In reply

We would like to thank Dr. Matsubara, who is a renowned obstetric surgeon, for his valuable contributions. We totally agree with his comments. There is an increasing trend in cesarean rates throughout the world and the need for better approaches for this challenging surgery is evident.

Our study [1] is, as far as we know, the largest randomized prospective paper in the English literature but due to the preliminary nature, the relatively small number of treated women prevents us from making conclusive statements. The big question remains on to how to choose the appropriate surgical approach for a specific placental invasive disorder.

We agree that the vesicouterine fold becomes chaotic in placenta percreta and filling the bladder will help the surgeon to better identify aberrant vessels that have been perfectly demonstrated in Matsubaraʼs study [2]. We expected to observe lower need for transfusion of blood products, shorter duration of surgery, and a lower rate of bladder injury in a statistically significant manner. But our results were encouraging enough for continuing the practice of bladder filling. We are currently recruiting more percreta cases to see if there is any difference between filling bladder or not with larger number of women treated.

The effect of “filling the bladder” should not be underestimated as it makes percreta hysterectomy easier. In the near future, there will be a greater demand for better surgical techniques for prophylaxis of surgical complications. Filling the bladder is a good option such as adding bilateral hypogastric artery ligation before cesarean hysterectomy (we are currently recruiting prospective data) or routine use of bulldog clamp on bilateral hypogastric arteries in cases with percreta [3]. We believe in parallel with Dr. Matsubara that obstetric surgeons may prefer to fill the bladder prior to surgery as a useful technique where anatomical landmarks are unclear, especially in cases with placenta percreta.

Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Özcan HÇ, Balat Ö, Uğur MG. et al. Use of Bladder Filling to Prevent Urinary System Complications in the Management of Placenta Percreta: a Randomized Prospective Study. Geburtsh Frauenheilk 2018; 78: 173-178
• 2 Matsubara S, Takahashi H, Baba Y. Handling aberrant vessels located in the posterior bladder wall in surgery for abnormally invasive placenta: a non/less-touch technique. Arch Gynecol Obstet 2017; 296: 851-853
• 3 Dursun P. Use of bulldog vascular clamps to reduce intraoperative bleeding during cesarean hysterectomy for placenta percreta. Int J Gynaecol Obstet 2018; 140: 379-380