Outcome of Recipient Surgery and 6-Month Follow-Up of the Swedish Live Donor Robotic Uterus Transplantation Trial

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.

Keywords: human; infertility; recipient; transplantation; uterus.

Figure 1

(A) Schematic graph illustrating surgical preparations in the recipient prior to the graft entering the pelvis. B = bladder, V = vaginal vault, R = rectum. (B) Principles for vascular anastomosis. The anterior portions of the internal iliac arteries are anastomosed end-to-side to the external iliac arteries. On the right side of the pelvis, a segment of the internal iliac vein, in continuation with the deep uterine vein, is anastomosed end-to-side to the external iliac vein. On the same side, the proximal part of the utero-ovarian vein is directly anastomosed end-to-side to the external iliac vein. On the left side of the pelvis, a segment of the internal iliac vein, in continuation with the deep uterine vein, is anastomosed end-to-side to the external iliac vein. On the same side, the proximal part of the utero-ovarian vein is anastomosed end-to-end to a branch of the donor internal iliac vein.

Figure 2

(A) Ectocervical biopsy 3 months after UTx (patient #1). There is a dense, mixed inflammatory infiltrate at the stromal–epithelial interface. In some areas, the vacuolization of basal epithelial cells is seen (arrows). These morphological changes are consistent with Grade 1 rejection. Bar = 250 micrometer. (B) Uterine graft explanted 1 month after UTx (patient #8). The large picture shows a scanned whole mount slide of the uterine cavity and wall. The left-hand side panel of higher magnification pictures shows (top) the outer myometrial wall with viable myometrium and an artery containing red blood cells. Middle: myometrium with dense neutrophilic infiltrate and necrotic tissue. Bottom: the uterine cavity with necrotic tissue, without viable endometrial glands. Bar = 10 mmeter.