome. Methods: We conducted a case-control study of data of all PAS cases between January 2017 and December 2021 at Dr. Soetomo General Hospital, Surabaya, Indonesia. Uterine dehiscence and any cases with incomplete data were excluded from the study. After surgery, the area of abnormal adherence was marked using small pins for histological analysis. The histopathology specimens were immersed in using Hematoxylin Eosin (HE). PAS cases were divided into three groups depending on the depth of villi: accreta, increta and percreta. Primary outcome was the vesicouterine adherence. Secondary outcomes were intraoperative topography, and surgical outcome. Results: Three hundred sixty-three cases were included for analyses. Our cohort comprised of 99 accreta cases, 246 increta cases and 18 percreta cases. Estimated blood loss was significantly higher in the high-grade PAS (increta and percreta) groups than in the low-grade PAS (accreta) group (2851.0 + 2437.7 mL vs 1970.8 + 1315.8 mL; p < 0.001). Sixty-five (17.9%) cases of vesicouterine adherence were observed. This was associated with higher odds of caesarean hysterectomy (adjusted odds ratio [Adj OR] 30.77 (95% CI 12.52–75.62; p 2500 mL) (Adj OR 1.06; 95% CI 0.52–2.16; p = 0.87). Cases with bladder injury had a higher estimated blood loss (p = 0.012) and concomitant caesarean hysterectomy (p 2500 mL) (p = 0.046) but not bladder injury (p = 0.442) and vesicouterine adherence (p = 0.503). Conclusions: Vesicouterine adherence is not associated with the depth of villi implantation, but rather with the presence of fibrosis between the bladder and uterus. These adhesions also correlated to iatrogenic bladder injuries. Vesicouterine adherence bladder injury placenta accreta spectrum villi implantation Figures Figure 1 Figure 2 Figure 3 Background Traditionally, placenta accreta spectrum (PAS) is defined as the abnormal attachment of placenta to the uterine wall 1 . The diagnosis of PAS is made clinically by the inability of the placenta to separate from the uterus and on histopathology based on the depth of villi implantation. However, significant differences do exist between clinical and histological classification of this condition which generally hinders an accurate depiction of extent of the condition 2 . The presence of villous tissue beyond the decidua have been described in PAS, and are used in the diagnosis and classification of PAS 3 . The International Federation of Obstetrics and Gynecology (FIGO) proposed a classification in an attempt to correlate intraoperative appearance of PAS with histopathological findings 4 . This classification gained further traction with a consensus panel of expert pathologists, who provided a comprehensive histological diagnostic criterion for each classification of PAS 3 . Despite numerous attempts to standardize histological analysis and reporting in PAS, it remains subject to criticism from experts in the field. Some argue that a major drawback is the absence of correlation with maternal outcomes. Unlike other medical specialties where histological diagnosis guides subsequent treatment phases, pathology input in PAS is primarily retrospective and may not directly impact patient care 5 . Additionally, the notorious lack of clinical and histological correlation as well as the potential for disruption of the specimen prior to pathology review 6 , further exacerbates this issue. Regardless, none of the existing standardized histological diagnostic and classification criteria 3 , 4 , 7 are based on their correlation with surgical difficulty, morbidity risk, or maternal outcomes. One of the complexities associated with PAS surgery is vesicouterine adherence, which is commonly referred to as bladder invasion 8 . It is recognized among experts that vesicouterine adherence is of a more severe form of placenta percreta, and it frequently results in urinary bladder injury 4 , 5 , 9 . However, the concept of “cancer-like” placenta invasion has been debunked by some experts and attribute the attachment of the bladder to the lower uterine segment to be as a result of adhesions 10 , 11 . In this study, we conducted a case-control study to examine the histological findings in cases of PAS, both with and without intraoperative vesicouterine adherence. Methods We conducted a case-control study of data obtained between January 2017 and December 2021 at Dr. Soetomo General Hospital, Surabaya, Indonesia. The electronic medical records which included the intraoperative notes and surgical pictures were obtained. Clinically, the diagnosis of PAS was made by the presence of the placenta “glued” to the uterine wall. Hence, cases of extensive lower uterine segment remodeling with complete placenta separation was considered as uterine dehiscence 5 , 12 , 13 and hence were excluded from the study. Preparation of the specimen for histopathology As part of our multidisciplinary PAS team protocol, the pathologist was presented with detailed intraoperative findings and procedures including a note of any iatrogenic disruption of the uterine serosa during surgery. Intraoperative photograph of lower uterine segment were captured to give additional information in pathology analysis (Fig. 1a). A photograph of any other abnormalities such as fibrin tissue of uteroplacental, vesicouterine adherence or uterine abnormalities were taken. After surgery, the area of abnormal adherence area was marked using a small pin (Fig. 1b) and immediately taken to the pathology anatomy lab (Fig. 1c). For cases of extensive vesciouterine adherence (Fig. 2a) where a modified subtotal hysterectomy was performed, the small pin was positioned at the closest area to the vesicouterine adherence for histological analysis (Fig. 2b). Bread-loaf cuts to demonstrate PAS defect and serial sections are arranged from left to right in Fig. 3. Histopathology analysis GA and CV reviewed all the histological images of the PAS cases within the study duration. These were done independently by the two pathologists who were blinded to the clinical and outcome information. Discrepancies were resolved by discussion. Cases of incomplete electronic medical records comprising of maternal outcome data, surgical report, or missing histopathological images were excluded. The histopathology specimens were immersed using Hematoxylin Eosin (HE) and reviewed based on the consensus definition by the expert panel on PAS disorders 3 . Grade 1(Accreta) was defined as the presence of the placenta villi directly implanted to the superficial myometrium without an intervening decidua. Grade 2 (Increta) was defined as the presence of an irregular placental-myometrial interface with the villi within the myometrium. Percreta which comprised of 3A, 3D and 3E was defined as the presence of deep invasion of the villi; 3A showed preservation of less than 25% of the wall thickness relative to the uninvolved myometrium, 3D was described as the disruption of the serosa and 3E was defined as the placenta invasion into adjacent organs. Management approach for PAS All cases were managed based on the intraoperative PAS topographic classification 14 . As part of routine protocol and good clinical practice, the women were counselled on the management approach(caesarean hysterectomy or the possibility uterine sparing surgery) outlining the risks of morbidity and lifelong implications. The final decision on the management approach was based on patient preference and safety. All women within our cohort opted for the possibility of uterine conservative-resective surgery. We proceeded with uterine conservative-resective surgery when the PAS location was above bladder trigone. Cesarean hysterectomy was performed when the PAS lesion was low or involved the cervix, with inadequate of lower tissue for uterine conservative-resective surgery 14 – 17 . The surgical procedures are described in the previous studies 14 , 15 , 17 – 19 . Intraoperative findings were discussed with all members of the multidisciplinary team team comprising of maternal-fetal medicine