Placenta accreta spectrum represents one of the most challenging scenarios in complex cesarean delivery, in which abnormal placental adherence coexists with a scarred myometrium. It remains a leading cause of severe obstetric hemorrhage, maternal morbidity, and peripartum hysterectomy. Although prenatal diagnosis has improved substantially, predicting surgical complexity and selecting the most appropriate operative strategy remain challenging. Traditional concepts centered on the depth of placental invasion do not consistently explain the marked variability in surgical findings or identify which patients are suitable candidates for uterine-preserving surgery. Emerging evidence suggests that PAS is better understood as a disorder of uterine scar remodeling, in which lesion topography, lower uterine segment anatomy, cervical involvement, and pelvic vascular remodeling are major determinants of operative complexity. These advances have shifted the role of prenatal imaging beyond confirming the diagnosis of placenta accreta spectrum toward defining lesion topography and anticipating the anatomic and vascular findings that influence surgical planning. In parallel, surgical staging and individualized operative strategies have expanded the range of treatment options beyond routine peripartum hysterectomy in selected patients. In this Clinical Opinion, we synthesize current evidence linking advances in PAS biology, prenatal imaging, vascular anatomy, and surgical management into a unified clinical framework. We discuss how topography-based ultrasound assessment, combined with surgical staging, may facilitate multidisciplinary planning, improve prediction of operative complexity, and support individualized selection between uterine-preserving surgery and peripartum hysterectomy. Although several of these concepts have previously been described independently, integrating them into a single decision-making framework may help clinicians translate emerging evidence into everyday practice while highlighting priorities for future research and standardized training.