Simplification of the uterus retrieval for transplantation: robotic-assisted approach and the graft outflow using ovarian veins
Authors:
J. Matěcha 1,2
; R. Chmel jr. 2,3; M. Nováčková 3; Z. Pastor 3
; R. Chmel 3
Authors‘ workplace:
Gynekologicko‑porodnická klinika 1. LF UK a Nemocnice Na Bulovce, Praha, přednosta doc. MUDr. M. Zikán, Ph. D.
1; Lékařská fakulta UK, Plzeň
2; Gynekologicko‑porodnická klinika 2. LF UK a FN Motol, Praha, přednosta doc. MUDr. R. Chmel, Ph. D.
3
Published in:
Ceska Gynekol 2020; 85(5): 339-343
Category:
Review Article
Overview
Objective: An analysis of assumptions and current results of a robotic-assisted approach to minimize the surgical morbidity and maintain the postoperative quality of life in living donors of uterus undergoing graft retrieval for transplantation.
Design: Review article.
Setting: Department of Obstetrics and Gynaecology, First Faculty of Medicine, Charles University and Hospital Bulovka, Prague and Department of Obstetrics and Gynaecology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague.
Methods: Literature search using the Web of Science, Google Scholar and Pubmed databases with keywords: absolute uterine factor infertility, donor surgery, living donor, robotic-assisted hysterectomy and, uterus transplantation, and an analysis of the articles published in peer-reviewed journals with impact factor.
Results: The experience with open, laparoscopic and robotic-assisted nerve-sparing radical hysterectomies to maintain the quality of life in women undergoing surgery confirms the need to preserve hypogastric and pelvic splanchnic nerves, including the vesical branches of the pelvic plexus. Precise robotic dissection of the ureters and uterine arteries should prevent injury to these nerve structures even in the procurement of the uterus for transplantation. It should help to the reduction of postoperative side effects as the bladder and rectum evacuation disorders as well as sexual dysfunction in the living donors of uterus. The preparation of uterine veins is the most difficult, time-consuming and worst predictable part of the uterine retrieval. In comparison, the preparation of the ovarian veins is technically simpler as well as effective in venous outflow from the uterine graft.
Conclusion: The simplification of the technique of uterine graft retrieval in the living donor should be one of the basic steps to introduce uterine transplantation as a causal treatment of infertility in women without uterus. Robotic-assisted procurement of the uterus and, moreover, the use of venous outflow from the graft exclusively via ovarian veins could contribute to the higher availability of the uterine transplantation, particularly due to a better reproducibility of the procurement surgeries in the living donors.
Keywords:
absolute uterine factor infertility – living donor – nerve-sparing surgery – robotic-assisted hysterectomy – uterus trans-plantation
Sources
1. Brännström, M., Boccio, MV., Pittman, J. Uterus transplantation: the science and clinical update. Curr Opin Physiol, 2020, 13, p. 49–54.
2. Brännström, M., Dahm-Kähler, P., Kvarnström, N. Robotic-assisted surgery in live-donor uterus transplantation. Fertil Steril, 2018, 109(2), p. 256–257.
3. Brännström, M., Dahm-Kähler, P., Kvarnström, N., et al. Live birth after robotic-assisted live donor uterus transplantation. Acta Obstet Gynecol Scand, 2020, Mar 20. doi: 10.1111/aogs.13853.
4. Brännström, M., Johannesson, L., Bokström, H., et al. Livebirth after uterus transplantation. Lancet, 2015, 385(9968), p. 607–616.
5. Brännström, M., Johannesson, L., Dahm-Kähler, P., et al. First clinical uterus transplantation trial: a six-month report. Fertil Steril, 2014, 101(5), p. 1228–1236.
6. Diaz-Garcia, C., Akhi, SN., Wallin, A., et al. First report on fertility after allogenic uterus transplantation. Acta Obstet Gynecol Scand, 2010, 89, p. 1491–1494.
7. Ejzenberg, D., Andraus, W., Baratelli Carelli Mendes, LR., et al. Livebirth after uterus transplantation from a deceased donor in a recipient with uterine infertility. Lancet, 2019, 392(10165), p. 2697–2704.
8. Enskog, A., Johannesson, L., Chai, DC., et al. Uterus transplantation in the baboon: methodology and long-term function after autotransplantation. Hum Reprod, 2010, 25, p. 1980–1987.
9. Evans, EC., Matteson, KA., Orejuela, FJ., et al. Salpingo-oophorectomy at the time of benign hysterectomy: A systematic review. Obstet Gynecol, 2016, 128(3), p. 476–485.
10. Fageeh, W., Raffa, H., Jabbad, H., Marzouki, A. Transplantation of the human uterus. Int J Obstet Gynecol, 2002, 76, p. 245–251.
11. Chmel, R., Cekal, M., Pastor, Z., et al. Assisted reproductive techniques and pregnancy results in women with Mayer-Rokitansky-Küster-Hauser syndrome undergoing uterus transplantation: the Czech experience. J Pediatr Adolesc Gynecol, 2020, 26. pii: S1083–3188(20)30196-0. doi: 10.1016/j.jpag.2020.03.006.
