Surgery for placenta accreta spectrum: Making “invisible” barriers visible

Abstract

Sir,

Paping and colleagues¹ demonstrated that among 22 centers specializing in placenta accreta spectrum (PAS), encompassing 234 patients over 2.5 years, only 10 centers performed focal resection on 38 patients. The reasons for this low rate (barrier) were multifactorial: Doctors' inexperience was considered the main factor. Their conclusion suggested that systemic training for doctors could enhance the utilization of focal resection. I, focusing on focal resection versus hysterectomy, suggest some “invisible” (nondescribed) barriers to focal resection.

The first invisible barrier is the lack of “evident” merit, apparent to the extent that many obstetricians, though not all, perceive it as a gut feeling. It has been 20 years since Palacios-Jaraquemada et al.² described the concept and technical details of focal resection, which was groundbreaking. Since then, many experts have highlighted its benefits. The indication for focal resection was reportedly broad: Approximately 80% of PAS patients can be managed by this surgery.³ Focal resection does not require specialized equipment. Taken together, focal resection is expected to gain much more popularity only if its merits are “evident” to everyone. This is the first possible barrier.

The second is the concern over whether one should aim to conduct training for PAS hysterectomy and focal resection simultaneously. Even within centers of excellence, the annual PAS surgery volume averaged 4.3 cases (234/22/2.5).¹ PAS hysterectomy, akin to focal resection, poses significant surgical challenges. However, one advantage of the PAS hysterectomy is that every obstetrician–gynecologist is well-versed in “hysterectomy,” and many procedures for PAS hysterectomy can be extrapolated from an ordinary non-PAS hysterectomy.⁴ Contrarily, focal resection presents unique features: resection and repair. Similarities may be found with uterine malformation repair surgery, a relatively rare procedure: The concept of focal resection is less integrated into doctors' lifelong practice than hysterectomy. It raises the question of whether managing a small caseload of PAS surgeries allows for obtaining proficiency in both procedures simultaneously.

Third, attributing outcomes to hysterectomy versus focal resection is often unclear due to the involvement of various accompanying procedures. This complexity makes it difficult to determine whether outcomes are specifically attributable to hysterectomy or focal resection, or to the accompanying procedures.

I propose the following three strategies to overcome each barrier. First, randomized controlled studies should be performed on a wider scale. A recent study³ showed that, when intrasurgical staging (operability) is appropriately done, a randomized study can be promising. This feasibility study³ demonstrated that partial resection “evidently” benefited patients where PAS was located at the upper anterior uterine wall (Type 1). Second, as Paping et al.¹ briefly mentioned, various simulation, virtual, or workshop studies should be conducted because the imbalance between the number of ambitious obstetric surgeons attempting resection surgery and the actual number of patients will continue. Third, as previously described,⁵ implementing registration systems that detail all procedures could provide valuable insights, which will help make a “fair” comparison between the two strategies.

We should make these invisible barriers visible, thereby involving many PAS specialists in the discussion of which strategy is better and for whom. I am eagerly awaiting a large-scale randomized controlled study.