Abstract
Uterus transplantation has proved to be a feasible treatment for uterine factor infertility. Herein, we report on recipient outcome in the robotic uterus transplantation trial of 2017–2019. The eight recipients had congenital uterine aplasia. The donors were six mothers, one sister, and one family friend. Donor surgery was by robotic-assisted laparoscopy. Recipient surgery was by laparotomy and vascular anastomoses to the external iliacs. The duration (median (ranges)) of recipient surgery, blood loss, measured (left/right) uterine artery blood flow after reperfusion, and length of hospital stay were 5.15 h (4.5–6.6), 300 mL (150–600), 43.5 mL/min (20–125)/37.5 mL/min (10–98), and 6 days (5–9), respectively. Postoperative uterine perfusion evaluated by color Doppler showed open anastomoses but restricted blood distribution in two cases. Repeated cervical biopsies in these two cases initially showed ischemia and, later, necrosis. Endometrial growth was not seen, and hysterectomy was later performed, with pathology showing partly viable myometrium and fibrosis but necrosis towards the cavity. The other six patients acquired regular menstrual cyclicity. Surgery was performed in two patients to correct vaginal stenosis. Reversible rejection episodes were seen in two patients. In conclusion, the rate of viable uterine grafts during the initial 6-months of the present study (75%) leaves room for improvement in the inclusion/exclusion criteria of donors and in surgical techniques. Initial low blood flow may indicate subsequent graft failure.
Highlights
Uterus transplantation (UTx), as a treatment for absolute uterine factor infertility (AUFI), proved its feasibility by the first live birth after UTx in 2014 [1], which involved the fifth UTx procedure within the first clinical trial of UTx, with surgeries performed in Sweden in 2012–2013 [2]
The main difficulty of the laparotomy technique in donor hysterectomy is the dissection of the distal ureters and the deep uterine veins
Due to difficulties in the dissection of the deep uterine veins, the venous outflow sections procured on the graft were solely the complete utero-ovarian veins on both sides
Summary
Uterus transplantation (UTx), as a treatment for absolute uterine factor infertility (AUFI), proved its feasibility by the first live birth after UTx in 2014 [1], which involved the fifth UTx procedure within the first clinical trial of UTx, with surgeries performed in Sweden in 2012–2013 [2]. Our approach is to develop live donor robotic-assisted hysterectomy, with the procurement of the deep uterine veins and the proximal parts of the utero-ovarian veins [7] This restricted recovery of only parts of the upper uterine venous outflow sections is compatible with preserved ovarian function. The purpose of procurement of both upper and lower uterine outflows (deep uterine veins) is to have several venous outflow options for the evaluation of the outflow and quality of veins on the back-table in order to select the most suitable veins for venous anastomoses Along these lines, we performed eight robotic-assisted donor hysterectomies in 2017–2019 and found an obvious evolution of the surgical procedures within the trial [11]. This is the largest trial of the use of minimally invasive surgery in UTx
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