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Evolution of surgical steps in robotics-assisted donor surgery for uterus transplantation: results of the eight cases in the Swedish trial

Open AccessPublished:August 19, 2020DOI:https://doi.org/10.1016/j.fertnstert.2020.05.027

      Objective

      To perform a stepwise development of the surgical method for robotics-assisted laparoscopy in donor hysterectomy for uterus transplantation (UTx), a unique treatment for absolute uterine-factor infertility.

      Design

      Prospective observational study.

      Setting

      University hospital.

      Patient(s)

      Eight donors, aged 38–62 years, underwent surgery for retrieval of the uterus and vasculature.

      Intervention(s)

      Robotics-assisted laparoscopy was performed in donors for 6–7 h with video recording. Conversion to laparotomy was performed for last parts of retrieval surgery.

      Main Outcome Measure(s)

      Description, evaluation, and timing of 12 specific surgical steps, as well as surgical outcomes and complications.

      Result(s)

      There was a progression during the course of eight surgeries. In the initial two cases, seven and six items were completed with robotics compared with all 12 items in the last three procedures. The passive surgical time decreased from ∼20% in the first four cases to ∼8% in the last three procedures. The estimated median (range) blood loss, total surgical time, and length of hospital stay were, respectively, 125 mL (100–600), 11.25 h (10–13), and 5.5 days (5–6). Two reversible complications occurred: One patient acquired pressure alopecia, and one developed pyelonephritis.

      Conclusion(s)

      The study demonstrates a clear evolution of a strategy toward fully robotic donor surgery in UTx. This is likely to become the main approach in donor surgery of live UTx donors.

      Clinical Trial Registration Number

      NCT02987023
      Evolución de los pasos quirúrgicos en cirugía asistida por robótica de donante para trasplante de útero: resultados de la ocho casos en el estudio sueco

      Objetivo

      Realizar un desarrollo escalonado del método quirúrgico para laparoscopia asistida por robótica en histerectomía de donante para trasplante de útero (UTx), un tratamiento único para la infertilidad absoluta por factor uterino.

      Diseño

      Estudio observacional prospectivo.

      Entorno

      Hospital universitario.

      Paciente (s)

      Ocho donantes, de 38 a 62 años de edad, se sometieron a cirugía para la extracción del útero y la vasculatura.

      Intervención (es)

      Se realizó laparoscopia asistida por robótica en los donantes durante 6-7 h con grabación de video. La conversión a laparotomía fue realizada para las últimas partes de la cirugía de extracción de la pieza quirúrgica.

      Principales medidas de resultado

      descripción, evaluación y tiempo de 12 pasos quirúrgicos específicos, así como resultados quirúrgicos y complicaciones.

      Resultado (s)

      Hubo una progresión durante el transcurso de ocho cirugías. En los dos casos iniciales, siete y seis ítems se completaron con robótica en comparación con los 12 pasos en los últimos tres procedimientos. El tiempo quirúrgico pasivo disminuyó del 20% en los primeros cuatro casos a 8% en los últimos tres procedimientos. La mediana (rango) de pérdida de sangre estimada, el tiempo quirúrgico total y la duración de la estancia hospitalaria fueron, respectivamente, 125 ml (100–600), 11,25 h (10–13) y 5,5 días (5–6). Ocurrieron dos complicaciones reversibles: una paciente adquirió alopecia por presión y otra desarrolló pielonefritis.

      Conclusión (es)

      El estudio demuestra una clara evolución de una estrategia hacia la cirugía de donante totalmente robótica en UTx. Es probable que esto se convierta en el enfoque principal en la cirugía de donante de donantes vivos para UTx.

      Key Words

      Discuss: You can discuss this article with its authors and other readers at https://www.fertstertdialog.com/users/16110-fertility-and-sterility/posts/30308
      Absolute uterine-factor infertility (AUFI) due to the absence of a functional uterus was until recently regarded as untreatable. In 2014, the first live birth occurred after uterus transplantation (UTx), when a 35-year-old Swedish woman with Mayer-Rokitansky-Küster-Hauser syndrome delivered a healthy boy less than 2 years after receiving a uterus from a 61-year old uterus donor (
      • Brännström M.
      • Johannesson L.
      • Bokström H.
      • Kvarnström N.
      • Mölne J.
      • Dahm-Kähler P.
      • et al.
      Livebirth after uterus transplantation.
      ). This first live birth was followed by several more births after UTx, from both live donors (
      • Testa G.
      • McKenna G.J.
      • Gunby Jr., R.T.
      • Anthony T.
      • Koon E.C.
      • Warren A.M.
      • et al.
      First live birth after uterus transplantation in the United States.
      ,
      • Brännström M.
      • Bokström H.
      • Dahm-Kähler P.
      • Diaz-Garcia C.
      • Ekberg J.
      • Enskog A.
      • et al.
      One uterus bridging three generations: first live birth after mother-to-daughter uterus transplantation.
      ) and deceased donors (
      • Ejzenberg D.
      • Andraus W.
      • Baratelli Carelli Mendes L.R.
      • Ducatti L.
      • Song A.
      • Tanigawa R.
      • et al.
      Livebirth after uterus transplantation from a deceased donor in a recipient with uterine infertility.
      ,
      • Flyckt R.
      • Falcone T.
      • Quintini C.
      • Perni U.
      • Eghtesad B.
      • Richards E.G.
      • et al.
      First birth from a deceased donor uterus in the United States: from severe graft rejection to successful cesarean delivery.
      ).
      Uterus transplantation is still at an early experimental phase and it is predicted that major developments of several aspects of the procedure will take place to increase the safety and efficiency of the procedure. In our initial UTx trial in Sweden, laparotomy surgery was exclusively used in both donors and recipients (
      • Brännström M.
      • Johannesson L.
      • Dahm-Kähler P.
      • Enskog A.
      • Mölne J.
      • Kvarnström N.
      • et al.
      First clinical uterus transplantation trial: a six-month report.
      ). The donor surgery proved to be very complicated, especially concerning the pelvic dissection of the deep uterine veins to isolate them completely together with their multiple branches from the firm attachments to ureters and paracervical/vaginal tissue. We reported durations of donor surgeries between 10 and 13 h (
      • Brännström M.
      • Johannesson L.
      • Dahm-Kähler P.
      • Enskog A.
      • Mölne J.
      • Kvarnström N.
      • et al.
      First clinical uterus transplantation trial: a six-month report.
      ). In a more recent live-donor UTx trial in the United States, including 13 live-donor open hysterectomies, the durations were reduced to 6–7 h (

      Johannesson L, Koon EC, Bayer J, McKenna GJ, Wall A, Fernandez H, et al. DUETS (Dallas Uterus Transplant Study): Early outcomes and complications of robot-assisted hysterectomy for living uterus donors. Transplantation. Published online March 20, 2020. https://doi.org/10.1097/TP.0000000000003211.

