Retrograde Postero-anterior Hysterectomy

We had a patient diagnosed to have placenta previa percreta on ultrasonography at 24 weeks. She had had a cesarean section in the past. I had asked our residents to get an MRI scan done on her to see if it was truly placenta percreta, so that we could plan her management in advance. The MRI showed central placenta previa percreta invading the bladder. She presented at 34 weeks with painless bleeding per vaginum. Two of our Assistant Professors performed an upper segment cesarean section on her under the supervision of our Associate Professor. They left the placenta undisturbed. The patient did well postoperatively until the next day, when she started bleeding vaginally again. The only interventional radiology unit in the civic hospitals is in our hospital (I am proud to say). But it was not available then because some part inside was broken and could not be replaced for lack of maintenance contract or some such thing (I am not proud to say). We were forced to perform an obstetric hysterectomy, with a urologist ready to help with resection of a part of the bladder and repair, with or without ureteric reimplantation if required. I really had planned to help out with the critical part and then let them continue with the operation, but I was forced to operate on her by my people, who washed up before I could, and promptly occupied positions of first and second assistants. When I offered to assist, the offer was politely but firmly declined. I carefully dissected between the uterus and the bladder. The tissue was edematous, loose, and the separation was easy except where the previous uterine scar was adherent to the bladder. I was reluctant to dissect the ballooned up lower segment and cervix right down to the bladder neck. So I decided to do something new – a retrograde postero-anterior hysterectomy. When one side adnexa is a mass of inflammatory origin such that cornuals and uterine pedicles cannot be secured during an abdominal hysterectomy, one has to cut and ligate all pedicles on the other side first, cut across the vagina to the affected side, and then divide and ligate the pedicles from below upwards – i.e. uterosacral-cardinal ligaments, uterine vessels, and cornuals in that order. This is called retrograde lateral hysterectomy. In this case the problem was anteriorly placed. So I divided and ligated the uterosacrals first. The posterior vagina was soft and friable, and opened transversely during upward traction on the uterus before I could cut across it. I cut the lateral vagina next, and the anterior vagina above the cervix last. Then I dissected the bladder away from the front of the cervix from below upwards. I had not known it before completing the dissection, but there was no placenta percreta right down to the pelvic floor level. The MRI people had goofed. If the diagnosis had been correct, my separation of the bladder from below upwards would have proved to be more useful, since the nor-percreta area below the percreta area would have been freed before the torrential bleeding started. I also feel that the dissection was easier than blind dissection downwards, not knowing what lay beyond.