Reply to: Modified cesarean hysterectomy technique for management of cases of placenta increta and percreta at a tertiar
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Reply to: Modified cesarean hysterectomy technique for management of cases of placenta increta and percreta at a tertiary referral hospital in Egypt David Atallah1 · Malak Moubarak1 · Nadine El Kassis1 Received: 4 May 2019 / Accepted: 7 June 2019 © Springer-Verlag GmbH Germany, part of Springer Nature 2019
Dear Editors, 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 * David Atallah [email protected] 1
Obstetrics and Gynecology Department, Hôtel‑Dieu de France University Hospital, Saint Joseph University, Beirut, Lebanon
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
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