      ).
      Minimal invasive surgery (MIS), via conventional or robotics-assisted laparoscopy, has a major role in complex gynecologic surgery, especially in gynecologic oncology surgery (
      • Lyons Y.A.
      • Stephan J.M.
      • Gonzalez Bosquet J.
      • Goodheart M.J.
      Gynecologic oncology: challenges of minimally invasive surgery in a field of maximal complexities.
      ) and surgery for deep-infiltrating endometriosis (
      • Touboul C.
      • Ballester M.
      • Dubernard G.
      • Zilberman S.
      • Thomin A.
      • Darai E.
      Long-term symptoms, quality of life, and fertility after colorectal resection for endometriosis: extended analysis of a randomized controlled trial comparing laparoscopically assisted to open surgery.
      ). Furthermore, robotics-assisted laparoscopy has been gradually introduced as an alternative to conventional laparoscopy and laparotomy in retrieval surgery of live kidney donors (
      • Giacomoni A.
      • di Sandro S.
      • Lauterio A.
      • Concone G.
      • Buscemi V.
      • Rossetti O.
      • et al.
      Robotic nephrectomy for living donation: surgical technique and literature systematic review.
      ) and is used in the kidney transplantation procedure itself (
      • Breda A.
      • Territo A.
      • Gausa L.
      • Tuğcu V.
      • Alcaraz A.
      • Musquera M.
      • et al.
      Robot-assisted kidney transplantation: the European experience.
      ). The advantage of robotics-assisted laparoscopy compared with conventional laparoscopy is the presence of a 3-dimensional (3D) camera that is fixed in a robotic arm that is maneuvered by the surgeon, as well as the use of articulated instruments, allowing excellent surgical access to narrow spaces, such as the deep pelvis, with a greater possibility for precision surgery.
      The first scientific report of robotics-assisted surgery in the setting of UTx was a single case of live-donor UTx performed in China with published follow-up for 12 months (
      • Wei L.
      • Xue T.
      • Tao K.S.
      • Zhang G.
      • Zhao G.Y.
      • Yu S.Q.
      • et al.
      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.
      ). The robotic surgery of the donor did not involve harvesting of the deep uterine veins, which is the traditional approach in live-donor hysterectomy for UTx (
      • Brännström M.
      • Johannesson L.
      • Dahm-Kähler P.
      • Enskog A.
      • Mölne J.
      • Kvarnström N.
      • et al.
      First clinical uterus transplantation trial: a six-month report.
      ). Instead, the utero-ovarian veins were harvested for outflow of blood from the uterus after transplantation. This surgical method necessitated oophorectomy in the 42-year-old uterus-donating mother (
      • Wei L.
      • Xue T.
      • Tao K.S.
      • Zhang G.
      • Zhao G.Y.
      • Yu S.Q.
      • et al.
      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.
      ). Oophorectomy in a woman of premenopausal age is controversial, because this will cause increased risk for cardiovascular morbidity and overall mortality (
      • Parker W.H.
      • Feskanich D.
      • Broder M.S.
      • Chang E.
      • Shoupe D.
      • Farquhar C.M.
      • et al.
      Long-term mortality associated with oophorectomy compared with ovarian conservation in the Nurses’ Health Study.
      ). In a recent case series report from USA, including five fully robotic live donor hysterectomies performed in 2019, the proximal parts of the utero-ovarian veins were bilaterally harvested in all cases for subsequent venous anastomoses, and this did not necessitate oophorectomy (

      Johannesson L, Koon EC, Bayer J, McKenna GJ, Wall A, Fernandez H, et al. DUETS (Dallas Uterus Transplant Study): Early outcomes and complications of robot-assisted hysterectomy for living uterus donors. Transplantation. Published online March 20, 2020. https://doi.org/10.1097/TP.0000000000003211.

      ) because the ovarian branches of the utero-ovarian veins were spared.
      Uterus transplantation is a low-volume procedure, exclusively for women with AUFI, and with the necessity for extensive preoperative investigations of recipients and donors to meet the strict inclusion criteria. Therefore, there is a need for studies presenting structured data and outcomes for complete cohorts, although they will be limited in numbers during this early experimental stage. In the present study we first demonstrate a step-by-step and structural developmental approach to evolve and assess robotics-assisted donor hysterectomy, including harvesting of the deep uterine veins, in the complete donor cohort of the Swedish robotics UTx trial. Second, we present data on surgical outcomes and complications.

      Materials and Methods

       Ethics Approval and Registration

      The study (Uterus Transplantation from Live Donors with Robotics-Assisted Surgery—Gothenburg II) was approved by the Regional Ethics Committee at Göteborg University (no. 362-16) and registered as a clinical trial (NCT02987023). Written informed consents were obtained from all donors. A requirement from the Ethics Committee was that a safety committee would monitor the study, provide specific recommendations, and have the right to stop the study for patient safety reasons.
      Patients were included as donors when they fulfilled the inclusion criteria according to the approved ethical protocol, which basically was identical to that previously described concerning the laparotomy study (
      • Brännström M.
      • Johannesson L.
      • Dahm-Kähler P.
      • Enskog A.
      • Mölne J.
      • Kvarnström N.
      • et al.
      First clinical uterus transplantation trial: a six-month report.
      ). In addition, a requirement was uterine arteries of good quality (diameter of >1.5 mm on at least one side, lack of atherosclerotic signs) according to results of three imaging modalities (see below). Exclusion criteria to become a donor included diabetes, cardiovascular disease (apart from mild hypertension), lung disease, or previous major intra-abdominal surgery, obstetrical complication, or malignancy. Surgical data, including estimated blood loss (EBL) and length of hospital stay (LOS), were recorded. Individual items of the surgical procedure steps were defined (Fig. 1). Any complication within 4 months after hysterectomy was recorded and classified according to the Clavien-Dindo system (
      • Clavien P.A.
      • Barkun J.
      • de Oliveira M.L.
      • Vauthey J.N.
      • Dindo D.
      • Schulick R.D.
      • et al.
      The Clavien-Dindo classification of surgical complications: five-year experience.
      ), including grades I–V, with grade III being complication requiring surgical, endoscopic, or radiologic intervention and grade IV being life-threatening complication requiring admission to intensive care unit. The eight cases were performed from May 2017 to November 2019.
      Figure thumbnail gr1
      Figure 1Schematic drawing of the nine predefined surgical steps and their locations in the right side of the pelvis. 1) Bladder and uterovaginal fossa dissection; 2) artery crude dissection—umbilical, uterine and internal iliac artery; 3) ureter crude dissection; 4) ureteric tunnel—proximal dissection; 5) artery fine dissection: 6) ureteric tunnel—distal dissection; 7) vein fine dissection; 8) salpingectomy and dissection of the proximal part of utero-ovarian vein; 9) pouch of Douglas dissection and division of sacrouterine ligaments.

