Standardization of recipient surgery for uterus transplantation.

OBJECTIVE: To present a standardized surgical technique of recipient transplant surgery for uterus transplantation (UTx).

DESIGN: Step-by-step description of surgical technique and live-action narrated surgical footage showing uterus recipient surgery in UTx.

SUBJECTS: Uterus transplantation can become a standard option for patients with absolute uterine factor infertility and their families (1, 2). Thirty-six uterus cases of UTx have been performed at Baylor University Medical Center in Dallas (January 2025). Most uterus recipients to date have a congenital absence of the uterus (Mayer-Rokitansky-Küster-Hauser syndrome [MRKH]). Our team has established standard methods for donor surgery and uterine graft back-table techniques. Because the uterus recipient surgery is typically performed using an open approach, high-quality educational videos of UTx are scarce. To aid institutions interested in initiating UTx, an educational video demonstrating our standardized recipient surgery is essential. This video shows the surgical procedure in a 39-year-old previously healthy woman with MRKH. The vascular nomenclature recommended by the United States Uterus Transplant Consortium is used in the manuscript (3).

EXPOSURE: Uterus transplant recipient surgeries are performed via laparotomy and are significantly shorter than the living donor hysterectomies, averaging 4-5 hours (4). The operative steps performed are as follows: 1) exposure of the external iliac vessels; 2) exposure of the vaginal anastomosis site; 3) graft implantation and vascular anastomosis; 4) vaginal transection and anastomosis; and 5) fixation of the uterus and ovaries. Steps 1-2 are performed jointly by the gynecology surgeon and transplant surgeon; step 3, involving the anastomosis of blood vessels, is conducted by the transplant surgeon. Although steps 1, 2, 4, and 5 are not particularly challenging for an experienced gynecologic oncology surgeon, the vascular anastomosis in step 3 is delicate. This anastomosis involves suturing blood vessels smaller than those used in kidney and liver transplants, using 7-0 monofilament for the arterial and 8-0 monofilament for the venous anastomosis. After reperfusion of the uterine graft, the vaginal anastomosis is completed, which is where most of the bleeding occurs during surgery. For this step (step 4), we use continuous suturing from the 3 to 9 o'clock positions. The vaginal approach is preferred because of the challenging anatomy, particularly in patients with MRKH, where the foreshortened vagina lies deep in the pelvis. Continuous sutures are used for hemostasis in the posterior vaginal wall, where venous blood flow is abundant. To attempt prevention of vaginal structuring, the anterior vaginal wall is sutured interrupted. Step 5 includes fixation of the uterus and ovaries. A trained gynecology surgeon is essential, because the technique may vary depending on the condition of the patient with MRKH. Before implantation of the uterine graft in the recipient, the uterus is removed from a living or deceased donor and subsequently placed on ice and flushed with cool preservation fluid on the back table. The back table is a sterile area used in transplantation surgery where the organ is prepared for transplantation. Preparation includes trimming and potential 86 reconstructions of the vessels that will be used. The living donor hysterectomy and the back table procedure 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 5 days. The uterus was successfully implanted with a successful pregnancy outcome.

CONCLUSION: Our standardized uterus recipient surgery technique minimizes harm to the recipient. Furthermore, the technique does not compromise the uterine graft function and pregnancy outcome. Further studies and more educational content using video will be key to the widespread adoption of uterine transplantation.