Conservative surgery vs hysterectomy for placenta accreta spectrum disorders: a systematic review and meta-analysis

AimResection and reconstruction of the uterus may be an alternative to hysterectomy in placenta accreta spectrum disorders. We aimed to review whether surgical and maternal outcomes were comparable between these techniques. MethodsMedline, Embase, and the Cochrane Library databases were searched until 1 January 2025. Randomized controlled trials (RCT) and nonrandomized studies (NRSI) comparing conservative surgery, involving resection and reconstruction of the myometrium without placental removal, to hysterectomy in patients with placenta accreta, increta, or percreta. The risk of bias was assessed with ROB-2 or ROBINS-I, and the quality of evidence with GRADE. The main analysis only included studies without a high risk of bias. ResultsWe included one RCT and eleven nonrandomized studies (1586 women). Compared to hysterectomy, conservative surgery may result in similar intraoperative blood loss (MD -320.89 mL, 95% CI -574.95 to -66.82; 1 RCT and 3 NRSI, 637 women; I2= 14%; low-certainty evidence), transfused packs of red blood cells (MD -0.70 packs, 95% CI -1.28 to -0.12; 1 RCT and 4 NRSI, 649 women; I2= 0%; low-certainty evidence), and no difference in the risk of bladder injury (RR 0.36, 95% CI 0.12 to 1.07; 1 RCT and 4 NRSI, 649 women; I2= 0%; low-certainty evidence). ConclusionsOn the basis of low evidence, conservative surgery did not increase the risk of clinically important harm compared to hysterectomy, with the benefit of uterus preservation. Further RCTs are needed to reach definitive conclusions about potential benefits. To improve the quality of evidence from low to moderate, a trial with an additional 181 participants in the conservative surgery arm would be necessary to avoid downgrading for imprecision. RegistrationPROSPERO CRD42024601117.