       Preoperative Investigations

      Blood group compatibility was assured. The donors were then screened by extensive blood chemistry, including tests for liver function, kidney function, coagulation, and hematology status. Furthermore, serology for cytomegalovirus, Epstein-Barr virus, human immunodeficiency virus, hepatitis, and syphilis was obtained. Electrocardiography (ECG), exercise ECG, and chest X-ray were also performed. Gynecologic examination with sampling for sexually transmitted diseases (gonorrhea, chlamydia) and cytology, including analysis of high-risk human papilloma virus, were performed. Imaging included pelvic contrast-enhanced magnetic resonance angiography, computerized tomography in the arterial contrast phase, and conventional digital subtraction angiography of the iliac arteries and uterine arteries. Taken together, the preoperative investigations performed would exclude major uterine pathology and ensure that uterine arteries were of a quality that would ensure good chance to provide adequate uterine blood flow after anastomosing and reperfusion in the recipient.

       Robotic Surgical Technique and Setting

      Anesthesia and postoperative medication were performed as previously described (
      • Brännström M.
      • Johannesson L.
      • Dahm-Kähler P.
      • Enskog A.
      • Mölne J.
      • Kvarnström N.
      • et al.
      First clinical uterus transplantation trial: a six-month report.
      ) with the exception of addition of epidural analgesia, active for 2–3 days after surgery, for optimal recovery and mobilization. Total surgical time was defined from first skin incision to last skin suture. For safety reasons, in the event of large bleeding, a hand-access device GelPort (AppliedMedical), was first applied through a 9-cm subumbilical midline incision (Fig. 2A). The device consists of a wound-protecting sheet, a wound retractor, and a gel seal cap. The robotics system was the Da Vinci Xi (Intuitive Surgical) dual-console system, with a 4-arm setup through 8-mm trocars. The camera robotic port (robotic arm no. 2) was introduced in the umbilical region by means of a nontraumatic technique, and the three remaining robotic ports were applied in a straight line from left to right, crossing the umbilicus (Fig. 2A). A 12-mm access port with AirSeal (ConMed) was introduced between the camera port and the lateral left robotic port (Fig. 2A). An additional laparoscopic port (5 mm) for conventional laparoscopic instruments was introduced in the left subcostal region. The 5-mm and 12-mm ports were used by the assisting laparoscopy surgeon. The patient was then put in a steep Trendelenburg position (angle 28°) and a DaVinci Xi system was side-docked (45°) toward the left hip of the patient, enabling full access to the vaginal probe (see below). Two robotics surgeons worked in the dual console system of the DaVinci Xi, and one laparoscopy surgeon plus an operating nurse were immediately adjacent to the patient. The robotic instruments used were Maryland bipolar forceps (robotic arm no. 1), monopolar curved scissors/large needle driver/medium-large clip applier (robotic arm no. 3) and ProGrasp forceps/vessel sealer extend (robotic arm no. 4). A spherical vault-presentation silicon probe (30103; Karl Storz) was inserted into the vagina to enable presentation of the vagina when needed.
      Figure thumbnail gr2
      Figure 2(A) Photographic overview of the docking sites with the robotic Da Vinci Xi system with a GelPort (1) and 4-arm setup with the port (5 mm) for robotic arm no. 2 (2) used for camera, the port (5 mm) for robotic arm no. 1 (3), the port (5 mm) for robotic arm no. 3 (4), the port (5 mm) for robotic arm no. 4 (5), and the 12 mm AirSeal access port (6). (B) Bladder and uterovaginal fossa dissection (step 1). (C) Artery crude dissection on the right side with uterine and umbilical arteries (step 2). (D) Ureter crude dissection on the right side (step 3). (E) Ureteric tunnel—proximal dissection (step 4). (F) Artery fine dissection on the left side—internal iliac artery with branches (step 5). Bl = bladder; Cx = cervix; Ext.I.a = external iliac artery; Int.I.a = internal iliac artery; U = ureter; U.a = uterine artery; Umb.a = umbilical artery.
      The safety committee had decided before the start of the study that the maximum robotic surgical time would be 6 h in the initial procedures and that an extension toward 7 h would be possible for the last procedures, in the event that no serious complication related to the robotic surgery or the position of the patient was seen in the initial procedures. This was to minimize donor risks related to robotic surgery or to the long duration in a steep Trendelenburg position, comprising described complications such as compartment syndrome, skin lesions, peripheral nerve injury, rhabdomyolysis, and ocular events, including blindness (
      • Tourinho-Barbosa R.R.
      • Tobias-Machado M.
      • Castro-Alfaro A.
      • Ogaya-Pinies G.
      • Cathelineau X.
      • Sanchez-Salas R.
      Complications in robotic urological surgeries and how to avoid them: a systematic review.
      ).

