Possible role of DaVinci Robot in uterine transplantation

Abstract

The first human uterine transplantation was attempted in Saudi Arabia in 2002. However, necrosis of the graft occurred 99 days after surgery; thus, the attempt failed (1) that was followed by a lot of criticism. The second case was a 21-year-old patient with Mayer-Rokitansky-Kuster-Hauser syndrome in Turkey who achieved normal cycles and an implanted embryo post transplantation (2). Moreover, recently nine women in Sweden successfully received a transplanted uterus (3). The 6-month results of the first clinical uterus transplantation trial revealed that the durations of donor and recipient surgery ranged from 10 to 13 h and from 4 to 6 h, respectively. No immediate perioperative complications occurred in any of the recipients, and after 6 months, seven uteri remained viable with regular menses. Mild rejection episodes occurred in four of these patients that were effectively reversed by corticosteroids. The two losses of grafts were because of acute bilateral thrombotic uterine artery occlusions and persistent intrauterine infection (3). The indications of uterine transplantation include women with a history of hysterectomy at a young age for malignant uterine tumors or benign diseases, such as fibroids or adenomyosis; history of emergency peripartum hysterectomy; and history of congenital uterine infertility e.g., Mayer-Rokitansky-Kuster-Hauser syndrome (4). Robotic surgery became a common technique used by gynecological surgeons over the last decade (5, 6). Three-dimensional view, improved dexterity, infiltration of a surgeon's natural tremor, and less operator fatigue are the main advantages of robot-assisted surgery (7,8). In contrast, robotic surgery has some drawbacks, among which increased costs, requirement for a larger operating room because of the bulky machinery, and necessity of a specific training for the surgical team. In the literature, only 12 cases of uterine transplantation have been described, all of which have been approached with the open technique (1-3, 9). The robot-assisted approach was never described or proposed in the field of uterus transplantation. Therefore, we suggest a new (robotic) approach in the already challenging uterine transplantation. The aim is to form a multicenter collaboration group to organize protocols in animal models as well as humans after ethical approval to clarify the possible role of da Vinci ® Robot in uterine transplantation. Two different protocols are proposed: initially, one for animal models, such as sheep or non-human primates and the second one for humans after the possible success in the animal models. Specifically, the sheep and non-human models have been demonstrated to be superior models to that of the pig because the uterus has a relatively smaller size and the vasculature is of similar dimension as that of humans (10, 11). The lack of experience in the field and the small number of suitable candidates for the procedure renders the need of a multicenter approach essential. The surgical technique should include the following steps: -Hysterectomy of ...

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

“…Robotic surgery has become a common technique for gynecological surgeons during the past decade (21,22). Some of the advantages of robotic surgery are a three-dimensional high-definition view, efficient microsuturing through laparoscopic ports, wristed instruments with seven degrees of freedom for improved dexterity, infiltration of a surgeon's natural tremor, and less operator fatigue (23)(24)(25). We have performed >1,000 robotic radical hysterectomies.…”

Clinical applications of uterus transplantation in China: Issues to take into consideration

“…Also, the first human uterus transplant using laparotomy or laparoscopy or robot is also based on the status of surgery and medical technology in each unit. 25 Spanish and Japanese teams favoring the Swedish LD model, whereas teams in Turkey, Italy, France, Belgium and the UK prefer using the DD. 26 As summarized in Table 1, living donors have to face the risk of hysterectomy for uterus retrieval, including massive bleeding, ureterovaginal fistula, ureter laceration, bladder hypotonia and ovarian dysfunction et al But an observational study revealed that it is feasible to retrieve a uterus safely from a LD regarding medical complications and psychosocial well beings of the donors.…”

“…Currently, there is no consensus on using the live donor (LD) or deceased donor (DD) for UTx, the choice is institution‐dependent and should be made based on the risk–benefit assessment from the research team (Figure ). Also, the first human uterus transplant using laparotomy or laparoscopy or robot is also based on the status of surgery and medical technology in each unit . Spanish and Japanese teams favoring the Swedish LD model, whereas teams in Turkey, Italy, France, Belgium and the UK prefer using the DD …”

Robotics in reproduction, fertility preservation, and ovarian transplantation

“…Another potential area of application of robotic assistance is in uterine transplantation. Though all 12 reported cases of uterine transplantation were via the open technique, robotic assistance might find future applications in this area as well 51,52…”