Preoperative cystoscopy as a risk stratification tool for massive hemorrhage in placenta accreta spectrum.

Abstract

Background: We aimed to evaluate preoperative cystoscopies performed in the setting of PAS at our institution, and compare their correlation with blood loss, histological diagnosis, and surgical complications.

Methods: We performed a retrospective review of patients with suspected PAS who underwent cystoscopy with ureteral stent placement at time of cesarean hysterectomy at a tertiary care center from 2018 to 2024. Inclusion criteria were scheduled cesarean hysterectomy, same surgeon, standardized surgical techniques, and availability of cystoscopy videos for review. Cystoscopies were reviewed for bulging, mucosal hyperemia (MH), MH around ureteral orifices (UOs), bridging blood vessels (BVs) with and without arterial pulsation, and distortion of trigone (DT.) Descriptive statistics were performed to evaluate for associations between cystoscopic variables and severe blood loss (SBL) over two liters, histologic grading, genitourinary tract injuries, REBOA use, and ICU admission. A p value < 0.05 was considered significant.

Results: 66 cases were included. Bulging was present in 73% of cases, MH in 61%, MH around UOs in 61%, BVs in 42%, arterial pulsation in 24%, and DT in 27%. 17 cases had SBL. The presence of BVs was significantly associated with SBL (n = 12, p = 0.009, OR 4.9 [95% CI: 1.49-16.47.]) DT was significantly associated with high grade lesions (n = 10, p = 0.02, OR 5.1 [95% CI 1.25-20.65]) and cystotomy (n = 8, p = 0.006, OR 6.11 [95% CI 1.67-22.41.]). There was presence of BVs in all cases of transfusion ≥ 4 units of pRBCs, both cases of REBOA use, and the one ICU admission. BVs were always on the lower posterior wall of the bladder.

Conclusion: In this study, the finding of bridging blood vessels on the lower posterior wall of the bladder was associated with severe blood loss of over two liters. Preoperative cystoscopy can assist surgeons in identifying patients with low posterior bladder lesions who may benefit from cesarean hysterectomy and prepare for massive blood transfusion or REBOA use, as well as help counsel patients more clearly on expectations.