specialists, pathologist and radiologists 20 . Statistical Analysis Statistical analysis was performed using the Statistical Package for Social Science (SPSS), version 29. Chi-square, T-test or Mann Whitney U test were perform to analyze the different between group of vesicouterine adherence depends on sample distributions. Results Within the study period, about 431 confirmed PAS cases were reviewed. Out of this number, 68 cases were excluded due to the lack of uteroplacental tissue within the paraffin coupe, rendering the analysis of the uteroplacental interface challenging. Finally, 363 cases were included our analysis with 18 cases (5%) of them in emergency surgery group. Our cohort comprised of 99 cases of Accreta, 246 cases of Increta and 18 cases of percreta. In all our cases, the villi was observed within the confines of the uterus regardless of the presence of the extensive vesciouterine adherence. All cases of percreta described in our cohort had less than 25% uninvolved myometrial tissue and hence were classified as 3A. The estimated blood loss in the high-grade PAS (increta and percreta) were significantly higher than that of the low-grade PAS (accreta) group (2851.0 + 2437.7ml vs 1970.8 + 1315.8ml; p < 0.001). Intraoperative topographic evaluation revealed that, 237/363 (65.3%) cases of the PAS lesions were above the bladder trigone and hence were managed by the one-step conservative surgery approach (OSCS). Comprehensive details on patient demographics have been outlined in table 1. Sixty-five (17.9%) cases of vesciouterine adherence were observed in our cohort. Vesicouterine adherence was associated with higher odds of caesarean hysterectomy (Adjusted odds ratio [Adj OR] 30.77 (95% CI 12.52 – 75.62; p 2500ml) (Adj OR 1.06; 95% CI 0.52 – 2.16; p = 0.87). Bladder injury was observed in 21(5.8%) cases. Those with bladder injury had a higher estimated blood loss (p = 0.012) and caesarean hysterectomy (p 2500ml) (Adj OR 1.6 (1.0 – 2.53; p = 0.046) but not bladder injury (Adj OR 0.67; 95% CI 0.24 – 1.86; p = 0.442) and vesicouterine adherence (Adj OR 1.26; 95% CI 0.64 – 2.49; p = 0.503) (Table 3). Discussion Our study revealed that, the depth of villi implantation is associated with higher blood loss but not vesicouterine adherence and bladder injury. Also, vesicouterine adherence was associated with caesarean hysterectomy, and bladder injury. In high-grade PAS cases, abnormal uterine vascular dilatation and uterine serosal vascular anastomosis with surrounding visceral structures (most commonly the adhered urinary bladder) are usually observed. We hypothesize that, the deep implantation of the extravillous trophoblast at the scar area results in the anchoring of the villi beyond the decidua with subsequent recruitment of the distal vasculature, in this case, the vesical vessels. With advancing gestation, these vessels often dilate to support the placental bed. However, these local neovascularity are often immature and friable 21,22 and are easily susceptible to rupture either spontaneously or during surgical manipulation which usually results in massive hemorrhage. This could explain the significant association between the depth of villi of implantation and blood loss observed in our study (p = 0.046) and the occurrences of spontaneous hematuria in PAS cases with bladder adherence reported in literature 23–25 . However, such overt hypervascularity are absent in low grade PAS regardless of the presence of vesicouterine adherence, which correlated with a significantly reduced incidence of significant blood loss (p < 0.001). Another finding from our study was the lack of association between the depth of villi implantation with bladder injury (p = 0.442) and vesicouterine adherence (p = 0.503). However, bladder injury was significantly associated with vesciouterine adherence (p = 0.003). When the peritoneum is injured during bladder dissection in a caesarean section, a coagulation cascade is activated, which results in the formation of fibrin clots 27 . The contact between the injured uterus and bladder, results in their adherence during healing process 28 . This abnormal adherence is associated with an increased risk of bladder injury even outside the context of PAS which usually occurs during peritoneal entry or while creating the bladder flap 29–31 . This finding was also observed in a large retrospective cohort of PAS cases in Italy 32 . However, the complexity arising from high-grade PAS lies in the co-existing presence of adhesions with extensive serosal hypervascularity and anastomotic neovascular channels. This increases the risk of surgical morbidity, as the surgeon tends to contend with the risk of massive blood loss from the rupture of friable neovasculature and the potential of bladder injury due to adhesions. In our cohort, estimated blood loss was higher in the group with vesicouterine adherence (p < 0.001) and bladder injury (p = 0.012) compared to those without these conditions. Out of the 21 patients that had bladder injury, none of them were managed by the one-step conservative surgery technique as they were managed by hysterectomy. However, it is worth noting that, the choice for the management approach relied exclusively on patient preference and the intraoperative topographic assessment of the PAS lesion. From table 1, it could be observed that, 20 out of the 21 patients with bladder injury were either type 3 (19%) or type 4 (76.2%) lesions which are often recommended for hysterectomy based on patient safety 19 . The major strength of this study lies in its extensive evaluation of the PAS cases. Also, the histological images were assessed independently by two experienced pathologists in PAS evaluation, ensuring a reduced risk of bias as they were blinded to the surgical and clinical outcomes. Also. uteroplacental interface was not gently dissected due to the concern of causing specimen damage, which generally affects histological classification of the depth of villi implantation. However, a limitation of this study is its retrospective study design. Even though, a prospective study may be ideal, it is well known that the histological assessment and classification are typically retrospective in the clinical setting. Hence, this retrospective study design approach offers very minimal bias and accurately reflects the daily occurrences in routine settings. Conclusions Vesicouterine adherence is not associated with the depth of villi implantation, but rather the presence of fibrosis between the bladder and uterus. The presence of this abnormal adherence increases the risk of massive blood loss, bladder injury and caesarean hysterectomy for those who would have otherwise opted for a uterine sparing surgery. List Of Abbreviations PAS, Placenta Accreta Spectrum, HE, Hematoxylin Eosin, OSCS, One-Step Conservative Surgery approach. Declarations Ethics approval Ethical approval was obtained from the Ethics Committee in Health Research of the Dr. Soetomo Academic General Hospital (Approval number: 0564/KEPK/I/2023). Consent to parcipate Not applicable Consent for publication Not applicable Availability of data and materials The supporting data for this study is available, but it has limitations. This study is licensed which it is not available to the public. However, data is available from the authors upon reasonable request and with the approval of the internal review board. Competing interests The authors declare that they have no competing interests Funding Information No Funding Acknowledgements Not applicable Disclosure Statement Dr. Rozi Aditya Aryananda is a member of the editorial board of the BMC Pregnancy and Childbirth. Authors Contribution CV: analysis, interpretation of data for the work, drafting the work GA: analysis, interpretation of data for the work, drafting the work BP: writing the manuscript, analysis, the acquisition, revising it critically for important intellectual content TKAB: writing the manuscript, analysis, revising it critically for important intellectual content JJD: revising it critically for important intellectual content, final approval of the version to be published RAA: writing the manuscript, the acquisition, analysis, design of the work, revising it critically for important intellectual content, agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved, final approval of the version to be published. References Jauniaux E, Collins S, Burton GJ. Placenta accreta spectrum: pathophysiology and evidence-based anatomy for prenatal ultrasound imaging. 