Journal of

Clinical Medicine
Review

Operative and Clinical Outcomes of Minimally Invasive
Living-Donor Surgery on Uterus Transplantation:
A Literature Review
Yusuke Matoba, Iori Kisu * , Kouji Banno and Daisuke Aoki
Department of Obstetrics and Gynecology, Keio University School of Medicine 35 Shinanomachi, Shinjku-Ku,
Tokyo 160-8582, Japan; y.matoba0212@gmail.com (Y.M.); kbanno@z7.keio.jp (K.B.); aoki@z7.keio.jp (D.A.)* Correspondence: iori71march@a7.keio.jp; Tel.: +81-3-3353-1211

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Citation: Matoba, Y.; Kisu, I.; Banno,K.; Aoki, D. Operative and Clinical
Outcomes of Minimally Invasive
Living-Donor Surgery on Uterus

Abstract: Background: The surgical approach and choice of drainage veins for uterus transplantation
living-donor surgery have been investigated to reduce invasiveness. Methods: A thorough search of
the PubMed database was conducted. The search was not limited by language or date of publication.
The data were collected on 13 October 2020. Two reviewers independently assessed each article anddetermined eligibility for inclusion in the review article. Inclusion criteria were English peer-reviewed
articles reporting surgical information or postoperative course, articles regarding animal researchon UTx, UTx on deceased donors, or not original articles. Results: Of the 51 operations within 26
articles reviewed, the mean operative time was shortest in the laparoscopic approach, and longest in
the robot-assisted approach. The mean blood loss was less in the laparoscopic and robot-assisted
approaches than in the open approach. In cases where the uterine veins were not preserved, themean operative time was shortened by each approach and the mean blood loss decreased with thelaparoscopic and robot-assisted approaches. Conclusions: These procedures may contribute to lessinvasive living-donor surgery.
Keywords: uterus transplantation; living donor surgery; laparotomy; laparoscopy; robot assisted;uterine vein; ovarian vein; utero-ovarian vein

Transplantation: A Literature Review.
J. Clin. Med. 2021, 10, 349. https://doi.org/10.3390/jcm10020349

1. Introduction
Academic Editor: Rudy Leon De
Wilde
Received: 23 December 2020
Accepted: 15 January 2021
Published: 18 January 2021

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with regard to jurisdictional claims inpublished maps and institutional affiliations.

Copyright: © 2021 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms andconditions of the Creative Commons
Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).

Absolute uterine factor infertility (AUFI) includes congenital uterine malformationand defects, such as Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome [1], which
occurs in one in 5000 women; acquired uterine defects caused by treatment of uterine
cancers or hysterectomy due to puerperal bleeding; extended uterine myomatosis; andAsherman’s syndrome, in which the endometrium is adhered [2].
A new transplantation technique, uterine transplantation (UTx), has been clinicallyapplied in recent years for the treatment of AUFI. UTx was first performed in Saudi Arabia
in 2000 [3]. Although the world’s first UTx failed with the removal of a transplanted
uterus, basic research using animal models was continued, and in 2014, a Swedish teamreported the first live birth after UTx [4]. Since then, UTx has been applied clinically inmany countries, and there have been some reports of live births from women who haveundergone UTx [5].
However, there are medical, ethical, and social challenges to UTx. One of the medical
challenges is the highly invasive procedure for living donors. In UTx living-donor surgery,the uterine artery is usually used for the arterial vessel, but there are several venous
options. The uterine vein (UV), a branch of the internal iliac vein, is widely used [6], asby the Swedish team that obtained the first live birth after UTx. When the UV is used, thesurgical operation is similar to radical hysterectomy. As the surgical isolation of the UV
is performed in a narrow and deep area of the pelvis and there is a complex network ofvessels, the procedure is sometimes difficult, resulting in longer surgical time and massive

J. Clin. Med. 2021, 10, 349. https://doi.org/10.3390/jcm10020349

https://www.mdpi.com/journal/jcm

J. Clin. Med. 2021, 10, 349

2 of 11hemorrhage. In addition, as the procedure is performed near the hypogastric nerve, there
is a risk of postoperative complications such as dysuria in the living donor [7].
To solve this problem, the use of ovarian veins (OV) and utero-ovarian veins (UOV)
as drainage veins has been investigated (Figure 1) [8]. When these veins are used, thesurgical technique is easier because the vessels to be preserved are in a more superficial
layer than when the UV is preserved. In addition, UTx living-donor surgery was initiallyperformed using an open approach, but recently there have been reports of laparoscopic [9]and robot-assisted approaches [10] for donor surgery.

