Uterine transplantation, abdominal trachelectomy, and other reproductive options for cancer patients

Multispectral imaging of organ viability during uterine transplantation surgery in rabbits and sheep

Uterine transplantation surgery (UTx) has been proposed as a treatment for permanent absolute uterine factor infertility (AUFI) in the case of the congenital absence or surgical removal of the uterus. Successful surgical attachment of the organ and its associated vasculature is essential for the organ’s reperfusion and long-term viability. Spectral imaging techniques have demonstrated the potential for the measurement of hemodynamics in medical applications. These involve the measurement of reflectance spectra by acquiring images of the tissue in different wavebands. Measures of tissue constituents at each pixel can then be extracted from these spectra through modeling of the light–tissue interaction. A multispectral imaging (MSI) laparoscope was used in sheep and rabbit UTx models to study short- and long-term changes in oxygen saturation following surgery. The whole organ was imaged in the donor and recipient animals in parallel with point measurements from a pulse oximeter. Imaging results confirmed the re-establishment of adequate perfusion in the transplanted organ after surgery. Cornual oxygenation trends measured with MSI are consistent with pulse oximeter readings, showing decreased StO2 immediately after anastomosis of the blood vessels. Long-term results show recovery of StO2 to preoperative levels.

Human Uterus Retrieval From a Multi-Organ Donor

OBJECTIVE

To determine if a uterus can be retrieved for reproductive organ transplantation and to describe the surgical technique.

METHODS

We participated in a local organ donor network retrieval team for over 6 months. Heart-beating, brain-dead multi-organ donors were identified through an existing donor network following routine protocols.

RESULTS

After institutional review board and organ donor network approval of the uterus transplantation project, approximately 1,800 eligible organ donors were identified as required by legislation. Multi-organ procurement surgery took place in approximate 150 of these, with nine specifically consented for the uterus retrieval. Regularly performed multi-organ transplantation retrievals included the uterus without complications in eight donors. Pedicles used included the ovarian, uterine, or internal iliac vessels. After retrieval, serial histology sections throughout the period of cold ischemia, taken every 15-30 minutes, showed no signs of change over 12 hours of cold ischemia.

CONCLUSION

The human uterus can be obtained from local organ donor networks using existing protocols.

LEVEL OF EVIDENCE

III.

A fertility-preserving option in early cervical carcinoma: laparoscopy-assisted vaginal radical trachelectomy and pelvic lymphadenectomy

OBJECTIVE

Laparoscopic vaginal radical trachelectomy is a fertility-preserving alternative to radical hysterectomy or chemoradiation in young women with stage IA2 to IB cervical cancers. The aim of this study is to describe the feasibility and outcome of laparoscopic radical vaginal trachelectomy and pelvic lymphadenectomy in women treated with early cervical cancers who wish to maintain fertility.

STUDY DESIGN

From August 2000 through December 2004, 16 patients were offered this procedure. Patients were selected for this treatment on the basis of favorable cervical tumors and a desire to maintain fertility. Laparoscopic pelvic lymphadenectomies were performed in all patients. Vaginal radical trachelectomy was performed immediately if removed lymph nodes were negative. Obstetrical and oncological outcomes were evaluated.

RESULTS

Sixteen women underwent this procedure. The mean operative time was 142 min (115-178 min), with a mean blood loss of 180 ml (120-230 ml), and the average hospital stay was 6.7 days. No intraoperative or postoperative complications occurred. With an average follow-up of 28.2 months, there have been no recurrences. Five pregnancies have subsequently occurred, with two third-trimester deliveries, two miscarriages at 24 and 26 weeks' gestation, and one patient is currently 18 weeks' pregnant.

CONCLUSIONS

Laparoscopy-assisted radical vaginal trachelectomy is an adequate treatment, with its minimally invasive procedure and shorter recovery time, for early-stage cervical cancer in women who wish to preserve fertility. However, fertility issues remain the largest unanswered problem with this technique.

