Subtotal versus total hysterectomy in placenta accreta spectrum management at a tertiary centre in saudi arabia: a retrospective study

BACKGROUND: Placenta accreta spectrum (PAS) is a major contributor to life-threatening obstetric hemorrhage and is increasingly encountered worldwide due to rising caesarean delivery rates. Caesarean hysterectomy remains the cornerstone of management in most cases; however, the optimal surgical techniques, subtotal versus total hysterectomy, continue to be debated. Current evidence is limited and heterogeneous, and practice often varies according to surgeon preference and intraoperative findings. By evaluating outcomes in a large cohort at a national tertiary referral center, this study aims to clarify the comparative safety and effectiveness of subtotal versus total hysterectomy in PAS management. METHODS: We conducted a retrospective cohort study of women with PAS who underwent caesarean hysterectomy between 2018 and 2023. The primary outcome was intraoperative quantified blood loss (QBL). Secondary outcomes included operative time and bladder injury. Multivariable linear regression on log-transformed QBL and operative time was used to estimate adjusted geometric mean ratios, while bladder injury was analyzed using multivariable logistic regression. All models adjusted for surgical urgency, antenatal PAS severity, suspected cervical involvement, number of prior caesarean deliveries, gestational age at delivery, and surgeon identifier. RESULTS: Among the included patients, subtotal hysterectomy was associated with significantly lower intraoperative blood loss compared with total hysterectomy (adjusted geometric mean ratio 0.36, 95% CI 0.32-0.41; p-value < 0.001). Operative time was also significantly shorter in the subtotal hysterectomy group (adjusted geometric mean ratio 0.54, 95% CI 0.50-0.59; p-value < 0.001). In addition, subtotal hysterectomy was associated with a significantly lower odds of bladder injury (adjusted odds ratio 0.19, 95% CI 0.05-0.68; p-value = 0.013). CONCLUSION: Subtotal hysterectomy was associated with significantly lower intraoperative blood loss, shorter operative time, and fewer bladder injuries compared to total hysterectomy for placenta accreta spectrum. These findings support subtotal hysterectomy as a feasible and potentially safer surgical option in selected cases. While these findings support subtotal hysterectomy as a viable option, the retrospective design and potential selection bias highlight the need for individualized decision-making. Further multicenter prospective research with standardized surgical criteria is needed to confirm these results, minimize confounding from PAS severity, and determine the most effective surgical approach.