       Defined Surgical Steps of Robotic Donor Hysterectomy

      Nine steps of the robotic surgery were planned ahead and identified. These individual items of the surgical procedure steps are specified below and the sites of surgery and anatomic locations for each procedure are schematically shown in Figure 1. Figures 2B–2E and 3 provide images of each step. Three of the items (nos. 5, 6, and 7) were considered to be complex and separate measurements were done for the left and right sides.
      Figure thumbnail gr3
      Figure 3(A) The ureteric tunnel on the right side—distal dissection. Ureter is brought upward with the use of a vessel loop (step 6). (B) Indocyanine green with Firefly mode, showing the arteries toward the cervix and bladder during the distal ureteric tunnel dissection (step 6). (C) Vein fine dissection toward the uterus on the right side (step 7). (D) Vein fine dissection with division of major venous branch toward the bladder. Hemoclips are secured with sutures after vein division (step 7). (E) Salpingectomy and dissection of the proximal part of utero-ovarian vein on the left side (step 8). (F) Pouch of Douglas dissection and division of sacrouterine ligaments (step 9). Cx = cervix; PD = pouch of Douglas; S = sacrouterine ligament; T = tube; U.a = uterine artery; U.v = uterine vein; U.O.v = proximal part of utero-ovarian vein.
      After robotic surgery was completed and the robotic arms had been de-docked, conversion to laparotomy was performed by extending to a full subumbilical midline incision. The vagina was divided by monopolar diathermy and scissors, acquiring a vaginal cuff on the specimen of ∼2 cm. Vascular clamps were placed optimally to harvest proximal parts of utero-ovarian veins, anterior portions of iliac arteries, and deep uterine veins with segments of the internal iliac veins in all cases. The vessels were cut and the specimen lifted directly to the back-table and prepared. The vascular ends were sutured with the use of continuous 6-0 polypropylene sutures and the vagina closed with the use of a continuous 2-0 resorbable multifilament suture (Vicryl; Ethicon). The abdomen was closed by means of standard technique. Infection prophylaxis was with the use of 4 g intravenous piperacillin/tazobactam every 8 h for 3 days, starting before skin incision. Thrombosis prophylaxis was with the use of 5,000 IU dalteparin subcutaneously for 6 weeks. An ultrasound of both legs was also performed before the discontinuation of daltaperin to conclude no evidence of thrombosis.
      Video recordings of the entire robotic procedures were made. These were analyzed after surgery to register times of defined steps. Passive surgical time (mainly intersurgeon discussions) was also registered. The defined surgical steps were as described below and also schematically outlined in Fig. 1. The abbreviations in brackets in the description below refer to the abbreviations of Figure 4.
      Figure thumbnail gr4
      Figure 4Overview of the surgical durations of each substep (described in detail in Materials and Methods) for the eight cases (Pat. 1–Pat. 8), with ages (years) indicated in parentheses. All times are given in minutes. Passive time is also expressed in % of total robotic time. dx = dexter (right side); sin = sinister (left side). 1) B. = bladder and uterovaginal fossa dissection. 2) A.c. = artery crude dissection. 3) U.c. = ureter crude dissection. 4) U.t.p. = ureteric tunnel—proximal dissection. 5) A.f. = artery fine dissection—internal iliac artery with branches. 6) U.t.d. = ureteric tunnel—distal dissection. 7) V.f. = vein fine dissection. 8) S. = salpingectomy and dissection of the utero-ovarian vein. 9) P.D. = pouch of Douglas dissection and division of sacrouterine ligaments.

       Step 1. Bladder and uterovaginal fossa dissection with division of round ligaments (B.)

      The round ligaments are divided laterally close to the inguinal ligament. An extensive and curved peritoneal flap (∼4–5 cm from the attachment to the cervix) of the bladder peritoneum is freed from the bladder. Then the bladder is isolated from the cervix to reach 2–3 cm below the vaginal-cervical border in the midline (Fig. 2B).

       Step 2. Artery crude dissection—the uterine arteries, anterior portions of internal iliac arteries, and umbilical arteries (A.c.)

      The obliterated umbilical artery is identified close to the inguinal ligament and the distal end of the artery, enclosed in surrounding tissue, and grasped for traction. The umbilical artery is then dissected in a proximal direction (Fig. 2C). The anterior portion of the internal iliac artery is crudely dissected free and mobilized from the pelvic sidewall. The uterine artery is identified and dissected free for ∼3 cm.

       Step 3. Ureter crude dissection (U.c.)

      Dissection of the ureter starts around halfway between the lateral-to-medial crossing of the ureter over the iliac vessels and the crossing under the uterine artery. The ureter is isolated from the surrounding tissue, with care to avoid damage to the ureteric vein, which typically is positioned beneath the ureter. A rubber vessel loop is placed around the ureter and the loop is secured by two hemoclips (Hem-o-lok ML 3–10 mm; Mediplast). Then the loop is used for traction of the ureter (Fig. 2D) during dissection of the ureter distally to reach ∼5 mm superior to the ureteric tunnel (crossing of uterine artery and major uterine veins).

       Step 4. Ureteric tunnel—proximal dissection (U.t.p.)

      The ureter is firmly attached to the paracervical fascia as well as to the uterine artery and veins in the ureteric tunnel. Several branches of small arteries and veins are attached to the ureter at this site. During the dissection procedure, with diathermy and transection of minor vessels, mostly bipolar diathermy and scissors are used to avoid thermic injury to the ureter. Traction and mobilization of the proximal aspect of the ureter, by a vessel loop around the ureter, aids in the dissection of the ureteric tunnel (Fig. 2E). The dissection from this proximal/supine angle is performed so that the ureter is freed from surrounding tissue and vessels for the major part of the tunnel.

       Step 5. Artery fine dissection—internal iliac arteries with branches (A.f.)

      The larger branches of the internal iliac artery are fully dissected (Fig. 2F), and with possible transection of branches after application of titanium clips or Hem-o-lok. These are secured by means of single stitch (6-0 polypropylene). The umbilical artery is cut after diathermy. The aim is to harvest the internal iliac artery, with transection just distal to the major posterior branch (gluteal artery). This step is separated in items for the left and right sides in the analysis of durations of substeps (see Results).

       Step 6. Ureteric tunnel—distal dissection (U.t.d.)

      The dissection takes place between the location where the uterine artery overrides the ureter and the bladder area, at the inlet of the ureter. Several larger venous branches, with some being parts of the major uterine veins, are in close proximity to the ureter. By means of traction of the more proximal part of the ureter, the deeply positioned ureter in the area close to the bladder is indicated. The tissues over the ureter, containing multiple veins, are dissected. This is aided by bipolar diathermy, scissors, and vessel sealer to divide larger veins. A tunnel is created under the ureter and a vessel loop, secured with Hem-o-lok, is applied. With upward traction on the ureter, further dissection to free the ureter from the paravaginal tissue is performed (Fig. 3A). The identification of deeper arteries and branches is aided with the use of intravenous administration of 0.25 mg/kg indocyanine green and 3D Firefly imaging (Fig. 3B; Da Vinci Xi surgical system). Care has to be taken not to divide essential branches of the uterine vein, which may pass in an arch toward the bladder on the way from the uterus to their inlets to the internal iliac vein (Fig. 3C). In this surgical step, the parasympathetic nerves, toward the bladder in the Yabuki space, are preserved. This step is separated in items for the left and right sides in the analysis of durations of substeps (see Results).

       Step 7. Vein fine dissection—internal iliac veins with branches, including distal parts of uterine veins (V.f.)