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Bladder injuries during cesarean section in a University Hospital: a 25-year review. Arch Gynecol Obstet. 2009;279(3):349–52. Giuseppe C, Salvatore P, Federica C, et al. Urinary tract injuries during surgery for placenta accreta spectrum disorders. Eur J Obstet Gynecol Reproductive Biology. 2023;287:93–6. Tables Table 1 Patient demographics comparison of without and with vesicouterine adherence cases. Without vesicouterine adherence (n = 298) With vesicouterine adherence (n = 65) P value OR (CI 95%) AOR (CI 95%) Maternal age 33 (30–37) 33 (30–37) 0.933 Parity 1 18 (27.7%) 18 (27.7%) 0.3281 2 30 (46.2%) 30 (46.2%) ≥ 3 17 (26.2%) 17 (26.2%) Previous caesarean 1 25 (38.5%) 25 (38.5%) 0.1149 2 34 (52.3%) 34 (52.3%) ≥ 3 6 (9.2%) 6 (9.2%) Gestational age at delivery 36 (34–37) 35 (32.5–36) 0.009 Surgical onset Planned surgery 292 (98.0%) 53 (81.5%) < 0.001 11.12 (95% CI 3.15–39.2; p < 0.001) 5.1 (95% CI 1.06–24.4; p = 0.042) Emergency surgery 6 (2%) 12 (18.5%) Surgical management Uterine sparing surgery 235 (78.9%) 6 (9.2%) < 0.001 Hysterectomy 63 (21.1%) 59 (90.8%) Topographic classification Type 1 233 (78.2%) 4 (6.2%) < 0.001 Type 2 13 (4.4%) 3 (4.6%) Type 3 50 (6.7%) 12 (18.5%) Type 4 1 (0.34%) 46 (70.8%) Type 5 1 (0.34%) 0 Surgical outcome Estimated blood loss 2000 (1100–3300) 2800 (1600–5300) < 0.001 Bladder injury 3 (1.0%) 18 (27.7%) < 0.001 15.04 (95% CI 5.07–44.4; p < 0.001) 5.35 (95% CI 1.434-20; p = 0.013) Histological diagnosis Accreta 89 (29.9%) 10 (15.4%) 0.0015 Increta 199 (66.8%) 47 (72.3%) Percreta 10 (3.4%) 8 (12.3%) The percreta cases comprised on 3A and 3D, no placenta villi was not seen within the urinary bladder serosa. Table 2 Maternal outcome and topographic classification comparison of bladder injury and without bladder injury. Bladder injury (n = 21) Without bladder injury (n = 342) P value Gestational age 34 (31.5–36) 36 (34–37) 0.047 Elective 14 (66.7%) 331 (96.8%) < 0.001 Emergency 7 (33.3%) 11 (3.2%) Uterine sparing surgery 0 241 (70.5%) < 0.001 Caesarean hysterectomy 21 (100%) 101 (29.5%) Blood loss 2100 (1650–8500) 2000 (1200–3500) 0.012 Topographic classification Type 1 1 (4.8%) 236 (69%) < 0.001 Type 2 0 16 (4.7%) Type 3 4 (19.0%) 58 (17.0%) Type 4 16 (76.2%) 31 (9.1%) Type 5 0 1 (0.3%) Histological grades Accreta 4 (19.1%) 95 (27.8%) < 0.001 Increta 15 (71.4%) 231 (67.5%) Percreta 2 (9.5%) 16 (4.7%) Table 3 Multivariate logistic regression analysis of selected variable in relation to vesicouterine adherence and bladder injury Crude Odds ratio (95% CI) Adjusted odds ratio (95% CI) *Bladder injury vs Histological grade 1.67 (0.70–3.40, p = 0.248) 0.67(0.24–1.86; p = 0.442) *Vesicouterine adherence vs Histological grade 2.51 (1.43–4.42, p = 0.001) 1.26 (0.64–2.49; p = 0.503) *Blood loss (> 2500ml) vs histological grade 1.2 (1.3–3.06; p = 0.002) 1.597 (1.0–2.53; p = 0.046) ** Blood loss(> 2500ml) vs vesciouterine adherence 2.28 (1.32–3.92; p = 0.003) 1.06(0.52–2.15; p = 0.878) ***Bladder injury vs vesicouterine adherence 37.7 (10.7–132.8; p < 0.001) 7.19 (1.94–26.64; p = 0.003) *Adjusted for gestational age at surgery, mode of delivery (elective or emergency), management approach. **Adjusted for mode of delivery (elective or emergency), histological classification, management approach, gestational age at surgery. *** Adjusted for gestational age at surgery, management approach, mode of delivery and histological grade for PAS Additional Declarations No competing interests reported. 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Duvekot","email":"","orcid":"","institution":"Erasmus University Medical Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Johannes","middleName":"J.","lastName":"Duvekot","suffix":""},{"id":314476956,"identity":"531c6ae9-f72f-49d8-abf3-d8026fa06a29","order_by":5,"name":"Rozi Aditya Aryananda","email":"","orcid":"","institution":"Dr. Soetomo Academic General Hospital, Universitas Airlangga","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Rozi","middleName":"Aditya","lastName":"Aryananda","suffix":""}],"badges":[],"createdAt":"2024-06-12 04:55:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4567510/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4567510/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":59284097,"identity":"d41ac08e-8b55-4ea0-8f62-1b5b8d6422d6","added_by":"auto","created_at":"2024-06-28 16:05:40","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":743593,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"Figure1legend.png","url":"https://assets-eu.researchsquare.com/files/rs-4567510/v1/456299cbc29823417c00c8da.png"},{"id":59284073,"identity":"cce92fe2-9c71-4cc2-8d37-2e75c4c0f3d8","added_by":"auto","created_at":"2024-06-28 16:05:39","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":829526,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"Figure2legends.png","url":"https://assets-eu.researchsquare.com/files/rs-4567510/v1/4e3b6d174a2ce350d21804fa.png"},{"id":59284096,"identity":"d1020a37-35f3-4c17-b229-0bd14f4ae5d7","added_by":"auto","created_at":"2024-06-28 16:05:39","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":859637,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"Figure3Legends.png","url":"https://assets-eu.researchsquare.com/files/rs-4567510/v1/fd16ea4fc460ed4b4775c3af.png"},{"id":79819261,"identity":"5a24b0c9-fc09-43cd-b514-8951498a474f","added_by":"auto","created_at":"2025-04-03 08:24:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3959010,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4567510/v1/38097df0-3319-4b98-b3a4-219dda6978a9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Vesicouterine adherence is independent of the degree of villi implantation: A retrospective case-control study","fulltext":[{"header":"Background","content":"\u003cp\u003eTraditionally, placenta accreta spectrum (PAS) is defined as the abnormal attachment of placenta to the uterine wall\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. The diagnosis of PAS is made clinically by the inability of the placenta to separate from the uterus and on histopathology based on the depth of villi implantation. However, significant differences do exist between clinical and histological classification of this condition which generally hinders an accurate depiction of extent of the condition\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. The presence of villous tissue beyond the decidua have been described in PAS, and are used in the diagnosis and classification of PAS\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. The International Federation of Obstetrics and Gynecology (FIGO) proposed a classification in an attempt to correlate intraoperative appearance of PAS with histopathological findings\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. This classification gained further traction with a consensus panel of expert pathologists, who provided a comprehensive histological diagnostic criterion for each classification of PAS\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. Despite numerous attempts to standardize histological analysis and reporting in PAS, it remains subject to criticism from experts in the field. Some argue that a major drawback is the absence of correlation with maternal outcomes. Unlike other medical specialties where histological diagnosis guides subsequent treatment phases, pathology input in PAS is primarily retrospective and may not directly impact patient care\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. Additionally, the notorious lack of clinical and histological correlation as well as the potential for disruption of the specimen prior to pathology review\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e, further exacerbates this issue. Regardless, none of the existing standardized histological diagnostic and classification criteria\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e are based on their correlation with surgical difficulty, morbidity risk, or maternal outcomes.