Standardization of robot-assisted living donor hysterectomy for uterus transplantation.

Abstract

Objective: To present a standardized surgical technique of robot-assisted living donor hysterectomy for uterus transplantation with preservation of the donor ovaries.

Design: Step-by-step description of surgical technique and live-action narrated surgical footage showing uterus donor hysterectomy.

Subjects: Nineteen robot-assisted living donor hysterectomies for uterus transplantation have been performed at Baylor University Medical Center at Dallas (September 2024). This video shows the surgical procedure in a 33-year-old previously healthy woman. She had a history of a unilateral laparoscopic ovarian cystectomy, and her obstetric history included three term vaginal deliveries. She independently contacted our institution expressing interest in becoming a nondirected uterus donor and underwent comprehensive evaluation by a multidisciplinary transplant team, including medical and psychological assessment for suitability to donate. She explicitly stated desire for no further children.

Intervention: Robot-assisted living donor hysterectomy using the da Vinci Xi robotic system. Surgery was performed with the patient in Trendelenburg position (15°), using CO₂ pneumoperitoneum (<12 mm Hg), with a four robotic-arm arrangement. Ureteric stents were placed bilaterally, and indocyanine green was injected retrograde to facilitate ureter identification using firefly mode during dissection. Retraction of the uterus was performed with a uterine manipulator. The operative steps performed were as follows: ligation of the round ligaments and exposure of the retroperitoneal space; dissection of the superior uterine veins; dissection of the uterine arteries and the inferior uterine veins; dissection of the ureters, bladder, and rectum; vaginotomy and transection of the vessels; transvaginal uterine graft extraction using a Endo Catch retrieval system and closure of the vaginal cuff. Anatomical terms are used in the video and narration with reference to common gynecological practice. After removal of the uterus from the donor, the uterus was placed on ice on the back-table and flushed with cool preservation fluid. The back-table is a sterile area used in transplantation surgery where the organ is prepared for transplantation. Preparation includes trimming and potential reconstruction of the vessels that will be used. It is on the back-table where the final decision to go ahead with the transplant surgery is made by the uterus transplant team. The back-table procedure and implantation surgery can be seen in separate videos.

Main outcome measures: Hospital stay, perioperative and long-term complications, uterine graft viability, and recipient pregnancy outcome.

Results: No surgical complications occurred. The postoperative course was uneventful, with early mobilization. The length of hospital stay was 2 days. At a 1-year follow-up, the donor reported no concerns and sexual activity without complications. The uterus was successfully implanted to a recipient with successful pregnancy outcome.

Conclusion: Our standardized robot-assisted living donor hysterectomy technique represents a safe approach to minimize donor harm and allows for preservation of the donor ovaries. Furthermore, the technique does not compromise the uterine graft function and pregnancy outcome.