      The internal iliac vein and the first part of the larger branches are fully dissected, allowing transection of branches after application of Hem-o-lok if needed. The clips are secured (Fig. 3D) by means of single stitch (6-0 polypropylene). Small branches of the veins are divided by a vessel sealer. The aim is to acquire a free segment of the internal iliac vein, with the inflow of one or up to three uterine veins. This step is separated in items for the left and right sides in the analysis of durations of substeps (see Results).

       Step 8. Salpingectomy and dissection of proximal part of the utero-ovarian vein (S.)

      The oviducts and the ovaries are freed from the uterus to expose the proximal parts of the utero-ovarian veins, until the levels of the branching of the ovarian veins. This is to be able to use these venous segments for extra outflow if the deep uterine veins are too thin or with complicated anatomy. The oviducts are elevated and the three to four branches from the proximal part of the utero-ovarian vein up to the oviducts are divided (Fig. 3E). The proximal part of the oviduct is then exposed to bipolar diathermy and transected. The ovarian ligament, containing a major artery, is then divided as above. The proximal parts of the utero-ovarian veins will then be exposed for a length of ∼5 cm.

       Step 9. Pouch of Douglas dissection and division of sacrouterine ligaments (P.D.)

      The peritoneum is opened just under the posterior portion of cervix, with the site for this dissection aided by pushing inside of the vaginal probe to present the posterior vaginal fornix. The rectum is dissected away from the back of the vagina and the sacrouterine ligaments are cauterized and transected (Fig. 3F) ∼3–4 cm from their insertion to the posterior aspect of the lower uterus. The hypogastric nerves are identified and preserved in the same manner as in nerve-sparing radical hysterectomy. Dissection is then performed toward the vaginal fascia and with division of parametrium below the level of the ureters and uterine vessels.

      Results

       Patients

      The donors were six mothers, one family friend, and one sister. The ages are shown in Figure 4. Their body mass indexes were from 22 to 28 kg/m2 and they had given birth to 1–4 children with birth weights from 2,500 to 4,355 g. All deliveries were vaginal births and at full term.

       Overall Surgical Times, Estimated Blood Loss, and Postoperative Recovery

      Total surgical duration was 13 h in procedure no. 1, 12.5 h in procedure nos. 2 and 4, 11.5 h in procedure nos. 3 and 5–7, and 10 h in the last procedure (no. 8). EBL was in general low (100–600 mL). The initial two cases, with EBLs of 600 and 400 mL, had the main blood loss during the open surgical part. In the following six cases, the EBLs were 100–250 mL, with a median of 125 mL. LOS was 6 days in procedures 3 and 4 and 5 days in the rest. There were two postoperative complications. Donor 4 acquired pressure alopecia (Clavien-Dindo II complication) after an immediate postoperative swelling in the back of the head. The alopecia reversed spontaneously. Donor 8 acquired a left-sided pyelonephritis 25 days after surgery, and owing to moderate unilateral ureteric dilation a double-J stent was applied in addition to intravenous antibiotic treatment (Clavien-Dindo IIIB complication). This complication also reversed and the ureteric stent was withdrawn. No further complications were seen during the follow-up which at the time of writing was 5 months.

       Durations and Progress of Surgical Steps

      The robotic surgery evolved by learning with gradually shorter durations for a majority of subsets of specific surgical procedures and also an increase in the number of surgical steps performed. The durations of the different surgical procedures (Figure 1, Figure 2, Figure 3) in each case are shown in Fig. 4. In the initial two robotic procedures (6 h), 7 and 6 steps were performed with the use of robotics, and in the last three procedures (6.5–7 h) all 12 steps were performed by robotics. In those three last procedures, most time was spent on dissection of the distal ureteric tunnel (Figs. 1 [step 6] and 3A-3C) and the fine dissection of uterine and internal iliac vein (Figs. 1 [step 7] and 3D). The total (bilateral) times for dissection of the distal ureteric tunnel and the fine dissection of larger veins were 85–94 min and 88–120 min, respectively (Fig. 4). All initial surgical steps decreased in time during the trial. Passive surgical time in the robotics procedure decreased from 19%–23% in the first three cases to 7%–8% in the last three cases (Fig. 4).

