Dear Editor,
We thank Professor Chikazawa et al.[1] for their interest in our paper[2] and for highlighting the importance of simulation during training for the management
of placenta accreta spectrum (PAS). There are multiple options to manage PAS and although
the disease exhibits a wide variety of clinical presentations (spectrum), most groups
choose a single therapeutic alternative and apply it to all their patients, making
it difficult to respond when deviations from the original plan arise. Few publications
propose a clear sequence of interventions applicable to all types of PAS. Our group
uses the protocolized approach described by Palacios-Jaraquemada et al.[3] applicable to patients with suspected prenatal PAS, but also to those diagnosed
intraoperatively, considering the nature (predominantly hypervascularization or presence
of vesicouterine fibrosis) and the topography of the lesion (which uterine wall is
affected, and which is the relationship of the lesion with the vesicouterine peritoneal
fold).[3]
[4] This protocol includes four steps ([Fig. 1]).
Fig. 1 Protocolized approach to PAS. Abbreviations: MSTH, Modified subtotal hysterectomy;
OSCS, One-step conservative surgery; PAS, Placenta accreta spectrum. *If the clinical
condition of the patient or her fetus does not allow to defer the procedure, avoid
manipulating the placenta.
First, the evaluation of the available resources and the clinical situation of the
patient (to define whether or not to go ahead with the surgery). Doctor Chikazawa
et al.[1] rightly point out that the process of training to manage PAS is a long one, and
that obstetricians without such training are likely to be faced with the intraoperative
finding of PAS. As useful as training in what to do, it is necessary to be very clear
about what to avoid in the event of a PAS intraoperative finding, without the appropriate
resources (human or technological), the greatest success of the obstetrician would
be to avoid a high number of interventions when the clinical situation of the patient
allows it.
Second, intraoperative staging through 4 actions: opening of the parametrium (to evaluate
the lateral uterine wall), digital evaluation of the retrovesical space (Pelosi maneuver),
dissection of the retrovesical space by ligating the vesicouterine pedicles (to evaluate
the anterior uterine wall), and exteriorization of the uterus to evaluate the posterior
uterine wall.
Third, the recommended treatment will be chosen (one step conservative surgery, total
hysterectomy or modified subtotal hysterectomy) based on the topographic classification,[3]
[4] and after answering the three following questions: Is it possible to separate the
bladder from the uterus? Is there > 2 cm of healthy myometrium cephalic to the cervix
and caudal to the PAS area? Does > 50% of the circumference of the uterus (in an axial
section at the level of the PAS area) has healthy myometrium? ([Fig. 1]).
Fourth and last, it is essential to have photographic and video recording elements
of the surgical procedures to later on debrief, self-assess, and provide research
activities that facilitate learning and continuous improvement of the performance
of the group. A standardized approach facilitates the construction of a mental map
that obstetricians can internalize or consult immediately, facilitating decision-making
in the face of a planned or unexpected PAS case.