Figure 1. Drainage vein options for uterus transplantation. In many cases of uterus transplantation
performed to date, the uterine veins from the internal iliac vein are used as drainage veins. However,this surgery is challenging because these vessels are located in the deep pelvic floor and surroundthe ureter. To minimise the invasiveness of living-donor surgery, the use of the ovarian vein or theutero-ovarian vein—which runs continuously from the ovarian vein through the mesosalpinx—asthe drainage vein, has been considered as an alternative to the use of the uterine vein. Ut, uterus; UV,
uterine vein; UOV, utero-ovarian vein; OV, ovarian vein

In many cases of UTx performed to date, the uterine veins from the internal iliac vein
are used as drainage veins. However, this surgery is challenging because these vessels arelocated in the deep pelvic floor and surround the ureter. To minimize the invasiveness ofliving-donor surgery, the use of the ovarian vein or the utero-ovarian vein—which runs
continuously from the ovarian vein through the mesosalpinx—as the drainage vein, hasbeen considered as an alternative to the use of the uterine vein (Ut, uterus; UV, uterine
vein; UOV, utero-ovarian vein; OV, ovarian vein).
In this review of the literature, we report on the differences in surgical and clinicaloutcomes by the variation of surgical approach and the preserved veins in UTx living-donor
surgery.
2. Materials and Methods
2.1. Search Strategy
A thorough search of the PubMed database was conducted. The search was not
limited by language or date of publication. The search strategies were as follows: (uterus[Title/Abstract] OR uterine [Title/Abstract] OR womb [Title/Abstract]) AND (transplantation OR transplant) AND (“surgery” [Title/Abstract] OR operation [Title/Abstract] ORlaparoscopy [Title/Abstract] OR laparoscopic [Title/Abstract] OR robot [Title/Abstract] OR
robotic [Title/Abstract] OR laparotomy [Title/Abstract] OR vein [Title/Abstract] OR veins[Title/Abstract] OR venous [Title/Abstract] OR anastomosis [Title/Abstract] OR ovarian [Title/Abstract] OR utero-ovarian [Title/Abstract] OR utero-ovarian [Title/Abstract]

J. Clin. Med. 2021, 10, 349

3 of 11OR living [Title/Abstract] OR donor [Title/Abstract] OR livebirth [Title/Abstract] ORlive-birth [Title/Abstract] OR human). The data were collected on 13 October 2020.
2.2. Eligibility Assessment
Two reviewers (Y.M. and I.K.) independently assessed each article and determined
eligibility for inclusion in the review article. Inclusion criteria were English peer-reviewed
articles reporting one of the following: (i) surgical information (operative approach, surgical time, blood loss, types and numbers of veins, and operative complications); or (ii)postoperative course (discharge timing, graft failure, and live birth after UTx). Articles
regarding animal research on UTx, UTx on deceased donors, not original articles (video
article, review, letter to the editor, commentary, and editorial), not written in English, orthat did not report the information above were excluded.
2.3. Data Extraction and Analysis
The included studies were reviewed by two independent reviewers (Y.M. and I.K.),
and relevant data were extracted including the number of performed human UTx cases,
surgical approach of living-donor surgery (open approach, laparoscopic approach, or
robot-assisted approach), surgical time, blood loss during donor surgery, the types andnumbers of removed veins (UV, UOV, or OV), operative complications, discharge timing,and live birth after UTx.
The data were classified into open, laparoscopic, and robot-assisted approaches
for analysis.
The data were also classified and analyzed according to whether the UV was removed
within each approach.
3. Results
This review included 26 original articles (Figure 2). Reports of living-donor uterustransplants from Saudi Arabia [3], Sweden [4,6,11–19], China [10,20], USA (Dallas) [8,21–24],
Czech Republic [7,25,26], Germany [27,28], and India [9,29] were identified, and 51 livingdonor UTx were incorporated. The surgical information and clinical data for each case areshown in Table 1. In one case in Germany, the uterus was removed from a donor, but was
found to be unsuitable for transplantation during back table processing, and the transplant
was not performed. In another case, the uterine veins were not used for transplantation,even though they were preserved and removed from the donor in a Czech case.
On 13 October 2020, an article search was conducted on PubMed according to thesearch strategy. Of 2382 articles, 26 original articles were finally included in the review.
They include the operative and clinical outcome data of the UTx living donor. UTx, uterine
transplantation
Of the 51 living-donor UTx cases, the open approach was used in 33 cases, thelaparoscopic approach in four cases, and the robot-assisted approach in 14 cases. The data ofeach approach are summarized in Table 2. The average operative time was 8 h 26 min ± 2 h
47 min for the open approach, 3 h 30 min ± 0 h 33 min for the laparoscopic approach, and10 h 59 min ± 1 h 45 min for the robot-assisted approach, with a trend toward shorter
operative times for the laparoscopic approach and longer operative times for the robotassisted approach. The mean blood loss was 715 ± 584 mL with the open approach,
100 ± 0 mL with the laparoscopic approach, and 209 ± 182 mL with the robot-assisted
approach, with a trend toward less blood loss with minimally invasive procedures, suchas the laparoscopic and robot-assisted approaches. The day of discharge was 6.2 ± 1.3
postoperative days on average with the open approach, 6.5 ± 0.5 days postoperatively
with the laparoscopic approach, and 4.3 ± 1.0 days postoperatively with the robot-assisted
approach. There were 19 surgical complications with the open approach (57.6%), zerowith the laparoscopic approach (0.0%), and six with the robot-assisted approach (42.9%).
There were nine cases (28.1%) of graft failure in open approach, zero cases (0.0%) on thelaparoscopic approach, and two cases (14.3%) in the robot-assisted approach. Live birth