12. Chmel, R., Novackova, M., Janousek, L., et al. Revaluation and lessons learned from a first 9 cases of a Czech uterus transplantation trial: four deceased donor and 5 living donor uterus transplantations. Am J Transplant, 2019, 19(3), p. 855–864.
13. Chmel, R., Novackova, M., Pastor, Z., Fronek, J. The interest of women with Mayer-Rokitansky-Küster-Hauser syndrome and laparoscopic Vecchietti neovagina in uterus transplantation. J Pediatr Adolesc Gynecol, 2018, 31(5), p. 480–484.
14. Chmel, R., Pastor, Z., Novackova, M., et al. Clinical pregnancy after deceased donor uterus transplantation: Lessons learned and future perspectives. J Obstet Gynaecol Res, 2019, 45(8), p. 1458–1465.
15. Johannesson, L., Enskog, A., Mölne, J., et al. Preclinical report on allogeneic uterus transplantation in non-human primates. Hum Reprod, 2013, 28, p. 189–198.
16. Johannesson, L., Koon, EC., Bayer, J., et al. DUETS (Dallas UtErus Transplant Study): Early outcomes and complications of robot-assisted hysterectomy for living uterus donors. Transplantation, 2020, 2. doi: 10.1097/TP.0000000000003211.
17. Kristek, J., Johannesson, L., Testa, G., et al. Limited availability of deceased uterus donors: a transatlantic perspective. Transplantation, 2019, 103(12), p. 2449–2452.
18. Mihara, M., Kisu, I., Hara, H., et al. Uterus autotransplantation in cynomolgus macaques: intraoperative evaluation of uterine blood flow using indocyanine green. Hum Reprod, 2011, 26, p. 3019–3027.
19. Mihara, M., Kisu, I., Hara, H., et al. Uterus autotransplantation in cynomolgus macaques: the first case of pregnancy and delivery. Hum Reprod, 2012, 27, p. 2332–2340.
20. Mölne, J., Broecker, V., Ekberg, J., et al. Monitoring of human uterus transplantation with cervical biopsies: a provisional scoring system for rejection. Am J Transplant, 2017, 17(6), p. 1628–1636.
21. Novackova, M., Pastor, Z., Chmel, R. Jr., et al. Urinary tract morbidity after nerve-sparing radical hysterectomy in women with cervical cancer. Int Urogynecol J, 2020, 31, p. 981–987.
22. Racho El-Akouri, R., Kurlberg, G., Dindelegan, D., et al. Heterotopic uterine transplantation by vascular anastomosis in the mouse. J Endocrinol, 2002, 174, p. 157–166.
23. Ramani, A., Testa, G., Ghouri, Y., et al. DUETS (Dallas UtErus Transplant Study): Complete report of 6-months and initial 2-year outcomes following open donor hysterectomy. Clin Transplant, 2020, 34(1), e13757.
24. Steptoe, RC., Edwards, RG. Birth after a reimplantation of human embryo. Lancet, 1978, 2, p. 366.
25. Testa, G., Koon, EC., Johannesson, L., et al. Living donor uterus transplantation: A single center´s observations and lessons learned from early setbacks to technical success. Am J Transplant, 2017, 17(11), p. 2901–2910.
26. Testa, G., McKenna, GJ., Gunby, RT. Jr., et al. First live birth after uterus transplantation in the United States. Am J Transplant, 2018, 18(5), p. 1270–1274.
27. Wei, L., Xue, T., Tao, KS., et al. Modified human uterus transplantation using ovarian veins for venous drainage: the first report of surgically successful robotic-assisted uterus procurement and follow-up for 12 months. Fertil Steril, 2017, 108(2), p. 346–351.e1.
28. Wranning, CA., El-Akouri, R., Lundmark, C., et al. Auto-transplantation of the uterus in the domestic pig (Sus scrofa): surgical technique and early reperfusion events. J Obstet Gynecol Res, 2006, 32, p. 358–367.
29. Wranning, CA., Marcickiewicz, J., Enskog, A., et al. Fertility after autologous ovine uterine-tubal-ovarian transplanration by vascular anastomosis to the external iliac vessels. Hum Reprod, 2010, 25, p. 1973–1979.
30. Zegers-Hochschild, F., Adamson, GD., de Mouzon, J., et al. International Committee for Monitoring Assisted Reproductive Technology; World Health Organization. Hum Reprod, 2009, 24(11), p. 2683–2687.
Labels
Paediatric gynaecology Gynaecology and obstetrics Reproduction medicineArticle was published in
Czech Gynaecology
2020 Issue 5
Most read in this issue
- Clinical significance of routine ultrasound screening of fetal growth restriction in third trimester of pregnancy
- Bilateral salpigektomy as a sterilization method – ovarian cancer prevetion and a rare complication
- Complete hydatidiform mole in perimenopausal patient imitating uterine cancer
- Cervical mucus and its role in reproduction