We would like to thank Dr. Matsubara, who is a renowned obstetric surgeon, for his
valuable contributions
. We totally agree with his comments. There is an increasing trend in cesarean rates throughout the world and the need for better approaches for this challenging surgery is evident.Our study
1
is, as far as we know, the largest randomized prospective paper in the English literature but due to the preliminary nature, the relatively small number of treated women prevents us from making conclusive statements. The big question remains on to how to choose the appropriate surgical approach for a specific placental invasive disorder.We agree that the vesicouterine fold becomes chaotic in placenta percreta and filling the bladder will help the surgeon to better identify aberrant vessels that have been perfectly demonstrated in Matsubaraʼs study
2
. We expected to observe lower need for transfusion of blood products, shorter duration of surgery, and a lower rate of bladder injury in a statistically significant manner. But our results were encouraging enough for continuing the practice of bladder filling. We are currently recruiting more percreta cases to see if there is any difference between filling bladder or not with larger number of women treated.The effect of “filling the bladder” should not be underestimated as it makes percreta hysterectomy easier. In the near future, there will be a greater demand for better surgical techniques for prophylaxis of surgical complications. Filling the bladder is a good option such as adding bilateral hypogastric artery ligation before cesarean hysterectomy (we are currently recruiting prospective data) or routine use of bulldog clamp on bilateral hypogastric arteries in cases with percreta
3
. We believe in parallel with Dr. Matsubara that obstetric surgeons may prefer to fill the bladder prior to surgery as a useful technique where anatomical landmarks are unclear, especially in cases with placenta percreta.