      Discussion

      Uterus transplantation has during the past decade evolved from a basic-science research project (
      • Brannstrom M.
      • Wranning C.A.
      • Altchek A.
      Experimental uterus transplantation.
      ) aimed at a future infertility treatment for women with AUFI into a clinical procedure, although still at a clinical experimental stage. After the first live birth after UTx in 2014 (
      • Brännström M.
      • Johannesson L.
      • Bokström H.
      • Kvarnström N.
      • Mölne J.
      • Dahm-Kähler P.
      • et al.
      Livebirth after uterus transplantation.
      ), which was after a live-donor UTx procedure in Sweden within the initial clinical UTx trial of 2013 (
      • Brännström M.
      • Johannesson L.
      • Dahm-Kähler P.
      • Enskog A.
      • Mölne J.
      • Kvarnström N.
      • et al.
      First clinical uterus transplantation trial: a six-month report.
      ), the field has evolved, with several more births after live-donor (
      • Brännström M.
      • Bokström H.
      • Dahm-Kähler P.
      • Diaz-Garcia C.
      • Ekberg J.
      • Enskog A.
      • et al.
      One uterus bridging three generations: first live birth after mother-to-daughter uterus transplantation.
      ) and deceased-donor procedures (
      • Ejzenberg D.
      • Andraus W.
      • Baratelli Carelli Mendes L.R.
      • Ducatti L.
      • Song A.
      • Tanigawa R.
      • et al.
      Livebirth after uterus transplantation from a deceased donor in a recipient with uterine infertility.
      ,
      • Flyckt R.
      • Falcone T.
      • Quintini C.
      • Perni U.
      • Eghtesad B.
      • Richards E.G.
      • et al.
      First birth from a deceased donor uterus in the United States: from severe graft rejection to successful cesarean delivery.
      ).
      The first report on use of robotic surgery in UTx was a publication from China, reporting a fully robotic retrieval of the uterus for UTx from a mother to the daughter (
      • Wei L.
      • Xue T.
      • Tao K.S.
      • Zhang G.
      • Zhao G.Y.
      • Yu S.Q.
      • et al.
      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.
      ). The authors describe difficulties when attempting to dissect the deep uterine veins, and instead the utero-ovarian veins were isolated to be used as effluents of blood flow after transplantation into the recipient. However, this surgical approach necessitated oophorectomy in the donor, who was a mother of premenopausal age. One should take into consideration that oophorectomy in premenopausal women is associated with increased risk of morbidity and mortality (
      • Parker W.H.
      • Feskanich D.
      • Broder M.S.
      • Chang E.
      • Shoupe D.
      • Farquhar C.M.
      • et al.
      Long-term mortality associated with oophorectomy compared with ovarian conservation in the Nurses’ Health Study.
      ). The surgical approach of the present study was to harvest the deep uterine veins on both sides in line with the surgical technique we developed for open surgery at uterus retrieval from a live donor (
      • Brännström M.
      • Johannesson L.
      • Dahm-Kähler P.
      • Enskog A.
      • Mölne J.
      • Kvarnström N.
      • et al.
      First clinical uterus transplantation trial: a six-month report.
      ). We would thereby avoid oophorectomy. Although our team had experience in the complex dissection and harvesting of deep uterine veins in open uterus-donor surgery (
      • Brännström M.
      • Johannesson L.
      • Dahm-Kähler P.
      • Enskog A.
      • Mölne J.
      • Kvarnström N.
      • et al.
      First clinical uterus transplantation trial: a six-month report.
      ), the recent negative experience in robotic uterus retrieval in the report from China (
      • Wei L.
      • Xue T.
      • Tao K.S.
      • Zhang G.
      • Zhao G.Y.
      • Yu S.Q.
      • et al.
      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.
      ), as well as our relatively limited experience in pelvic venous dissection, acquired from robotics-assisted gynecologic-oncology surgery and robotic UTx surgery in the pig model, prompted us to design this study to be a systematic and step-by-step developmental study, where we would aim for robotic dissection of deep uterine veins without injuring the ovarian blood flow.
      This is the first publication on the progression of a stepwise approach on MIS for uterus procurement in a human clinical UTx trial. The study protocol was to limit the time for robotic surgery with the steep Trendelenburg position for the patient for 6–7 h, to minimize risk for serious side-effects that may come from a long duration in this position (
      • Tourinho-Barbosa R.R.
      • Tobias-Machado M.
      • Castro-Alfaro A.
      • Ogaya-Pinies G.
      • Cathelineau X.
      • Sanchez-Salas R.
      Complications in robotic urological surgeries and how to avoid them: a systematic review.
      ). Therefore, before the study we had identified certain steps of the robotic surgery that could progressively be completed by robotics. The described steps are in line with the surgical steps previously used in our first human clinical UTx trial, including retrieval of the deep uterine veins with patches or segments of the internal iliac veins (
      • Brännström M.
      • Johannesson L.
      • Dahm-Kähler P.
      • Enskog A.
      • Mölne J.
      • Kvarnström N.
      • et al.
      First clinical uterus transplantation trial: a six-month report.
      ).
      In the initial two surgeries, which were performed in 2017, only 6 and 7 of the 12 (including three bilateral items) surgical steps could be accomplished during the 6 h of robotic surgery. The completed steps in these two procedures did not include the most complex steps, which in our hands are the dissection of the distal ureter, between the crossing of ureteric/uterine artery crossing and the ureteric inlet into the bladder, and the fine dissection of the deep uterine veins, including the branching into the internal iliac vein. From the third case in April 2018 on, there was a clear and steady progress to the last two cases of the series, completed in November 2019. The goal was at this stage to initially perform complete ureteric dissection, so that the ureters would be totally freed from attachments to the paracervical/vaginal tissue as well from their multiple attachments to blood vessels. Completion of this step would then facilitate the identification and fine dissection of the uterine veins, including segments of the internal iliac vein, which we were able to complete by the robot, unilaterally in case no. 5 and bilaterally in the subsequent three cases. In these last three cases, all surgical steps were completed with the use of robotic surgery. A majority of the individual surgical steps showed decreased durations throughout the trial, and there was a 50% decrease in passive surgical time. Thus the evolution follows a typical learning curve for a complex surgical procedure.
      In both open and MIS donor hysterectomy, the dissection of the deep uterine veins, which are closely attached to the ureters, seem to be the most difficult and time-consuming subprocedure of the surgery. Our robotics-assisted approach to UTx used six ports. Four were robotic ports of 8 mm and two were assistant ports of 12 mm and 5 mm. These multiple ports, together with the dual console, enabled very good conditions for surgery with open surgical fields, which is essential in dissection of deep uterine veins. With conventional laparoscopy in UTx, the number of ports may be lower, and this could be advantageous to reduce risk for hernia complications in ports as well as for cosmetic reasons. Other advantages of traditional laparoscopy compared with robotics-assisted laparoscopy for UTx are the lower cost for laparoscopy and the faster conversion time to laparotomy in case of large bleeding or other major injury that needs open surgery. However, deep uterine dissection is in our experience clearly aided by the articulated instruments in robotic surgery, and this surgical step was not yet been reported in any laparoscopic donor hysterectomy for UTx.
      We were able to complete the distal ureteric dissection and the fine dissection of the uterine veins and their inlets into the internal iliac veins bilaterally in the last three procedures, but the collective time for these procedures had a long duration of ∼3–3.5 h, which is about one-half of the total robotics time. Naturally, this substep has to be developed further for a faster robotics procedure, or there should be investigations of alternate venous outflow sections. The fully robotic retrieval case performed in China described great difficulty in retrieving the deep uterine veins and therefore they harvested only the utero-ovarian veins and had to perform oophorectomy because ovarian veins and arteries were part of the retrieved specimen (
      • Wei L.
      • Xue T.
      • Tao K.S.
      • Zhang G.
      • Zhao G.Y.
      • Yu S.Q.
      • et al.
      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.
      ). The same procedure to use the utero-ovarian veins was also used by the team in India, who published four cases with conventional laparoscopic uterus retrieval (
      • Puntambekar S.
      • Puntambekar S.
      • Telang M.
      • Kulkarni P.
      • Date S.
      • Panse M.
      • et al.
      Novel anastomotic technique for uterine transplant using utero-ovarian veins for venous drainage and internal iliac arteries for perfusion in two laparoscopically harvested uteri.
      ,
      • Puntambekar S.
      • Telang M.
      • Kulkarni P.
      • Puntambekar S.
      • Jadhav S.
      • Panse M.
      • et al.
      Laparoscopic-assisted uterus retrieval from live organ donors for uterine transplant: our experience of two patients.
      ). In the five fully robotic cases in the USA (

      Johannesson L, Koon EC, Bayer J, McKenna GJ, Wall A, Fernandez H, et al. DUETS (Dallas Uterus Transplant Study): Early outcomes and complications of robot-assisted hysterectomy for living uterus donors. Transplantation. Published online March 20, 2020. https://doi.org/10.1097/TP.0000000000003211.

