Evaluating a novel approach to placenta accreta spectrum management: the modified Triple-P technique with cystoinflation (a randomized controlled trial)

Placenta accreta spectrum (PAS), or morbidly adherent placenta, is a life-threatening condition requiring caesarean section (C-section) and often hysterectomy due to massive postpartum haemorrhage. The widely adopted conservative management-the Triple-P procedure-carries a risk of substantial blood loss. Modifications like blunt bladder dissection and haemostatic suturing can help control bleeding however, bladder injury remains a concern, as identifying vesicouterine planes can be difficult among placental and prior C-sections adhesions. While some studies have used Cystoinflation (retrograde bladder filling) to delineate bladder edges in complex C-sections, its efficacy in preventing bladder injury during PAS surgeries is inconclusive, and no trial has evaluated its integration with the Modified Triple-P technique. To address this gap, we conducted a single-centre, single-blinded controlled trial with 150 women with PAS confirmed during C-section. Participants were randomised to either Modified Triple-P alone or the combined approach with Cystoinflation. Bladder injury, the primary outcome, occurred in 2 (2.7%) of the Cystoinflation group versus 14 (18.7%) of the controls (P < .0001). Secondary outcomes, including blood loss, hysterectomy rates, urologic complications, neonatal outcomes, and fertility, also favoured the combined approach. These results suggest adding Cystoinflation to Modified Triple-P enhances bladder safety and optimises maternal and foetal outcomes in PAS management.Trial registration This trial is a part of project "Cystoinflation to Prevent Bladder Injury in Obstetrics and Gynaecology Surgery" with ethical approval from King Edward Medical University. Trial Registration NCT04302545.