\u003c/p\u003e \u003cp\u003eOne of the complexities associated with PAS surgery is vesicouterine adherence, which is commonly referred to as bladder invasion\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. It is recognized among experts that vesicouterine adherence is of a more severe form of placenta percreta, and it frequently results in urinary bladder injury\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. However, the concept of \u0026ldquo;cancer-like\u0026rdquo; placenta invasion has been debunked by some experts and attribute the attachment of the bladder to the lower uterine segment to be as a result of adhesions\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. In this study, we conducted a case-control study to examine the histological findings in cases of PAS, both with and without intraoperative vesicouterine adherence.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e We conducted a case-control study of data obtained between January 2017 and December 2021 at Dr. Soetomo General Hospital, Surabaya, Indonesia. The electronic medical records which included the intraoperative notes and surgical pictures were obtained. Clinically, the diagnosis of PAS was made by the presence of the placenta \u0026ldquo;glued\u0026rdquo; to the uterine wall. Hence, cases of extensive lower uterine segment remodeling with complete placenta separation was considered as uterine dehiscence\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e and hence were excluded from the study.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePreparation of the specimen for histopathology\u003c/h2\u003e \u003cp\u003eAs part of our multidisciplinary PAS team protocol, the pathologist was presented with detailed intraoperative findings and procedures including a note of any iatrogenic disruption of the uterine serosa during surgery. Intraoperative photograph of lower uterine segment were captured to give additional information in pathology analysis (Fig.\u0026nbsp;1a). A photograph of any other abnormalities such as fibrin tissue of uteroplacental, vesicouterine adherence or uterine abnormalities were taken. After surgery, the area of abnormal adherence area was marked using a small pin (Fig.\u0026nbsp;1b) and immediately taken to the pathology anatomy lab (Fig.\u0026nbsp;1c). For cases of extensive vesciouterine adherence (Fig.\u0026nbsp;2a) where a modified subtotal hysterectomy was performed, the small pin was positioned at the closest area to the vesicouterine adherence for histological analysis (Fig.\u0026nbsp;2b). Bread-loaf cuts to demonstrate PAS defect and serial sections are arranged from left to right in Fig.\u0026nbsp;3.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eHistopathology analysis\u003c/h2\u003e \u003cp\u003eGA and CV reviewed all the histological images of the PAS cases within the study duration. These were done independently by the two pathologists who were blinded to the clinical and outcome information. Discrepancies were resolved by discussion. Cases of incomplete electronic medical records comprising of maternal outcome data, surgical report, or missing histopathological images were excluded. The histopathology specimens were immersed using Hematoxylin Eosin (HE) and reviewed based on the consensus definition by the expert panel on PAS disorders\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. Grade 1(Accreta) was defined as the presence of the placenta villi directly implanted to the superficial myometrium without an intervening decidua. Grade 2 (Increta) was defined as the presence of an irregular placental-myometrial interface with the villi within the myometrium. Percreta which comprised of 3A, 3D and 3E was defined as the presence of deep invasion of the villi; 3A showed preservation of less than 25% of the wall thickness relative to the uninvolved myometrium, 3D was described as the disruption of the serosa and 3E was defined as the placenta invasion into adjacent organs.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eManagement approach for PAS\u003c/h2\u003e \u003cp\u003eAll cases were managed based on the intraoperative PAS topographic classification\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. As part of routine protocol and good clinical practice, the women were counselled on the management approach(caesarean hysterectomy or the possibility uterine sparing surgery) outlining the risks of morbidity and lifelong implications. The final decision on the management approach was based on patient preference and safety. All women within our cohort opted for the possibility of uterine conservative-resective surgery. We proceeded with uterine conservative-resective surgery when the PAS location was above bladder trigone. Cesarean hysterectomy was performed when the PAS lesion was low or involved the cervix, with inadequate of lower tissue for uterine conservative-resective surgery\u003csup\u003e\u003cspan additionalcitationids=\"CR15 CR16\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. The surgical procedures are described in the previous studies\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. Intraoperative findings were discussed with all members of the multidisciplinary team team comprising of maternal-fetal medicine specialists, pathologist and radiologists \u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was performed using the Statistical Package for Social Science (SPSS), version 29. Chi-square, T-test or Mann Whitney U test were perform to analyze the different between group of vesicouterine adherence depends on sample distributions.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eWithin the study period, about 431 confirmed PAS cases were reviewed. Out of this number, 68 cases were excluded due to the lack of uteroplacental tissue within the paraffin coupe, rendering the analysis of the uteroplacental interface challenging. Finally, 363 cases were included our analysis with 18 cases (5%) of them in emergency surgery group. Our cohort comprised of 99 cases of Accreta, 246 cases of Increta and 18 cases of percreta. In all our cases, the villi was observed within the confines of the uterus regardless of the presence of the extensive vesciouterine adherence. All cases of percreta described in our cohort had less than 25% uninvolved myometrial tissue and hence were classified as 3A. The estimated blood loss in the high-grade PAS (increta and percreta) were significantly higher than that of the low-grade PAS (accreta) group (2851.0 \u003cu\u003e+\u003c/u\u003e 2437.7ml vs 1970.8 \u003cu\u003e+\u003c/u\u003e 1315.8ml; p \u0026lt; 0.001). \u0026nbsp;Intraoperative topographic evaluation revealed that, 237/363 (65.3%) cases of the PAS lesions were above the bladder trigone and hence were managed by the one-step conservative surgery approach (OSCS). Comprehensive details on patient demographics have been outlined in table 1.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSixty-five (17.9%) cases of vesciouterine adherence were observed in our cohort. Vesicouterine adherence was associated with higher odds of caesarean hysterectomy (Adjusted odds ratio [Adj OR] 30.77 (95% CI 12.52 \u0026ndash; 75.62; p \u0026lt; 0.001) and bladder injury (Adj OR 7.19; 95% CI 1.94 \u0026ndash; 26.64; \u003cem\u003ep\u0026nbsp;\u003c/em\u003e= 0.003) but not estimated blood loss(\u0026gt;2500ml) (Adj OR 1.06; 95% CI 0.52 \u0026ndash; 2.16; p = 0.87). Bladder injury was observed in 21(5.8%) cases. Those with bladder injury had a higher estimated blood loss (p = 0.012) and caesarean hysterectomy (p \u0026lt; 0.001) compared to those without bladder injury (Table 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe depth of villi implantation was associated with higher blood loss (\u0026gt;2500ml) (Adj OR 1.6 (1.0 \u0026ndash; 2.53; p = 0.046) but not bladder injury (Adj OR 0.67; 95% CI 0.24 \u0026ndash; 1.86; p = 0.442) and vesicouterine adherence (Adj OR 1.26; 95% CI 0.64 \u0026ndash; 2.49; p = 0.503) (Table 3).