LAUSR

Dear editor, We read with great interest the article ‘Striking decrease in blood loss with a urologist-assisted standardized multidisciplinary approach in the management of abnormally invasive placenta’, by Lekic et al. [1]. They compared the outcomes of cesarean hysterectomy for abnormally invasive placenta (AIP) before (n1⁄4 10) and after (n1⁄4 9) the introduction of standardized multidisciplinary team management including urologists. Before versus after the introduction of this approach, antenatal diagnosis was made in 11% (1/9) versus 100% (10/ 10), respectively, and bladder separation was performed after versus before the infant’s delivery, respectively: the latter (bladder separation before delivery) was used to reduce the hysterectomy time. Importantly, in a patient with bladder invasion, intentional cystotomy was performed before delivery: a ‘bladder flap attached to the uterus’ technique. Introduction of this protocol markedly decreased blood loss and yielded better overall maternal outcomes. We have some concerns. First, it is unclear which factor(s) accounted for this better outcome. After the introduction of the new protocol, the following occurred: (i) the involvement of a multidisciplinary team; (ii) the availability of such a team even in an emergency setting; (iii) team staff becoming more accustomed to this surgery; (iv) performing bladder separation first; (v) the employment of ‘bladder flap attached to the uterus’ before infant delivery in cases with bladder invasion; and (vi) the involvement of urologists. Better outcomes may have resulted from a total effect of these factors. Whether and how each factor contributed to the better outcome was unclear, which leads to our second and third concerns. The second concern is that it is yet to be determined whether ‘bladder separation first’ is beneficial. This procedure aims to make hysterectomy easier and thus to reduce the time of hysterectomy [2], which may reduce the incidence of partial placental separation during hysterectomy, a causative factor of massive bleeding. We agree that partial placental separation should be avoided; thus, similarly to Lekic et al., we do not use uterine contracting agents during hysterectomy [3]. However, aberrant vessels at the vesicouterine fold are much more engorged before than after infant delivery. Even with very fine techniques and cautious hands, these engorged vessels may sometimes be injured, causing massive bleeding, meaning that massive bleeding can occur at the beginning of the surgery [3]. After infant delivery, the reduced volume of the uterus enables its exteriorization, making bladder separation easier. We sometimes fill the bladder with 200–300ml of water after delivery, which also enables easier separation of the bladder [3]. Thirdly, intentional cystotomy (‘bladder flap attached to the uterus’) usually causes massive bleeding. To our knowledge, we were the first to report intentional cystotomy/cystectomy in cesarean hysterectomy for an AIP patient with bladder invasion, the ‘open bladder technique’ [3,4]. The ‘bladder flap attached to the uterus’ technique by Lekic et al. was fundamentally the same as ours [3,4], with the exception that Lekic’s and our techniques are performed before versus after infant delivery, respectively. We used the automatic stapling/cutting apparatus Endo-GIA (Covidien, Dublin, Ireland) for cytotomy and closure to reduce bleeding; however, even with this apparatus, there was still notable bleeding [4]. We wonder what technique and apparatus Lekic et al. used in intentional cystotomy to have yielded this marked reduction in bleeding even when performing the cystotomy ‘before’ infant delivery. A ‘multidisciplinary team approach’ may provide a better outcome than a ‘single-disciplinary team approach’ only if it is well organized. This may be true for almost any treatment for any disorder, not being confined to AIP treatment. This is common sense regarding current medicine and surgery. Progress in procedures and the accumulation of experience have made many studies possible, comparing before versus after procedures: ‘after’ has almost always been more successful. Undoubtedly, a planned multidisciplinary approach for prediagnosed AIP (after) is better than its counterpart (before). We would never claim that urologists’ participation is not needed. Rather, their participation in this life-threatening surgery may be a bonus for obstetricians for reducing bleeding, better handling of the lower urinary tract (such as in bladder separation or identification of the ureter), avoiding urological injuries and repairing these injuries if they occur. In particular, intentional cystotomy/cystectomy, regardless of whether it is performed before or after delivery of the infant, requires urologists’ attendance; however, bladder invasion accounts for only a small fraction of AIP (0.8%: 2/250 AIP; 0.01%: 2/25,254 births) [5]. In addition, placing too much emphasis on the importance of urologists’ attendance may create legal issues, such as when a poor outcome occurred in the absence of urologists even though it was not actually due to their absence. We believe that their attendance should depend on the situations of both individual institutes and patients.