Ultrasound-first, anatomy-based algorithm to tailor the extent of hysterectomy in placenta accreta spectrum

Placenta accreta spectrum (PAS) represents one of the most challenging scenarios in obstetric surgery, with cesarean hysterectomy remaining the standard approach in cases of suspected placenta percreta. However, objective and reproducible criteria to guide the extent of hysterectomy, particularly the decision to preserve or remove the cervix, remain insufficiently defined. We propose a structured, anatomy-based decision-making framework to tailor the extent of hysterectomy in PAS, integrating preoperative imaging with intraoperative assessment. Ultrasound is used as the primary modality to evaluate key anatomic parameters, including placental location, depth of invasion, the relationship between the placental edge and the external cervical os, and the integrity of the vesicouterine interface. Magnetic resonance imaging is selectively employed in cases with equivocal findings, particularly when cervical or bladder invasion is uncertain. These variables are incorporated into a stepwise, ultrasound-first algorithm to support surgical planning and guide the choice between total and subtotal hysterectomy. The clinical application of this framework is illustrated through a representative case with detailed imaging-surgical correlation and operative video. By translating imaging findings into actionable surgical criteria, this approach aims to improve reproducibility and standardization in PAS management. When strict anatomic criteria are met, subtotal hysterectomy may represent a safe alternative to total hysterectomy in selected cases, potentially reducing morbidity associated with deep pelvic dissection. This framework is not intended to replace established guidelines but to operationalize decision-making in experienced, multidisciplinary settings. Further validation in larger cohorts is warranted to confirm its clinical utility and generalizability.