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study revealed that, the depth of villi implantation is associated with higher blood loss but not vesicouterine adherence and bladder injury. Also, vesicouterine adherence was associated with caesarean hysterectomy, and bladder injury.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn high-grade PAS cases, abnormal uterine vascular dilatation and uterine serosal vascular anastomosis with surrounding visceral structures (most commonly the adhered urinary bladder) are usually observed. We hypothesize that, the deep implantation of the extravillous trophoblast at the scar area results in the anchoring of the villi beyond the decidua with subsequent recruitment of the distal vasculature, in this case, the vesical vessels. With advancing gestation, these vessels often dilate to support the placental bed. However, these local neovascularity are often immature and friable\u003csup\u003e21,22\u003c/sup\u003e and are easily susceptible to rupture either spontaneously or during surgical manipulation which usually results in massive hemorrhage. This could explain the significant association between the depth of villi of implantation and blood loss observed in our study (p = 0.046) and the occurrences of spontaneous hematuria in PAS cases with bladder adherence reported in literature\u003csup\u003e23\u0026ndash;25\u003c/sup\u003e. However, such overt hypervascularity are absent in low grade PAS regardless of the presence of vesicouterine adherence, which correlated with a significantly reduced incidence of significant blood loss (p \u0026lt; 0.001).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnother finding from our study was the lack of association between the depth of villi implantation with bladder injury (p = 0.442) and vesicouterine adherence (p = 0.503). However, bladder injury was significantly associated with vesciouterine adherence (p = 0.003). When the peritoneum is injured during bladder dissection in a caesarean section, a coagulation cascade is activated, which \u0026nbsp;results in the formation of fibrin clots \u003csup\u003e27\u003c/sup\u003e. The contact between the injured uterus and bladder, \u0026nbsp;results in their adherence during healing process\u003csup\u003e28\u003c/sup\u003e. This abnormal adherence is associated with an increased risk of bladder injury even outside \u0026nbsp;the context of PAS which usually occurs during peritoneal entry or while creating the bladder flap\u003csup\u003e29\u0026ndash;31\u003c/sup\u003e. This finding was also observed in a large retrospective cohort of PAS cases in Italy\u003csup\u003e32\u003c/sup\u003e. \u0026nbsp; However, the complexity arising from high-grade PAS lies in the co-existing presence of adhesions with extensive serosal hypervascularity and anastomotic neovascular channels. This increases the risk of surgical morbidity, as the surgeon tends to contend with the risk of massive blood loss from the rupture of friable neovasculature and the potential of bladder injury due to adhesions. In our cohort, estimated blood loss was higher in the group with vesicouterine adherence (p \u0026lt; 0.001) and bladder injury (p = 0.012) compared to those without these conditions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOut of the 21 patients that had bladder injury, none of them were managed by the one-step conservative surgery technique as they were managed by hysterectomy. However, it is worth noting that, the choice for the management approach relied exclusively on patient preference and the intraoperative topographic assessment of the PAS lesion. From table 1, it could be observed that, 20 out of the 21 patients with bladder injury were either type 3 (19%) or type 4 (76.2%) lesions which are often recommended for hysterectomy based on patient safety\u003csup\u003e19\u003c/sup\u003e. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe major strength of this study lies in its extensive evaluation of the PAS cases. Also, the histological images were assessed independently by two experienced pathologists in PAS evaluation, ensuring a reduced risk of bias as they were blinded to the surgical and clinical outcomes. Also. uteroplacental interface was not gently dissected due to the concern of causing specimen damage, which generally affects histological classification of the depth of villi implantation. However, a limitation of this study is its retrospective study design. Even though, a prospective study may be ideal, it is well known that the histological assessment and classification are typically retrospective in the clinical setting. Hence, this retrospective study design approach offers very minimal bias and accurately reflects the daily occurrences in routine settings.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eVesicouterine adherence is not associated with the depth of villi implantation, but rather the presence of fibrosis between the bladder and uterus. The presence of this abnormal adherence increases the risk of massive blood loss, bladder injury and caesarean hysterectomy for those who would have otherwise opted for a uterine sparing surgery.\u003c/p\u003e"},{"header":"List Of Abbreviations","content":"\u003cp\u003ePAS, Placenta Accreta Spectrum, HE, Hematoxylin Eosin, OSCS, One-Step Conservative Surgery approach.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the Ethics Committee in Health Research of the Dr. Soetomo Academic General Hospital (Approval number: 0564/KEPK/I/2023).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to parcipate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe supporting data for this study is available, but it has limitations. This study is licensed which it is not available to the public. However, data is available from the authors upon reasonable request and with the approval of the internal review board.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo Funding\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDr. Rozi Aditya Aryananda is a member of the editorial board of the BMC Pregnancy and Childbirth.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCV:\u0026nbsp;analysis, interpretation of data for the work, drafting the work\u003c/p\u003e\n\u003cp\u003eGA: analysis, interpretation of data for the work, drafting the work\u003c/p\u003e\n\u003cp\u003eBP:\u0026nbsp;\u0026nbsp;writing the manuscript, analysis,\u0026nbsp;the acquisition, revising it critically for important intellectual content\u003c/p\u003e\n\u003cp\u003eTKAB:\u0026nbsp;writing the manuscript, analysis,\u0026nbsp;revising it critically for important intellectual content\u003c/p\u003e\n\u003cp\u003eJJD: revising it critically for important intellectual content, final approval of the version to be published\u003c/p\u003e\n\u003cp\u003eRAA: writing the manuscript, the acquisition, analysis, design of the work, revising it critically for important intellectual content, agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved, final approval of the version to be published.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eJauniaux E, Collins S, Burton GJ. Placenta accreta spectrum: pathophysiology and evidence-based anatomy for prenatal ultrasound imaging. Am J Obstet Gynecol. 2018;218(1):75\u0026ndash;87.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBhide A, Sebire N, Abuhamad A, Acharya G, Silver R. Morbidly adherent placenta: the need for standardization. Ultrasound Obstet Gynecol. 2017;49(5):559\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHecht JL, Baergen R, Ernst LM, et al. Classification and reporting guidelines for the pathology diagnosis of placenta accreta spectrum (PAS) disorders: recommendations from an expert panel. Mod Pathol. 