Uterus-preserving surgery for placenta accreta spectrum: An expert, illustrated review of techniques and its outcomes.

Placenta accreta spectrum (PAS) disorders are associated with substantial maternal morbidity and remain one of the most challenging conditions in modern obstetrics. Although cesarean hysterectomy with the placenta left in situ is widely regarded as the standard treatment, uterus-preserving surgical strategies have emerged as viable alternatives in carefully selected cases managed in specialized centers. Building on our recently published systematic review and meta-analysis, this expert-illustrated review provides a comprehensive and critical appraisal of conservative surgical approaches for PAS, with a particular focus on operative techniques, patient selection, and short- and long-term outcomes. We clearly differentiate two fundamentally distinct conservative strategies: myometrial resection techniques and leaving the placenta in situ. For each approach, we synthesize current evidence, describe procedural nuances, highlight technical prerequisites, and discuss expected intraoperative and delayed complications. The most commonly performed myometrial resection techniques-including one-step conservative surgery, the Triple-P procedure, and the Kasr Alainy technique-are detailed step-by-step and illustrated to emphasize key surgical principles. Expectant management with the placenta left in situ is also reviewed, with particular attention to indications, postoperative surveillance, delayed morbidity, and fertility outcomes. Data from 50 studies encompassing 2659 patients undergoing myometrial resection and 552 managed with the placenta left in situ are integrated to contextualize reported outcomes and failure rates. This expert review aims to support clinical decision-making by clarifying the indications, limitations, and risks of conservative PAS management. We argue that uterus-preserving strategies can be safely and effectively implemented in selected patients when performed by experienced multidisciplinary teams, while emphasizing that readiness to convert to hysterectomy remains essential. By distinguishing techniques and aligning them with patient-specific factors, this review provides practical guidance for maternal-fetal medicine specialists managing PAS in contemporary clinical practice.