基于病理解剖的局灶性切除术治疗穿透性胎盘植入：新生血管化的挑战
该回顾性病例系列纳入2020至2025年间15例胎盘植入谱系疾病（FIGO 2-3b级）患者，采用标准化局灶性切除术。14例（93%）成功保留子宫，中位出血量2000 mL，6例（40%）发生膀胱损伤但无远期后遗症，无孕产妇死亡。局灶性切除至FIGO 3b级及急诊情况下可行，母体并发症有限。
要点
- 保留子宫成功率为93%（14/15），1例因不可控出血行急诊子宫次全切除。
- 中位出血量2000 mL（IQR 1500-2500 mL），4例无需输血。
- 膀胱损伤发生率40%（6/15），≥1年随访无远期后遗症。
核心结论
- 基于病理解剖缺陷和新生血管化而非组织侵袭性的局灶性切除术可保留子宫，母体并发症有限。
- 该技术在高至FIGO 3b级及急诊情况下可行，组织病理学确认和术中视频记录支持其可重复性和诊断准确性。
研究设计与样本
- 回顾性病例系列，纳入2020至2025年间一家三级转诊中心的15例连续胎盘植入谱系疾病（FIGO 2-3b级）患者。
- 诊断由腹部和经阴道超声确立，术前计划包括详细患者咨询、多学科团队协调和血制品准备。
- 手术步骤包括精细膀胱分离、逐步血管结扎和穿透性胎盘植入区域的靶向切除。
主要发现
- 14/15例（93%）实现保留子宫手术，1例（7%）因不可控出血需急诊子宫次全切除。
- 中位出血量2000 mL（四分位距1500-2500 mL），4例患者无需输血。
- 6例（40%）发生膀胱损伤，均成功处理且≥1年随访无远期后遗症。
- 无孕产妇死亡报告。
临床怎么用
- 对于FIGO 2-3b级胎盘植入谱系疾病，可考虑基于病理解剖的局灶性切除术以保留子宫。
- 术前需多学科团队协调、血制品准备和详细患者咨询。
- 术中需精细膀胱分离和逐步血管结扎，并准备应对膀胱损伤和急诊子宫切除。
局限性
- 回顾性设计，样本量小（15例），来自单一三级转诊中心，结果外推需谨慎。
以上解读依据论文摘要（全文未开放获取或许可不允许翻译转载）。
原文
OBJECTIVE: To evaluate the feasibility, safety, and outcomes of a modified uterus-preserving focal excision technique for Placenta Accreta Spectrum Disorder, including placenta percreta, based on pathoanatomical defects and neovascularization rather than tissue invasiveness. STUDY DESIGN: We retrospectively reviewed 15 consecutive cases of Placenta Accreta Spectrum Disorder (International Federation of Gynecology and Obstetrics stages 2-3b) treated between 2020 and 2025 at a tertiary referral center using a standardized focal resection technique. Diagnosis was established by abdominal and transvaginal sonography. Preoperative planning included detailed patient counseling, multidisciplinary team coordination, and preparation of blood products. The surgical procedure involved meticulous bladder dissection, stepwise ligation of vessels, and targeted excision of placenta percreta areas. RESULTS: Uterus-preserving surgery was achieved in 14 of 15 patients (93%). One (7%) patient required emergency supracervical hysterectomy due to uncontrolled hemorrhage. Median blood loss was 2000 mL (interquartile range, 1500-2500 mL), and 4 patients required no transfusion. Bladder injury occurred in 6 patients (40%), all of which were managed successfully without long-term sequelae at ≥1 year of follow-up. No maternal deaths were reported. Focal resection was feasible even in emergency situations and in cases of high-grade Placenta Accreta Spectrum Disorder (up to International Federation of Gynecology and Obstetrics 3b). Histopathological confirmation and intraoperative video documentation supported the reproducibility and accuracy of the diagnosis and technique. CONCLUSION: This study reports a series of cases with focal excision of Placenta Accreta Spectrum Disorder, allowing preservation of the uterus and associated with limited maternal morbidity, which compares favorably with the commonly used cesarean hysterectomy.
引用
- Vural M, Pohle-Rüffer MC, Rauh M, et al. Focal excision for placenta percreta based on pathoanatomy: the challenge of neovascularization. Am J Obstet Gynecol. 2026. PMID: 42162710. doi:10.1016/j.ajog.2026.05.003
供执业医师工作参考，不替代临床判断；数值与分级以指南原文为准。