      ) there was no reported upper time limit for the robotics part. The protocol was to harvest both proximal parts of the utero-ovarian veins, which would not necessitate oophorectomy, as well as the deep uterine veins. Nevertheless, because only five out of ten possible deep uterine veins were harvested and only two out of ten were used for anastomosis, it is likely that great difficulties were found when harvesting these veins completely with patches of the internal iliac veins. Moreover, the long surgical duration of these cases (median 10 h 48 min) compared with the five cases of uterus harvesting with the use of MIS, dissection of only the utero-ovarian veins (
      • Wei L.
      • Xue T.
      • Tao K.S.
      • Zhang G.
      • Zhao G.Y.
      • Yu S.Q.
      • et al.
      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.
      ,
      • Puntambekar S.
      • Puntambekar S.
      • Telang M.
      • Kulkarni P.
      • Date S.
      • Panse M.
      • et al.
      Novel anastomotic technique for uterine transplant using utero-ovarian veins for venous drainage and internal iliac arteries for perfusion in two laparoscopically harvested uteri.
      ,
      • Puntambekar S.
      • Telang M.
      • Kulkarni P.
      • Puntambekar S.
      • Jadhav S.
      • Panse M.
      • et al.
      Laparoscopic-assisted uterus retrieval from live organ donors for uterine transplant: our experience of two patients.
      ), and the results of the present study, with total long durations for the fine dissections of veins, indicate the great difficulty in this part of dissection.
      There is one report of live birth after UTx with no use of deep uterine veins as outflows but rather use of only the proximal parts of the utero-ovarian veins (
      • Testa G.
      • McKenna G.J.
      • Gunby Jr., R.T.
      • Anthony T.
      • Koon E.C.
      • Warren A.M.
      • et al.
      First live birth after uterus transplantation in the United States.
      ). Because only the proximal parts were used, oophorectomy was not needed. Future studies, presenting complete fertility data after UTx with the use of different vascular techniques will shed light on the issue of optimal venous outflow from live donors, when taking both donor safety and efficiency of UTx, regarding live birth rate, into account. Importantly, in the present study we could in all eight cases retrieve both the uterine veins bilaterally for optimal vein anastomosis and the proximal parts of the utero-ovarian veins as possible salvage options for venous anastomosis.
      Surgical outcomes in robotic surgery in other indications, such as endometrial and urologic cancers, have presented decreased EBL and LOS compared with outcomes of standard open surgery (
      • Boggess J.F.
      • Gehrig P.A.
      • Cantrell L.
      • Shafer A.
      • Ridgway M.
      • Skinner E.N.
      • et al.
      A comparative study of 3 surgical methods for hysterectomy with staging for endometrial cancer: robotic assistance, laparoscopy, laparotomy.
      ,
      • Lindfors A.
      • Åkesson A.
      • Staf C.
      • Sjoli P.
      • Sundfeldt K.
      • Dahm-Kähler P.
      Robotic vs. open surgery for endometrial cancer in elderly patients: surgical outcome, survival, and cost analysis.
      ,
      • Hamilton Z.A.
      • Uzzo R.G.
      • Larcher A.
      • Lane B.R.
      • Ristau B.
      • Capitanio U.
      • et al.
      Comparison of functional outcomes of robotic and open partial nephrectomy in patients with pre-existing chronic kidney disease: a multicenter study.
      ). The EBLs of the last six cases in the present trial were 100–250 mL (median 125 mL) and this was less (P<.01, Mann-Whitney test) than we previously reported (median 600 mL (range 300-2,400 mL) for open surgery (
      • Brännström M.
      • Johannesson L.
      • Dahm-Kähler P.
      • Enskog A.
      • Mölne J.
      • Kvarnström N.
      • et al.
      First clinical uterus transplantation trial: a six-month report.
      ) and in concordance with the report from the single robotic case in China (
      • Wei L.
      • Xue T.
      • Tao K.S.
      • Zhang G.
      • Zhao G.Y.
      • Yu S.Q.
      • et al.
      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.
      ) as well as what was reported in the four cases of laparoscopy-assisted uterus retrieval from India (
      • Puntambekar S.
      • Puntambekar S.
      • Telang M.
      • Kulkarni P.
      • Date S.
      • Panse M.
      • et al.
      Novel anastomotic technique for uterine transplant using utero-ovarian veins for venous drainage and internal iliac arteries for perfusion in two laparoscopically harvested uteri.
      ,
      • Puntambekar S.
      • Telang M.
      • Kulkarni P.
      • Puntambekar S.
      • Jadhav S.
      • Panse M.
      • et al.
      Laparoscopic-assisted uterus retrieval from live organ donors for uterine transplant: our experience of two patients.
      ). A recent study, including the five robotic cases of live-donor surgery in the USA, (

      Johannesson L, Koon EC, Bayer J, McKenna GJ, Wall A, Fernandez H, et al. DUETS (Dallas Uterus Transplant Study): Early outcomes and complications of robot-assisted hysterectomy for living uterus donors. Transplantation. Published online March 20, 2020. https://doi.org/10.1097/TP.0000000000003211.

      ) reported EBLs of 20–100 mL. Taken together, all studies on uterus retrieval from live donors performed with the use of MIS indicate less blood loss than with the use of open surgery. However, it should be noted that there is a risk for large bleeding in uterus retrieval, especially related to lacerations of large veins. In the present study we applied a hand-access device GelPort to be used in a situation of large bleeding, but in this cohort of patients that safety procedure was not needed.
      Complications after surgery will always occur to some extent, and in live-donor nephrectomies the total rate of complications according to the Clavien-Dindo classification is ∼20% and the rate of major complications ∼3% (
      • Mjoen G.
      • Oyen O.
      • Holdaas H.
      • Midtvedt K.
      • Line P.D.
      Morbidity and mortality in 1022 consecutive living donor nephrectomies: benefits of a living donor registry.
      ). In the present study, two of the eight donors (25%) acquired complications according to the Clavien-Dindo classification. One patient developed reversible pressure alopecia on the vertex of the head, with a hairless area of ∼5 cm in diameter. The cause of this complications was possibly related to the Trendelenburg position of the patient, with a position of the head well below the heart and with possible fluid extravasation at the lowest point because of insufficient venous backflow (
      • Arvizo C.
      • Mehta S.T.
      • Yunker A.
      Adverse events related to Trendelenburg position during laparoscopic surgery: recommendations and review of the literature.
      ). It should be noted that pressure alopecia was also reported in one of the five recent robotic cases in the USA (

      Johannesson L, Koon EC, Bayer J, McKenna GJ, Wall A, Fernandez H, et al. DUETS (Dallas Uterus Transplant Study): Early outcomes and complications of robot-assisted hysterectomy for living uterus donors. Transplantation. Published online March 20, 2020. https://doi.org/10.1097/TP.0000000000003211.