Complications after fertility-preserving radical trachelectomy

OBJECTIVE

We report a case of cervical cancer treated by radical trachelectomy complicated by pelvic inflammatory disease, tubo-ovarian complex, and infertility.

DESIGN

Case report.

SETTING

Tertiary referral university hospital.

PATIENT(S)

A 35-year-old with stage IB1 cervical cancer underwent an uneventful radical vaginal trachelectomy. Three years later she presented with pelvic pain and fever after a new partner. Cervical chlamydia was positive, and sonography showed bilateral complex adnexal masses. Her symptoms resolved with prolonged IV, followed by oral, antibiotics. Temperature, cultures, and blood tests have all normalized but her sonogram demonstrates persistent bilateral hydrosalpinx. She has not conceived and underwent laparoscopic salpingectomy prior to IVF. She remains cancer free.

INTERVENTION(S)

Radical vaginal trachelectomy, salpingectomy and assisted reproductive techniques.

MAIN OUTCOME MEASURE(S)

Cancer disease status and fertility preservation.

RESULT(S)

Three years later, the patient remains cancer free but has been unable to conceive or carry a pregnancy.

CONCLUSION(S)

Fertility-preserving cancer treatments are relatively new. Complications may be encountered that must be reported, collected, and analyzed to maximize cancer cure and fertility preservation.

Short-term ischaemic storage of human uterine myometrium--basic studies towards uterine transplantation

BACKGROUND

Transplantation of the uterus has been suggested as a possible future treatment of absolute uterine infertility. The tolerability of human uterine tissue to cold ischaemic storage was tested in the present study.

METHODS

Small tissue samples of human uteri were subjected to cold (4 degrees C) ischaemia (6 and 24 h) in Ringer acetate (RIN), the intracellular-like University of Wisconsin solution (UW) or the extracellular-like Perfadex solution (PER). The ability of myometrial strips to contract, histology by light and electron microscopy as well as tissue concentrations of glutathione, ATP and protein were used as parameters to detect cold ischaemic injuries.

RESULTS

Contractile ability and response to prostaglandin F(2alpha) (PGF(2alpha)) was better preserved after 6 h cold ischaemia in UW and PER in comparison with the other groups. Histological examination did not reveal any major changes after 6 and 24 h cold ischaemic storage in UW and PER solutions, while specimens stored in RIN for 24 h displayed degenerative changes on the electron microscopy level. UW and PER preserved ATP concentrations significantly better than RIN. Myometrium stored in UW contained more total glutathione but also a larger proportion of oxidized glutathione than specimens stored in RIN and PER. Protein concentrations did not change with storage time in any of the solutions.

CONCLUSIONS

The results show that human uterine myometrial tissue is resistant towards cold ischaemia for at least 6 h if stored in UW and PER solutions.

Treatment of gonadal damage in recipients of allogeneic or autologous transplantation for haematological malignancies

Management of iatrogenic gonadal reproductive failure and sexual morbidity assumes a priority, especially in young recipients of high-dose chemotherapy and stem cell transplantation (SCT). Hormone replacement treatment (HRT) is beneficial for correction of sexual symptoms and osteoporosis in both sexes, especially in females. Sperm banking is the standard technique for preservation of fertility in adult and sexually mature adolescent males. Testicular tissue cryopreservation has a place in well-selected azoospermic adults and in mentally and sexually competent adolescents. In vitro fertilisation using superovulation with embryo-cryopreservation (for future embryo transfer) is the most tried method in female SCT recipients with good results. In mentally and sexually competent adolescents and adults without a partner, ovarian cortical tissue cryopreservation has a place for subsequent re-implantation to orthotopic or heterotopic sites. Gonadotrophin releasing hormone (GnRH) co-treatment during chemotherapy, is a promising method for the future. Although generally reassuring, continued monitoring of the offspring of SCT survivors and follow-up of all recipients of SCT is important for return of spontaneous or induced fertility.