Uterus transplantation from a deceased donor

Uterine Transplant Optimization From a Preclinical Donor Model With Controlled Cardiocirculatory Arrest

Background

Uterus transplantation from deceased donors offers a promising solution to the organ shortage, but optimal preservation methods are crucial for successful outcomes. Our primary objective is to conduct an initial assessment of the contribution of oxygenated hypothermic perfusion in uterine transplantation.

Methods

We performed a preclinical study on a porcine model of controlled donation after circulatory death (60 min warm ischemia). Ten uterus grafts were preserved for 12 h using static cold storage or hypothermic machine perfusion (VitaSmart device, perfusion pressure at 15 mm Hg). Subsequently, they were reperfused using ex vivo normothermic machine perfusion (Liverassist, perfusion pressure at 30 mm Hg) with oxygenated autologous blood to assess early ischemia/reperfusion injury. Not only resistance index assessment and oxygenation evaluation but also immunochemistry and gene expression analysis were performed.

Results

This study demonstrates the feasibility of using hypothermic machine perfusion for uterine graft preservation, showing improvements in reperfusion capacity (decrease of resistance indexes; P < 0.0001) and tissue oxygenation (higher oxygen level) compared with static cold storage.

Conclusions

These findings provide valuable insights for further research and refinement of uterine transplantation procedures.

Evolution and Transformation of Uterine Transplantation: A Systematic Review of Surgical Techniques and Outcomes

BACKGROUND

 Uterine transplantation (UTx) is acknowledged to be on the second (2A) of five steps of development in accordance with the staging system for the evaluation of surgical innovations. Accordingly, we aimed to systematically review the available evidence of the surgical techniques and outcomes of UTx in terms of graft survival.

METHODS

 A comprehensive search was conducted across PubMed Medline, Cochrane-EBMR, Scopus, Web of Science, and CENTRAL through November 2020.

RESULTS

 Forty studies, reporting 64 recipients and 64 donors, satisfied inclusion criteria. The surgical time and the estimated blood loss were 515 minutes and 679 mL for graft procurement via laparotomy, 210 minutes and 100 mL for laparoscopic-assisted graft harvest, and 660 minutes and 173 mL for robotic-assisted procedures, respectively. Urinary tract infections (n = 8) and injury to the urinary system (n = 6) were the most common donor complications. Using the donor's internal iliac system, two arterial anastomoses were performed in all cases. Venous outflow was accomplished through the uterine veins (UVs) in 13 cases, a combination of the UVs and the ovarian/uteroovarian veins (OVs/UOVs) in 36 cases, and solely through the OVs/UOVs in 13 cases. Ischemia time was 161 and 258 minutes when using living donors (LD) and deceased donors (DD), respectively. Forty-eight uteri were successfully transplanted or fulfilled the purpose of transplantation, 41 from LDs and 7 from DDs. Twenty-five and four live childbirths from LDs and DDs have been reported, respectively.

CONCLUSION

 UTx is still experimental. Further series are required to recommend specific surgical techniques that best yield a successful transplant and reduce complications for donors and recipients.

The changing paradigm of ethics in uterus transplantation: a systematic review

The first uterus transplantation was performed in 2000. As key milestones are reached (long-lasting graft survival in 2011, and first birth from a transplanted womb in 2014), the ethical debate around uterus transplant evolves. We performed a systematic review of articles on uterus transplantation. Ethical themes were extracted and categorized according to four bioethical principles. Papers were divided into time periods separated by key events in uterus transplant history: Phase I (first technical achievement, 2002-2011), Phase II (clinical achievement, 2012-2014), and Phase III (after the first childbirth, 2015-2018). Eighty-one articles were included. The majority of ethics papers were published in Phase III (65%, P < 0.0001), that is after the first birth. Eighty percent of papers discussed nonmaleficence making it the most discussed principle. The first birth acted as a pivotal point: nonmaleficence was discussed by a lower proportion of articles (P = 0.0073), as was beneficence (P = 0.0309). However, discussion of justice increased to become the most discussed principle of the time period (P = 0.0085). The ethical debate surrounding uterus transplantation has evolved around landmark events that signify scientific progress. As safety and efficacy become evident, the focus of ethical debate shifts from clinical equipoise to socioeconomic challenges and equitable access to uterus transplantation.