Approaches to reduce urinary tract injury during management of placenta accreta, increta, and percreta: a systematic review

J Matern Fetal Neonatal Med. 2012 Apr;25(4):329-34. doi: 10.3109/14767058.2011.576720.


Objective: A systematic review of the literature was conducted to answer the following question: are there enhancements to standard peripartum hysterectomy technique that minimize unintentional urinary tract (UT) injury in pregnancies complicated by invasive placental attachment (INPLAT)?

Methods: A PubMed search of English language articles on INPLAT published by June 2010 was conducted. Data regarding the following parameters was required for inclusion in the quantitative analysis of the review's objective: (1) type of INPLAT, (2) details pertaining to medical and surgical management of INPLAT, and (3) complications, if any, associated with management. An attempt was made to identify approaches that may lower the risk of unintentional UT injury.

Results: Most cases (285 of 292) were managed by hysterectomy. There were 83 (29%) cases of unintentional UT injury. Antenatal diagnosis of INPLAT lowered the rate of UT injury (39% vs. 63%; P = 0.04). Information regarding surgical technique or medical management was available for 90 cases; 14 of these underwent a standard hysterectomy technique. Methotrexate treatment and 11 modifications of the surgical technique were associated with 16% unintentional UT injury rate as opposed to 57% for standard hysterectomy (P = 0.002). The use of ureteral stents reduced risk of urologic injury (P = 0.01). Multiple logistic regression analysis identified antenatal diagnosis as the significant predictor of an intact UT.

Conclusions: Antenatal diagnosis of INPLAT is paramount to minimize UT injury. Utilization of management modifications identified in this review may reduce urologic injury due to INPLAT.

Publication types

  • Review
  • Systematic Review

MeSH terms

  • Female
  • Humans
  • Hysterectomy / adverse effects
  • Hysterectomy / methods
  • Intraoperative Complications / prevention & control*
  • Methotrexate / therapeutic use
  • Placenta Accreta / diagnostic imaging
  • Placenta Accreta / drug therapy
  • Placenta Accreta / surgery*
  • Pregnancy
  • Ultrasonography, Prenatal
  • Urinary Tract / injuries*


  • Methotrexate