SUPLEMENTARY MATERIAL 1

IMAGE 1. Type 1 PAS. The abnormal invasion of the placenta affects mainly the upper part

of the uterine segment concerning the upper posterior bladder

1
IMAGE 2. Type 3 PAS. The placenta invasion is between the lower uterine segment or the

cervix and the trigon. But there is a dissectible between the uterus and the bladder.

2
IMAGE 3. Type 4 PAS shares the exact topographic location of PAS type 3. Still, in PAS

type 4, it is impossible to identify a dissection plane of vesicouterine space by the presence

of dense fibrous tissue

3
IMAGE 4: The picture shows the application of circular suture in all of the circumference of

the lower uterine segment, below hysterotomy.

4
IMAGE 5: The image shows when the uterine segment is cut between circular hemostatic

sutures.

5
IMAGE 6: The image shows that the cervix and the lower uterine segment (caudal to the

vesicouterine fibrosis begins) remain attached to the posterior lower bladder

6
IMAGE 7: The illustration showed the anatomy of the low anastomotic circle (Blue inter-

rupted line). The low posterior vesical area, low uterine segment, and the cervix shared arte-

rial anastomotic branches, originated in the inferior and superior vesical arteries, the cervical

artery, the vaginal arteries (superior from the uterine artery, middle from the internal iliac

artery, and the inferior arising from the internal pudendal artery). The ipsilateral and contra-

lateral component widely communicate this system.

7
IMAGE 8: The picture shows the placements of the compression sutures in the uterine seg-

ment and cervix to compress the anterior and posterior uterine segment surfaces.

8
IMAGE 9: Intrasurgical view of placement example of the compressive suture into the blad-

der lumen. Patient with persistent hematuria after fetal extraction. Following an intentional

cystotomy, the bleeding site (BS) is identified in the posterior bladder wall. (PBW). Then,

the compressive suture is applied and tight around the invasion area with an absorbable suture

to stop the bleeding. 1) Bladder wall borders

9
IMAGE 10: The picture showed a histological analysis of a PAS type 4 with persistent he-

maturia, treated with "in-bloc resection technique," including the uterine and bladder walls.

The presence of fibrous tissue is distinct from this PAS type 4.

10
IMAGE 11: The scheme showed a low anastomotic circle and its confluence (purple circle)

between the cervix, the trigon, and the upper vagina. Accidental bleeding during dissection

over fibrous tissue is challenging to be solved. Blood loss is feeding by multiple sources,

which turns almost impossible to be embolized without the risk of producing a non-target

embolization. SVA: Superior vesical artery; IVA: Inferior vesical artery.

11
IMAGE 12: Intrasurgical view: This picture shows a case of low bladder tissue rupture con-

secutive to an insistent dissection attempt in PAS type 4. Notice the size of the enlarged

vessels in the trigonal area

12
IMAGE 13: The picture shows the lower anastomotic circle location in a parasagittal pelvis

cut. 1. Cervical and upper vaginal artery components; 2. The internal pudendal artery's main

vaginal arterial components include the azygos vaginal artery. 3. Superior vesical compo-

nent; 4. Inferior vesical component. Purple circle: Topographical location of the PAS T3 and

T4 areas

13
IMAGE 14: Intrasurgical view: Patient with severe cervical-trigon invasion. Part of the low

uterine segment, the cervix, and the trigon left attached. White asterisk: Enlarged vessels that

involve the cervix and the trigon. All placenta tissues were removed with minimal blood loss.

BL: Bladder, CE: Cervix.

14