      ). Pressure alopecia may possibly be prevented by repeated repositioning of the head during time of the steep Trendelenburg position, which was practised in the following cases of the present study. The other complication that we noted was a pyelonephritis that occurred more than 3 weeks after surgery. This was treated with the use of intravenous antibiotics and unilateral application of a double-J stent because ultrasound showed mild to moderate hydronephrosis on the left side. This complication is probably associated with partial ureteric wall injury due to the extensive ureteric dissection, as well as with nearby diathermy, which is necessary during the organ procurement surgery to get optimal vessels to the graft. In the robotic case series in the USA (

      Johannesson L, Koon EC, Bayer J, McKenna GJ, Wall A, Fernandez H, et al. DUETS (Dallas Uterus Transplant Study): Early outcomes and complications of robot-assisted hysterectomy for living uterus donors. Transplantation. Published online March 20, 2020. https://doi.org/10.1097/TP.0000000000003211.

      ), two of the five donors acquired ureteric complications, which needed intervention with insertion of ureteral stents. One patient showed unilateral hydronephrosis and another acquired bilateral ureteric-vaginal fistulation. The periods with stents were >4 months in both cases. Taken together, the complication rate of these initial trials of robotic uterine removals for UTx, involving the study from the USA (

      Johannesson L, Koon EC, Bayer J, McKenna GJ, Wall A, Fernandez H, et al. DUETS (Dallas Uterus Transplant Study): Early outcomes and complications of robot-assisted hysterectomy for living uterus donors. Transplantation. Published online March 20, 2020. https://doi.org/10.1097/TP.0000000000003211.

      ) and the present study, has been fairly high. It is of importance that ongoing and future trials of robotics-assisted UTx report complications to identify risk factors and other associations that may affect and minimize risk of donor complications.
      One aim of the present study, besides acquiring finer dissection and improved patient recovery, was that total surgical time of the donor, toward the end of the study, would be reduced compared with our experience from the initial Swedish trial with open surgery (10–13 h) (
      • Brännström M.
      • Johannesson L.
      • Dahm-Kähler P.
      • Enskog A.
      • Mölne J.
      • Kvarnström N.
      • et al.
      First clinical uterus transplantation trial: a six-month report.
      ). However, total surgical time of the present study was also 10–13 h (median 11.5 h). It should be noted that the surgical duration of the present study also includes ∼15 min for docking of the robot and ∼30 min for de-docking and conversion from robotic surgery to laparotomy, so the duration of active surgery is somewhat lower than stated in the present article. Nevertheless, it is far more than a duration <8 h, which was our hope. The surgical time of the present study was similar to that of the five robotic UTx procurements performed in the USA with a range of 9.5–12 h (

      Johannesson L, Koon EC, Bayer J, McKenna GJ, Wall A, Fernandez H, et al. DUETS (Dallas Uterus Transplant Study): Early outcomes and complications of robot-assisted hysterectomy for living uterus donors. Transplantation. Published online March 20, 2020. https://doi.org/10.1097/TP.0000000000003211.

      ). However, differences exist between the studies. The present study was not fully robotic, although the total surgical times were similar, and our study did not include the last steps of robotic retrieval, including vaginal transection, vascular clamping, retrieval of organ, and suturing of vascular ends. The study from the United States did most likely not perform full dissection of deep uterine veins, because only two out of ten possible deep uterine veins could be used for anastomosis.
      One limitation of the present study is the small number of cases (n = 8), but in relation to the previously published reports of MIS in UTx, with numbers from one to five (

      Johannesson L, Koon EC, Bayer J, McKenna GJ, Wall A, Fernandez H, et al. DUETS (Dallas Uterus Transplant Study): Early outcomes and complications of robot-assisted hysterectomy for living uterus donors. Transplantation. Published online March 20, 2020. https://doi.org/10.1097/TP.0000000000003211.

      ,
      • Wei L.
      • Xue T.
      • Tao K.S.
      • Zhang G.
      • Zhao G.Y.
      • Yu S.Q.
      • et al.
      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.
      ,
      • Puntambekar S.
      • Puntambekar S.
      • Telang M.
      • Kulkarni P.
      • Date S.
      • Panse M.
      • et al.
      Novel anastomotic technique for uterine transplant using utero-ovarian veins for venous drainage and internal iliac arteries for perfusion in two laparoscopically harvested uteri.
      ,
      • Puntambekar S.
      • Telang M.
      • Kulkarni P.
      • Puntambekar S.
      • Jadhav S.
      • Panse M.
      • et al.
      Laparoscopic-assisted uterus retrieval from live organ donors for uterine transplant: our experience of two patients.
      ), the present study is comparatively large and is of a size similar to our original laparotomy UTx study from 2013 (
      • Brännström M.
      • Johannesson L.
      • Dahm-Kähler P.
      • Enskog A.
      • Mölne J.
      • Kvarnström N.
      • et al.
      First clinical uterus transplantation trial: a six-month report.
      ). A strength of the present study is the prospective observational study design with collection of predetermined data and complete video recordings, allowing evaluation of performed steps and registration of passive times. Moreover, we closely monitored our patients for follow-up concerning complications for several months and notably they will also, like the donors from the original Swedish trial (
      • Kvarnström N.
      • Järvholm S.
      • Johannesson L.
      • Dahm-Kähler P.
      • Olausson M.
      • Brännström M.
      Live donors of the initial observational study of uterus transplantation-psychological and medical follow-up until 1 year after surgery in the 9 cases.
      ,
      • Järvholm S.
      • Kvarnström N.
      • Dahm-Kähler P.
      • Brännström M.
      Donors’ health-related quality-of-life and psychosocial outcomes 3 years after uterus donation for transplantation.
      ), be followed long-term concerning both medical and psychologic issues.
      In conclusion, robotics-assisted laparoscopy for uterus retrieval in UTx is feasible, with a clear progress in surgical steps performed and associated with indications of decreased EBL compared with open surgery. Further developments should be toward fully robotics-assisted uterus retrieval, with harvesting of the deep uterine veins and retrieval through the vagina. At a later stage, we anticipate that fully robotics-assisted surgery will also be used in the recipient.

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