2020;33(12):2382\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJauniaux E, Ayres-de-Campos D, Langhoff-Roos J, Fox KA, Collins S, Panel FPAD. FIGO classification for the clinical diagnosis of placenta accreta spectrum disorders. Int J Gynecol Obstet. 2019;146(1):20\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdu-Bredu TK, Ridwan R, Aditiawarman A, Ariani G, Collins SL, Aryananda RA. Three-Dimensional Volume Rendering Ultrasound for Assessing Placenta Accreta Spectrum Severity and Discriminating it from Simple Scar Dehiscence. Am J Obstet Gynecol MFM. Published online March 17, 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJauniaux E, Hussein AM, Zosmer N, et al. A new methodologic approach for clinico-pathologic correlations in invasive placenta previa accreta. Am J Obstet Gynecol. 2020;222(4):379. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e.e1-379.e11\u003c/span\u003e\u003cspan address=\"http://.e1-379.e11\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLuke RK, Sharpe JW, Greene RR. Placenta accreta: the adherent or invasive placenta. Am J Obstet Gynecol. 1966;95(5):660\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLitwin MS, Loughlin KR, Benson CB, Droege GF, Richie JP. Placenta percreta invading the urinary bladder. Br J Urol. 1989;64(3):283\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLucidi A, Jauniaux E, Hussein AM, et al. Urological complications in women undergoing Cesarean section for placenta accreta spectrum disorders: systematic review and meta-analysis. Ultrasound Obstet Gynecol. 2023;62(5):633\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEinerson BD, Comstock J, Silver RM, Branch DW, Woodward PJ, Kennedy A. Placenta Accreta Spectrum Disorder: Uterine Dehiscence, Not Placental Invasion. Obstet Gynecol. 2020;135(5).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEinerson BD, Kennedy A, Silver RM, Branch DW, Comstock J, Woodward PJ. Ultrasonography of the Explanted Uterus in Placenta Accreta Spectrum: Correlation With Intraoperative Findings and Gross Pathology. Obstet Gynecol. 2023;141(3).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdu-Bredu TK, Owusu-Bempah A, Collins S. Accurate prenatal discrimination of placenta accreta spectrum from uterine dehiscence is necessary to ensure optimal management. BMJ Case Rep. 2021;14(7):e244286.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNieto-Calvache \u0026Aacute;J, Palacios-Jaraquemada JM, Basanta N, Aryananda RA. How to differentiate intraoperatively between placenta accreta spectrum and uterine dehiscence? BJOG. 2023;130(10):1288\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePalacios-Jaraquemada JM, Basanta N, Nieto-Calvache \u0026Aacute;, Aryananda RA. Comprehensive surgical staging for placenta accreta spectrum. J Maternal-Fetal Neonatal Med. 2022;35(26):10660\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAryananda RA, Aditiawarman A, Gumilar KE, et al. Uterine conservative\u0026ndash;resective surgery for selected placenta accreta spectrum cases: Surgical\u0026ndash;vascular control methods. Acta Obstet Gynecol Scand. 2022;101(6):639\u0026ndash;48.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePalacios-Jaraquemada JM, Fiorillo A, Hamer J, Mart\u0026iacute;nez M, Bruno C. Placenta accreta spectrum: a hysterectomy can be prevented in almost 80% of cases using a resective-reconstructive technique. J Maternal-Fetal Neonatal Med. 2022;35(2):275\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePalacios-Jaraquemada JM, Nieto-Calvache \u0026Aacute;J, Aryananda RA, Basanta N, Campos CI, Ariani G. Placenta accreta spectrum with severe morbidity: fibrosis associated with cervical-trigonal invasion. J Maternal-Fetal Neonatal Med. 2023;36(1):2183741.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNieto-Calvache AJ, Palacios-Jaraquemada JM, Aryananda R et al. How to perform one-step conservative surgery for placenta accreta spectrum move by move. Am J Obstet Gynecol MFM. Published online November 2022:100802.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePalacios-Jaraquemada JM, Nieto-Calvache \u0026Aacute;J, Aryananda RA, Basanta N. Advantages of individualizing the placenta accreta spectrum management. Front Reproductive Health. 2023;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDannheim K, Shainker SA, Hecht JL. Hysterectomy for placenta accreta; methods for gross and microscopic pathology examination. Arch Gynecol Obstet. 2016;293(5):951\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchwickert A, Henrich W, Vogel M, et al. Placenta Percreta Presents with Neoangiogenesis of Arteries with Von Willebrand Factor-Negative Endothelium. Reproductive Sci. 2022;29(4):1136\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlessandrini L, Aryananda R, Ariani G et al. The correlation between serum levels and placental tissue expression of PLGF and sFLT-1 and the FIGO grading of the placenta accreta spectrum disorders. J Maternal-Fetal Neonatal Med. 2023;36(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKoesmarsono B, Aryananda RA, Ariani G, Mardiyana L. Lifesaving diagnosis of placenta accreta spectrum using MRI: Report of five cases. Radiol Case Rep. 2022;17(5):1803\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBalan R, Radu VD, Giușcă SE, et al. A Rare Cause of Massive Hematuria: Placenta Percreta With Bladder Invasion. Vivo (Brooklyn). 2021;35(6):3633. LP \u0026ndash;\u0026thinsp;3639.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePushpalatha K, Patel S, Singh B, Jain H. Haematuria from early pregnancy in a morbidly adherent placenta: Case report and a short review. J Family Med Prim Care. 2022;11(6).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWright JL, Wessells H. Urinary and Genital Trauma. Penn Clinical Manual of Urology. Elsevier; 2007. pp. 283\u0026ndash;309.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHellebrekers BWJ, Kooistra T. Pathogenesis of postoperative adhesion formation. Br J Surg. 2011;98(11):1503\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDavey AK, Maher PJ. Surgical adhesions: A timely update, a great challenge for the future. J Minim Invasive Gynecol. 2007;14(1):15\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSalman L, Aharony S, Shmueli A, Wiznitzer A, Chen R, Gabbay-Benziv R. Urinary bladder injury during cesarean delivery: Maternal outcome from a contemporary large case series. Eur J Obstet Gynecol Reproductive Biology. 2017;213:26\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFriedrich L, Mor N, Weissmann-Brenner A, et al. Risk factors for bladder injury during placenta accreta spectrum surgery. Int J Gynecol Obstet. 2023;161(3):911\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRahman MS, Gasem T, Al Suleiman SA, Al Jama FE, Burshaid S, Rahman J. Bladder injuries during cesarean section in a University Hospital: a 25-year review. Arch Gynecol Obstet. 2009;279(3):349\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGiuseppe C, Salvatore P, Federica C, et al. Urinary tract injuries during surgery for placenta accreta spectrum disorders. Eur J Obstet Gynecol Reproductive Biology. 2023;287:93\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":" \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cdiv class=\"SimplePara\"\u003ePatient demographics comparison of without and with vesicouterine adherence cases.