Design: Case series describing three patients with early PAS desiring uterine conservation

Setting: Single tertiary academic center

Patients or Participants:

Three patients were diagnosed with early PAS between 8 and 12 weeks gestational age. Diagnosis was made ultrasonographically. Features suggestive of PAS include absent overlying myometrium, absent retroplacental “clear space,” and bulging, thickening, and nodularity in the lower uterine segment abutting the bladder.

Interventions:

Preoperative preparation comprised of extensive counseling and detailed imaging review with maternal fetal medicine and gynecologic surgery specialists. The operating room was prepared for possible conversion to hysterectomy or open, and blood products were on standby.

Two cases were also preceded by uterine artery embolization (UAE) using temporary gel foam.

Intraoperatively, an obliterated anterior cul-de-sac required extensive lysis of adhesions (LOA) to visualize the pregnancy. A colpotomy cup with a short or absent uterine manipulator tip provided cephalad tension. Vasopressin was injected circumferentially in the myometrium surrounding the bulging pregnancy.

In two cases, suction dilation and curettage was performed just prior to hysterotomy to decompress the uterus allowing improved access and contraction of the myometrium.

An elliptical hysterotomy was made around the invasive pregnancy using monopolar shears. The endometrial cavity was entered and explored to ensure complete removal. 2-0 barbed sutures were used to close the uterine defect in a multilayered fashion. A sheet of regenerated cellulose was placed for adhesion prophylaxis.

Measurements and Main Results: All three patients underwent successful robotic-assisted laparoscopic resection of PAS and repair of the uterine defect. Mean estimated blood loss (EBL) was 217cc with lowest EBL following preoperative UAE. Operative time averaged 164 minutes.

Conclusion: Robotic-assisted laparoscopic excision and repair of early PAS is safe and feasible. Further studies are warranted to ensure optimal perioperative management and determine long- term outcomes.