Work

Where Are We Now? Systematic Review of Surgical Techniques and Outcomes of Uterine Transplantation

Year: 2021

Type: review

Abstract: PURPOSE: Uterine Transplantation (UTx) is acknowledged to be on the second of five steps of development in accordance with the staging system for the evaluation of surgical innovations. Accordingly, we systematically reviewed the available evidence on the surgical particularities and outcomes of UTx. METHODS: A comprehensive search was conducted across PubMed, Cochrane EBMR, SCOPUS, Web of Science, and Cochrane CENTRAL through November 2020. Data regarding the surgical techniques, vascular anastomoses, surgical outcomes, and reproductive medicine were extracted. RESULTS: Forty studies, including 64 recipients and 64 donors, satisfied the inclusion criteria. Fifty-three uteri were retrieved from living donors (LD) and eleven from deceased donors (DD). The average surgical time and the estimated blood loss (EBL) were 515 minutes and 679 mL for allograft procurement via laparotomy, 210 minutes and 100 mL for laparoscopic-assisted allograft harvest, and 660 minutes and 173 mL for robotic-assisted procedures, respectively. Urinary tract infections (UTIs) (n = 8) and injury to the urinary system (n = 6) were the most common donor complications. The average surgical time and EBL of recipients were 311 minutes and 568 mL, reported in 44 recipients. All uteri were placed in an orthotopic position. The average time for anastomosis of vessels was 59 minutes, reported in 17 patients. The arterial anastomoses were accomplished with 2 uterine arteries (UA) with/without the anterior division of the IIA in 36 cases, with two UA with a segment or patch of the IIA in 24 cases, and two UA with a conduit or a reconstruction in 2 cases. Arterial anastomoses were performed end-to-side in 58 cases and to the recipient’s external iliac artery in 59 cases. Venous outflow was accomplished through the uterine veins (UVs) in 13 cases, a combination of the UVs and the ovarian/utero-ovarian veins (OVs/UOVs) in 36 cases, and solely through the OVs/UOVs in 13 cases. Ischemia time was 161 minutes and 258 minutes when using LD and DD, respectively. Overall, 75% (n = 48) of allografts have survived or fulfilled the purpose of transplantation. Sixteen allografts (25%) failed due to mechanical occlusion of the uterine vessels (n = 1), arterial obstructive disease (n = 1), arterial or/and venous thrombosis (n = 11), or fungal (n = 1), viral (n = 1) or bacterial infection (n = 1). Four allograft failures were from DDs (36.4%) and twelve from LDs (22.6%). Recipient complications included UTIs (n = 5); retroperitoneal hematoma (n = 1), significant blood loss (n = 3), bladder injury with intraoperative bladder repair (n = 1), stenosis of graft-to-vagina anastomosis (n = 6), ureterovaginal fistula (n = 1), persistent postoperative anemia (n = 1), and genital tract infections with Enterococcus, Enterobacter, and Klebsiella (n = 2). Twenty-eight recipients from LDs and six from DDs have been pregnant at least once. Twenty-five live childbirths (47.2%) from LDs and four live childbirths (36.4%) from DDs have been reported; nevertheless, two recipients have delivered a second newborn. CONCLUSIONS: UTx, although feasible, is still experimental. This procedure is associated with significant risk, with the potential for complications in both donors and recipients and a considerable risk of allograft failure. In this scenario, an interdisciplinary approach for UTx is required, especially during reperfusion and the early postoperative period.

Source: Plastic & Reconstructive Surgery Global Open

DOI: 10.1097/01.gox.0000799464.53713.a2