\u003c/div\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003eWithout vesicouterine adherence (n\u0026thinsp;=\u0026thinsp;298)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003eWith vesicouterine adherence (n\u0026thinsp;=\u0026thinsp;65)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eP value\u003c/span\u003e\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eOR (CI 95%)\u003c/span\u003e\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eAOR (CI 95%)\u003c/span\u003e\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eMaternal age\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e33 (30\u0026ndash;37)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e33 (30\u0026ndash;37)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.933\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cdiv class=\"SimplePara\"\u003eParity\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e18 (27.7%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e18 (27.7%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.3281\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e30 (46.2%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e30 (46.2%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;3\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e17 (26.2%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e17 (26.2%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cdiv class=\"SimplePara\"\u003ePrevious caesarean\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e25 (38.5%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e25 (38.5%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.1149\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e34 (52.3%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e34 (52.3%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;3\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e6 (9.2%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e6 (9.2%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eGestational age at delivery\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e36 (34\u0026ndash;37)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e35 (32.5\u0026ndash;36)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.009\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eSurgical onset\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ePlanned surgery\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e292 (98.0%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e53 (81.5%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u0026lt;\u0026thinsp;0.001\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cdiv class=\"SimplePara\"\u003e11.12 (95% CI 3.15\u0026ndash;39.2; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cdiv class=\"SimplePara\"\u003e5.1 (95% CI 1.06\u0026ndash;24.4; p\u0026thinsp;=\u0026thinsp;0.042)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eEmergency surgery\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e6 (2%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e12 (18.5%)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eSurgical management\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eUterine sparing surgery\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e235 (78.9%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e6 (9.2%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u0026lt;\u0026thinsp;0.001\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eHysterectomy\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e63 (21.1%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e59 (90.8%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eTopographic classification\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eType 1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e233 (78.2%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e4 (6.2%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"4\" rowspan=\"5\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u0026lt;\u0026thinsp;0.001\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eType 2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e13 (4.4%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e3 (4.6%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eType 3\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e50 (6.7%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e12 (18.5%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eType 4\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e1 (0.34%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e46 (70.8%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eType 5\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e1 (0.34%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eSurgical outcome\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eEstimated blood loss\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e2000 (1100\u0026ndash;3300)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e2800 (1600\u0026ndash;5300)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u0026lt;\u0026thinsp;0.001\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eBladder injury\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e3 (1.0%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e18 (27.7%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u0026lt;\u0026thinsp;0.001\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e15.04 (95% CI 5.07\u0026ndash;44.4; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003e5.35 (95% CI 1.434-20; p\u0026thinsp;=\u0026thinsp;0.013)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eHistological diagnosis\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAccreta\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e89 (29.9%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e10 (15.4%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.0015\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eIncreta\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e199 (66.8%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e47 (72.3%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ePercreta\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e10 (3.4%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e8 (12.3%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eThe percreta cases comprised on 3A and 3D, no placenta villi was not seen within the urinary bladder serosa.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003cbr/\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cdiv class=\"SimplePara\"\u003eMaternal outcome and topographic classification comparison of bladder injury and without bladder injury.\u003c/div\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003eBladder injury (n\u0026thinsp;=\u0026thinsp;21)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003eWithout bladder injury (n\u0026thinsp;=\u0026thinsp;342)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eP\u003c/span\u003e value\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eGestational age\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e34 (31.5\u0026ndash;36)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e36 (34\u0026ndash;37)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.047\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eElective\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e14 (66.7%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e331 (96.8%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u0026lt;\u0026thinsp;0.001\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eEmergency\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e7 (33.3%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e11 (3.2%)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eUterine sparing surgery\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e241 (70.5%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u0026lt;\u0026thinsp;0.001\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eCaesarean hysterectomy\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e21 (100%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e101 (29.5%)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eBlood loss\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e2100 (1650\u0026ndash;8500)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e2000 (1200\u0026ndash;3500)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.012\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eTopographic classification\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eType 1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e1 (4.8%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e236 (69%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"4\" rowspan=\"5\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u0026lt;\u0026thinsp;0.001\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eType 2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e16 (4.7%)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eType 3\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e4 (19.0%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e58 (17.0%)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eType 4\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e16 (76.2%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e31 (9.1%)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eType 5\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e1 (0.3%)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cdiv class=\"SimplePara\"\u003eHistological grades\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eAccreta\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e4 (19.1%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e95 (27.8%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u0026lt;\u0026thinsp;0.001\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eIncreta\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e15 (71.4%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e231 (67.5%)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003ePercreta\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e2 (9.5%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e16 (4.7%)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003cbr/\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cdiv class=\"SimplePara\"\u003eMultivariate logistic regression analysis of selected variable in relation to vesicouterine adherence and bladder injury\u003c/div\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eCrude Odds ratio (95% CI)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003eAdjusted odds ratio (95% CI)\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e*Bladder injury vs Histological grade\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e1.67 (0.70\u0026ndash;3.40, p\u0026thinsp;=\u0026thinsp;0.248)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.67(0.24\u0026ndash;1.86; p\u0026thinsp;=\u0026thinsp;0.442)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e*Vesicouterine adherence vs Histological grade\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e2.51 (1.43\u0026ndash;4.42, p\u0026thinsp;=\u0026thinsp;0.001)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e1.26 (0.64\u0026ndash;2.49; p\u0026thinsp;=\u0026thinsp;0.503)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e*Blood loss (\u0026gt;\u0026thinsp;2500ml) vs histological grade\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e1.2 (1.3\u0026ndash;3.06; p\u0026thinsp;=\u0026thinsp;0.002)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e1.597 (1.0\u0026ndash;2.53; p\u0026thinsp;=\u0026thinsp;0.046)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e** Blood loss(\u0026gt;\u0026thinsp;2500ml) vs vesciouterine adherence\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e2.28 (1.32\u0026ndash;3.92; p\u0026thinsp;=\u0026thinsp;0.003)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e1.06(0.52\u0026ndash;2.15; p\u0026thinsp;=\u0026thinsp;0.878)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e***Bladder injury vs vesicouterine adherence\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e37.7 (10.7\u0026ndash;132.8; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e7.19 (1.94\u0026ndash;26.64; p\u0026thinsp;=\u0026thinsp;0.003)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e*Adjusted for gestational age at surgery, mode of delivery (elective or emergency), management approach.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e**Adjusted for mode of delivery (elective or emergency), histological classification, management approach, gestational age at surgery.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e*** Adjusted for gestational age at surgery, management approach, mode of delivery and histological grade for PAS\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003cbr/\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","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":"Vesicouterine adherence, bladder injury, placenta accreta spectrum, villi implantation","lastPublishedDoi":"10.21203/rs.3.rs-4567510/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4567510/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eThe presence of differences between the clinical and histological classification of PAS hinders an accurate depiction of the extent of the maternal condition. None of the existing histological classification criteria are based on and correlate with surgical difficulty, morbidity risk, or maternal outcome.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eWe conducted a case-control study of data of all PAS cases between January 2017 and December 2021 at Dr. Soetomo General Hospital, Surabaya, Indonesia. Uterine dehiscence and any cases with incomplete data were excluded from the study. After surgery, the area of abnormal adherence was marked using small pins for histological analysis. The histopathology specimens were immersed in using Hematoxylin Eosin (HE). PAS cases were divided into three groups depending on the depth of villi: accreta, increta and percreta. Primary outcome was the vesicouterine adherence. Secondary outcomes were intraoperative topography, and surgical outcome.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eThree hundred sixty-three cases were included for analyses. Our cohort comprised of 99 accreta cases, 246 increta cases and 18 percreta cases. Estimated blood loss was significantly higher in the high-grade PAS (increta and percreta) groups than in the low-grade PAS (accreta) group (2851.0\u0026thinsp;+\u0026thinsp;2437.7 mL vs 1970.8\u0026thinsp;+\u0026thinsp;1315.8 mL; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Sixty-five (17.9%) cases of vesicouterine adherence were observed. This was associated with higher odds of caesarean hysterectomy (adjusted odds ratio [Adj OR] 30.77 (95% CI 12.52\u0026ndash;75.62; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and bladder injury (Adj OR 7.19; 95% CI 1.94\u0026ndash;26.64; p\u0026thinsp;=\u0026thinsp;0.003) but not estimated blood loss (\u0026gt;\u0026thinsp;2500 mL) (Adj OR 1.06; 95% CI 0.52\u0026ndash;2.16; p\u0026thinsp;=\u0026thinsp;0.87). Cases with bladder injury had a higher estimated blood loss (p\u0026thinsp;=\u0026thinsp;0.012) and concomitant caesarean hysterectomy (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) compared to those without bladder injury. The depth of villi implantation was associated with higher blood loss (\u0026gt;\u0026thinsp;2500 mL) (p\u0026thinsp;=\u0026thinsp;0.046) but not bladder injury (p\u0026thinsp;=\u0026thinsp;0.442) and vesicouterine adherence (p\u0026thinsp;=\u0026thinsp;0.503).\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e \u003cp\u003eVesicouterine adherence is not associated with the depth of villi implantation, but rather with the presence of fibrosis between the bladder and uterus. These adhesions also correlated to iatrogenic bladder injuries.\u003c/p\u003e","manuscriptTitle":"Vesicouterine adherence is independent of the degree of villi implantation: A retrospective case-control study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-28 16:05:34","doi":"10.21203/rs.3.rs-4567510/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":"4fb015f2-b3a4-4815-be12-66ec378843ae","owner":[],"postedDate":"June 28th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-04-03T08:23:50+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-28 16:05:34","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4567510","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4567510","identity":"rs-4567510","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}