Analysis of the relationship between the dissection of avascular spaces and blood loss in various modifications of radical hysterectomy performed for placenta percreta, ovarian cancer or cervical cancer

Introduction. The treatment of pregnant women with placenta accreta spectrum (PAS) remains both an organizational and therapeutic challenge. In recent years, the number of caesarean sections has increased, and caesarean section, alongside placenta previa , is one of the main risk factors for placental invasion. The PAS is no longer rare, with placenta percreta (invasive placenta) accounting for 5% of cases — these being the most severe in terms of treatment comple­xity. The currently recommended approach involves an elective classical caesarean section with leaving the placenta in utero and performing simultaneous peripartum hysterectomy. Alternatively, conservative management with leaving the placenta in situ and possible delayed hysterectomy is an option. Hemorrhage and other severe complications can occur in up to half of PAS cases, with an even higher incidence in conservative management. Therefore, the technique of hysterectomy and the surgical expertise of the operator play a crucial role in minimizing the risk of hemorrhage and urinary tract injury. Peripartum hysterectomy for placenta percreta falls into the category of multiorgan resections, incorporating a modified radical hysterectomy. Technically very similar procedures are commonly performed by gy­necologic oncologists in the treatment of advanced ovarian malignancies. The preferred technique in such cases is often the Hudson operation, a modification of the classical Wertheim procedure. In order to properly perform such an operation, it is necessary to dissect the avascular spaces within the operative field, which helps prevent hemorrhage and reduces the number of other complications. Material and methods. A multicenter retrospective comparative study included 166 patients. Clinical and organi­zational parameters characterizing the course of surgical treatment were analyzed in the following patient groups: those operated on for placenta percreta and ovarian cancer. The reference group consisted of patients who underwent surgery for cervical cancer. Results. The risk of hemorrhage in modified radical hysterectomy was highest in procedures performed for placenta percreta . In these cases, statistically more units of packed red blood cells (pRBC) and fresh frozen plasma (FFP) were transfused, although the procedure itself did not take significantly longer. Blood loss was lower when more avascular spaces were dissected. The highest number of avascular spaces were prepared in radical hysterectomy for cervical cancer, while the lowest number was associated with surgeries for placenta percreta . Conclusions. The dissection of avascular spaces is one of the methods to reduce the risk of uncontrolled blood loss during radical hysterectomy.