Objective: To compare peripartum outcomes of uterus preserving procedures to caesarean hysterectomy in women with placenta accreta spectrum (PAS), and to identify risk factors associated with adverse maternal outcomes. Design: Retrospective study (ClinicalTrials.gov identifier: NCT04384510) Setting:11 tertiary centres from 9 countries Population or Sample: women with of PAS who were managed in participating centres between January 1st, 2010 and December 31st, 2019. Women who had confirmed diagnosis with PAS with adequate documentation and follow-up, were considered eligible. Main Outcome Measures: Primary outcome was massive PAS-associated perioperative blood loss (intraoperative blood loss ≥ 2500 ml, bleeding associated massive transfusion protocol, or complicated by disseminated intravascular coagulopathy). Results: Out of 797 women, 727 were eligible for the study. Five hundred ninety-two (81.43%) women were managed by uterus preserving procedures versus 135 (18.56%) who underwent caesarean hysterectomy. After adjustment for significant or close-to-significance variables, type of management was not associated with higher risk of massive blood loss (aOR 1.71, 95% CI 0.78 - 3.81). Other factors that were significantly associated with higher risk of massive PAS-associated blood loss included body mass index, preoperative haemoglobin, centrally located placenta, diffuse placental invasion, parametrial invasion, and intrauterine foetal death. Conclusions: In the presence of sufficient experience, uterus preserving procedures may not be associated with higher risk of massive blood loss compared to caesarean hysterectomy. Funding: none

Background: Standard management of ovarian cancer is surgical debulking and adjuvant chemotherapy. The role of systematic lymphadenectomy, as a part of debulking, has been controversial. Objective: To assess prognostic value of systematic lymphadenectomy in women with ovarian cancer based on stage, control group and type of chemotherapy Search strategy: A literature search was conducted on SCOPUS, PUBMED, COCHRANE, MEDLINE, and WEB OF SCIENCE databases. Selection criteria: All comparative studies that assess outcomes of systematic lymphadenectomy in patients with ovarian cancer were eligible. Data Collection and Analysis: overall survival was analyzed by pooling log hazard ratio (HR) and standard error of multivariable Cox regression models. MOGGE Meta-analysis Matrix is a novel illustration tool that was used to demonstrate multiple subgroup analyses of included studies. Main results: Twenty-two studies were eligible. Systematic lymphadenectomy was associated with better overall survival, that was close to significance, compared to control group (HR 0.93, 95%CI 0.86-1.00). Among women treated with adjuvant chemotherapy, overall survival improved in women with stage IIB-IV who underwent systematic lymphadenectomy (HR 0.91, 95%CI 0.84-0.99) and was most significant among patients with III to IV (HR 0.85, 95%CI 0.73-0.99). Systematic lymphadenectomy did not improve survival in women who received neoadjuvant chemotherapy (HR 0.97, 95%CI 0.73-1.29). Systematic lymphadenectomy was associated with improved progress-free survival compared to control group (HR 0.88, 95%CI 0.79-0.99). Conclusion: Data from clinical trials do not support role of systematic lymphadenectomy in advanced ovarian cancer. However, further studies may be warranted to assess substage-specific survival outcomes in women with advanced stages.

Background: High intensity focused ultrasound (HIFU) is a non-invasive procedure that has been recently studied in management of placenta accreta spectrum (PAS). Objective: To appraise efficacy and safety of HIFU in management of PAS and to highlight restrictions of transitioning uterus-preserving studies to clinical practice. Search Strategy: A search on Scopus, Cochrane, PubMed and Web of Science was conducted from date of database inception to January 31st, 2020. Selection Criteria: Studies on use of HIFU in management of PAS were eligible. Review articles, conference papers, animal studies, and case reports were excluded. Data Collection and Analysis: A standardized data collection sheet was used to abstract data from eligible studies. CON-PAS registry was used to include studies on other conservative modalities of management of PAS. Results: Out of 30 studies, four were eligible (399 patients). Average residual placental volume was 61.74 cm3 (6.01-339). Treatment was successful in all patients. Normal menstruation recovered after 48.8 days (15-150). Average time for normalization of β-HCG was 16.5 (1-82) days. No major complications were encountered. Sixty-one studies were retrieved from CON-PAS registry; uterine artery embolization (23 studies), Prophylactic balloon placement (15), compression sutures (10), leaving placenta in situ (7), and uterine wall excision (6) were successful in 83.7% 92.9% 87.9%, 85.2%, and 79.3% of patients, respectively. Conclusions: HIFU yields promising success and safety profile in management of PAS in certain clinical situations. A global research strategy is recommended to incorporate conservative approaches in selected patients within a comprehensive protocol to manage PAS.