Outcome and Surgical Technique of Robot-Assisted Living Donor Hysterectomy for Uterus Transplantation

Objective

To show our standardized minimally invasive living uterus donor surgery for uterus transplantation and present the outcome.

Setting

Uterus transplantation (UTx) is a novel clinical treatment for women with absolute uterine factor infertility who hope to have children [1, 2, 3, 4]. While the outcomes for recipients and live births are crucial concerns, it is equally important to ensure that the living donor surgery is minimally invasive and safe. However, Uterus vessels are suboptimal due to small caliber, thin walls, and variable anatomic presentation [5]. Since living donors are healthy individuals, improving surgical procedures to reduce invasiveness and complications is essential.

Participants

Eighteen living donors performed by robot-assisted hysterectomy for UTx.

Interventions

The steps of the robotic-assisted living donor hysterectomy presented are:

1. Ligation of the round ligaments and exposure of the retroperitoneal space.

2. Dissection of the superior uterine veins.

3. Dissection of the uterine arteries and the inferior uterine veins.

4. Dissection of the ureters, bladder, and rectum.

5. Vaginotomy and transection of the vessels.

6. Transvaginal uterine graft extraction and closure of the vaginal cuff.

The results were analyzed in two phases: cases performed between 2019 and 2022, (n = 8), and cases performed between 2023 and 2024 (n = 10). There was no significant difference in the background characteristics of the patients between both groups. However, surgical time and complication rates improved in the later phase (Supplementary Tables 1 and 2). At a 1-year follow-up, donors reported no concerns with sexual activity and no complications. Additionally, ovarian hormone levels remained stable with no significant decreases observed.

Conclusions

While the primary goal of UTx is to achieve live birth, it is crucial that donor surgery remains safe and efficient. All uteri were successfully implanted in recipients, so far resulting in 10 successful live births. Our standardized technique represents a safe approach that minimizes donor harm and allows for the preservation of donor ovaries. Although our standardized technique represents a safe approach that minimizes living donor harm and allows for the preservation of donor ovaries, it is important that this procedure is only carried out in centers with vast experience with transplantation and gynecological surgery. Our data shows a steep learning curve and better results with growing experience.