Objective: To compare the estimated blood loss (EBL) and surgical outcomes between the pregnancy with placenta accreta spectrum (PAS) who underwent cesarean hysterectomy with and without radiological intervention. Design: Retrospective cohort study Setting: Study site in tertiary care, university hospital in Thailand. Population: Pregnant women with pathological proven PAS Methods: Patient who undergone cesarean hysterectomy were defined as controls (n=21) and who undergone cesarean hysterectomy with radiological intervention were defines as intervention group (n=23). Main Outcome Measures: The primary outcome was EBL. The secondary outcomes were transfusion requirement, operation time, postoperative intensive care unit (ICU) admission, adverse surgical outcomes, neonatal Apgar score, and hospital cost. Result: Compared with the control group, pregnancy in the intervention group had significantly lower EBL (3590.48 vs 1993.48 mL; p = 0.017) and total blood component requirement (6 vs 1 units; p = 0.002) but longer operation time (232.61 vs 166.19 min; p = 0.002) and higher hospital cost (4,290 vs 1,844 USD; p < 0.001). Postoperative length of stay, ICU admission, and adverse surgical outcomes were not significantly different. Apgar score at 1-min and 5-min were not significantly different. Conclusions: Cesarean hysterectomy with adjunctive pelvic devascularization significantly improved surgical outcomes in pregnancy with PAS by reducing blood loss by 44.5% and transfusion decreased by 83.3%. The challenges included requirement for a multidisciplinary team, especially intervention radiologists and hybrid operating room, longer operation time, and higher hospital expense. Funding: none Keywords: placenta accreta spectrum, radiological intervention, cesarean hysterectomy, massive postpartum hemorrhage, adverse surgical outcome