Abstract 
Background and aim: the management of PAS during CD is already a challenge owing to the presence of maternal comorbidities and suspected mortality. This study aimed to determine proper timing of bladder dissection during CD thus improving the outcome via decreasing blood loss and urinary tract injuries.  
Methods: a randomized controlled trial included 100 patients planned for elective CD at Mansoura University Hospitals, Egypt from July 2020 to July 2021. They were assigned into two equal groups. Group 1, bladder was dissected earlier before uterine incision meanwhile in group 2, bladder was dissected late after uterine incision and fetal extraction. Outcome measures were intra and postoperative blood loss, pre and postoperative hemoglobin levels, associated urinary tract injuries and emergent hysterectomy.   
Results: baseline patients' characteristics did not show any statistically significant change in both groups [p>0.05]. The mean estimated blood loss during and after cesarean delivery was significantly lower in group 2 compared to group 1 (2654.12 ± 1412.48 ml vs. 3356.2 ± 1906.63, p=0.039). Similarly, the need for additional packed RBCs and plasma were significantly higher in group 1 than group 2 (p values are 0.001 and 0.046 respectively). Also, there was more urinary bladder injuries and emergent hysterectomy in group 1 compared to group 2 (10 vs 4 cases, p =0.04 and 12 vs 5 cases, p =0.02 respectively). Therefore, the mean operative time (±SD) is longer in group 1 (p = 0.02). On the other hand, there were irrelevant differences regarding the need for platelet or Voluven transfusion, postoperative Hb level, maternal or neonatal ICU admission, PPH, fever or hospital stay time (p values >0.05).   
Conclusion: surgical management of PAS by CD proved that bladder dissection after delivery of the baby is much better in terms of decreasing blood loss, urinary tract injuries and emergent hysterectomy than if done earlier.