Archives of Gynecology and Obstetrics
https://doi.org/10.1007/s00404-019-05138-4

NEWS AND VIEWS

Uterus transplantation: advantages and disadvantages of a deceaseddonor
Iori Kisu1· Kouji Banno1 · Yusuke Matoba1 · Daisuke Aoki1© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Dear Editor,
First successful livebirth following uterus transplantation(UTx) from a deceased donor was recently reported byEjzenberg et al. [1]. In 2014, Brännström et al. achieved thefirst successful delivery after UTx from a live donor [2]. Todate, more than 50 UTx procedures have been performed
worldwide, leading to more than 10 newborns after UTx
from live donors. However, the report of successful livebirth
after UTx from a deceased donor increases the potential ofUTx for women with uterine factor infertility (UFI).
Most UTx procedures use a uterus from a live donor,
but living-to-living UTx is a highly invasive surgery.
Brännström et al. perfected their surgical technique in animal experiments for more than 10 years and conducted clinical studies of UTx in many women; however, the time ofdonor surgery in the first trial was still ~ 10 h and the blood
loss was high [3]. This is because an extremely precise surgical procedure is required to remove a part of the deep uterine
vein located in the pelvic floor and the internal iliac vein as
drainage veins. Robot-assisted surgery has been performed
for less-invasive surgery in living donors and novel operative
procedures using the ovary or utero-ovarian vein as a drainage vein in place of the uterine vein have been developed [4,5]. These methods reduce the operative time and bleeding
volume, and consequently, should reduce risks for living
donor UTx surgery in the future.
Despite the advances in living donor UTx, the guiding
principles of organ transplantation still indicate that theorgan should be collected from a deceased donor. The first
UTx from a deceased donor was performed in Turkey in2011 and the patient became pregnant, but had repeated* Iori Kisu
iori71march@hotmail.co.jp; iori71march@a7.keio.jp
1

Department of Obstetrics and Gynecology, Keio University
School of Medicine, 35 Shinanomachi, Shinjuku‑ku,
Tokyo 160‑8582, Japanabortion and no livebirth [6]. UTx from deceased donors
was then performed in the United States (Cleveland and Dallas) [7, 8] and the Czech Republic [9], but without subsequent livebirth, which raised a question of the feasibility ofsuch transplantation.
The greatest advantage of UTx from deceased donors
is elimination of surgical stress in living donors. Resection of extended vascular pedicles of greater length thanthose from living donors and extraction of the uterus canbe achieved in a faster procurement time. However, thereare also several disadvantages. First, it is difficult to plansurgery. Management by multidisciplinary experts is necessary for UTx, since the procedure remains in the experimental stage, with careful preoperative preparation, patient
selection, and sufficient informed consent required. These
procedures are more difficult for UTx from deceased donors,
which may explain why UTx from living donors is currently
more common. Second, thorough preoperative screening isdifficult for deceased donors. Living donors undergo preoperative uterine imaging and angiography by CT and MRI,
and uterine cancer screening including HPV testing, Pap
smear, and endometrial biopsy; however, these examinations are not fully performed due to the limited time for UTx
from deceased donors. In addition, no details of medical
history can be obtained. Third, ischemic time (particularlycold ischemic time) is longer than that in living donors. The
uterus of a living donor is transferred to a recipient in thenext operating room, whereas the uterus of a deceased donor
may be transferred to a recipient in another institution. Furthermore, the uterus of a brain-dead multi-organ donor is
not a vital organ and it is the final procurement after that ofvital organs, resulting in an extended ischemic time. Fourth,vasoactive drugs including catecholamines are frequently
administered to patients in the agonal stage; consequently,
vascular insufficiency and systemic inflammatory changes
may have negative effect on organs. Vasoactive drugs wereadministered to the deceased donor for 4 h before transplantation in Ejzenberg et al. [1].

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The final difficulty with UTx from a deceased donor isthat microvessels located in tissues surrounding the uterus
must be carefully ligated for transplantation. Failure to doso results in hemorrhage after reperfusion during recipient
surgery. With regard to dissection and ligation in back-tablepreparation of the uterus of a deceased donor, it is difficult tofind fine vessels around a white uterus that was washed out
with organ-protecting solution. This makes vascular treatment before reperfusion in a deceased donor more difficult
than that in a living donor. As stated in Ejzenberg et al. [1],the hemorrhage volume of the recipient was 1200 mL, indicating substantial blood loss, and most blood was lost fromthe transplanted uterus after reperfusion. Previous reports of
UTx had hemorrhage volumes of the recipient ranging from500 to 1000 mL in transplantation [3, 4, 9, 10], mainly due
to bleeding around the uterus after reperfusion, rather thanblood loss in vascular anastomosis. Furthermore, recipients
had postoperative complications including retroperitoneal
hematoma and hematoma surrounding the uterus [3, 10].
UTx from a deceased donor still has disadvantages to beresolved, but does not have the greatest problem in living-toliving UTx, which is the risk to the donor. Establishment ofthe proof of concept and feasibility of UTx from a deceased
donor has opened up a new option, in place of adoption andsurrogacy, for women with UFI. This major achievement
constitutes a medical milestone in assisted reproduction andtransplantation. This success is expected to motivate performance of UTx from deceased donors worldwide, and thesecases will provide new evidence with regard to the safetyand efficacy of UTx from a deceased donor.

Author contributions IK wrote this comment. KB, YM and DA revised
the manuscript. All authors read and approved the final manuscript.

Compliance with ethical standards
Conflict of interest The authors declare no competing interests.
Human participants or animal experiments This article does not contain any studies involving human participants or animals.

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