LAUSR

I want to congratulate Hussein et al. [1] for their extensive work. I am aware of the catastrophic figures of percreta due to the epidemics of cesarean section in their country. In fact, Egypt is the third country on the row considering the rate of cesarean section. The total Egyptian population is more than 100 million and the natality is approximately 4 per woman. Lebanon is a smaller country with a similarly high rate of cesarean section. We organized the management of this disease by creating a network collaboration between three university hospitals that receive all cases from the whole country. In my department, I extrapolated gynecologic oncology techniques to apply them in the management of percreta cases. In fact, as I have stated in my first letter in 2013, the disease is different from one patient to another and the management differs from a patient to another, opening the door for conservation [2]. The problem is percreta, when we have an anterior bladder invasion and sometimes lateral invasion with new vessels and huge veins formation in the parametrium. The fact of approaching the dissection laterally and then anteriorly at the level of bladder attachment to the lower uterine segment, as described by Hussein et al., will expose the surgeon to a heavy bleeding [3]. Dr. Matsubara addressed the fact that lateral approach was very difficult [4]. Although this approach is difficult, it is possible by opening the paravesical space that allows mobilization and then lifting of the uterus and the lower segment, exposing the iliac vessels and the ureters. Moreover, I noticed some confusion in the previous two letters between the retroperitoneal approach and the posterior approach, which is the next step after ligating the uterine artery in the retroperitoneum. The posterior approach is essential because it helps the surgeon to access the vagina, to lift the uterus with both fingers inserted in, and to perform a total hysterectomy regardless of the status and the location of the placenta [2]. Keeping the dissection of the bladder till the end is strategic because of a risk of bleeding which may be uncontrollable, even with delicate dissection. Unlike what Hussein et al. said [5], our data were published, proved the efficacity and safety of this standardized technique and showed less blood loss and zero ureteral injury [6, 7]. All our operated cases were percreta while the majority of patients in Hussein’s series were increta (92%, 58 out of 63 cases and only 5 were percreta). That is why they were able to perform subtotal hysterectomy because the majority of their cases were not percreta. A supracervical hysterectomy should not be an option in case of real placenta percreta. At the contrary, leaving the cervix in situ may lead to severe bleeding and increase the rate of reoperation. Moreover, we were able to show that our technique is universal and applicable to both emergency and scheduled cases with no differences in terms of intra-operative complications, surgery duration, intra-operative transfusions, hemoglobin values, estimated blood loss, post-operative complications, hospital stay, and neonatal outcomes. Unfortunately, the colleagues have excluded the emergent cases. In addition, when reading in our colleagues’ statement “all women underwent ureterolysis and ureteric stent placement”, we would like to state that ureteral stenting is not feasible in emergent bleeding and is actually not mandatory with our procedure [3]. In my department, we are operating regularly using the retroperitoneal and posterior first approach without any hazards. * David Atallah [email protected]