J. Clin. Med. 2021, 10, 349

4 of 11after living-donor UTx was reported in 16 cases (48.5%) with the open approach, zerocases (0.0%) with the laparoscopic approach, and two cases (14.3%) with the robot-assisted
approach.

Figure 2. Flowchart of article selection.

Clinical data for each operative approach with or without the uterine veins are also
shown in Table 2. In the open approach, the mean operative time was 8 h 45 min ± 2 h
39 min and the mean blood loss was 711 ± 586 mL in the cases where UVs were preserved(n = 29), and in the cases where UVs were not preserved (n = 4), the mean operative
time was 6 h 14 min ± 0 h 26 min, and the mean blood loss was 738 ± 569 mL. In thelaparoscopic approach, the mean operative time was 4 h 0 min ± 0 h 0 min and the mean
blood loss was 100 ± 0 mL in the UVs preserved cases (n = 2), and the mean operative
time was 3 h 0 min ± 0 h 20 min and the mean blood loss was 100 ± 0 mL in the non-UVs
preserved cases (n = 2). In the robot-assisted approach, the mean operative time andmean blood loss were 11 h 19 min ± 1 h 8 min and 245 ± 197 mL in the UVs preservedcases (n = 12), respectively, and the mean operative time was 9 h 1 min ± 3 h 1 min andthe mean blood loss was 100 ± 0 mL in the non-UVs preserved cases (n = 2). In eachapproach, the operative time was reduced in the non-UVs preserved cases. The discharge
time was 6.3 ± 1.4 postoperative days for the open approach in the UVs preserved casesand 5.8 ± 0.8 days in the non-UVs preserved cases, and was 7.0 ± 0.0 postoperative days
for the laparoscopic approach in the UVs preserved cases and 6.0 ± 0.0 postoperativedays in the non-UVs preserved cases. In the robot-assisted approach, the postoperative
discharge time was 4.4 ± 1.0 days in the UVs preserved cases and 4.0 ± 0.0 days in the nonUVs preserved cases. There was little difference between patients with and without UVs
preserved. Operative complications were found in 17 (58.6%) cases for the open approachwith UVs preserved, and in two (50.0%) cases for non-UVs preserved. No complications
were reported with the laparoscopic approach in both of the UVs preserved and non-UVs
preserved cases. Complications tended to occur more frequently in the robot-assisted
approach, with six cases (50.0%) observed solely in the UVs preserved cases, with none in
the non-UVs preserved cases. Complications were more frequent in the UVs preservedcases. In the robot-assisted approach, graft failure was reported in two patients (16.7%)
with UVs preserved. Live births after UTx utilizing the laparoscopic approach were notreported in any of the papers included in this review. In the robot-assisted approach, onecase (8.3%) of a live birth was reported from the UVs preserved cases, and one (50.0%) was
reported from the non-UVs preserved cases.

J. Clin. Med. 2021, 10, 349

5 of 11

Table 1. Reported operative and clinical data of living-donor surgery for uterus transplantation.
Country

Operation

No.

Surgical Time(h:min)Blood Loss(mL)

Preserved Vein

Graft Failure

Saudi Arabia [3]

OPEN

1

N/R

N/R

2 × UVYes

Sweden [4,6,11–19]

OPEN

1

10:54

300

2 × UV, 1 × UOV

No

OPEN

2

12:37

2400

2 × UV, 1 × UOV

Yes

OPEN

3

12:53

800

2 × UV, 1 × UOV

No

OPEN

4

10:34

600

2 × UV, 1 × UOV

No

OPEN
OPEN
OPEN
OPEN
OPEN
ROBOT

5
6
7
8
9
1

10:17
10:52
10:17
11:23
13:08
13:00

600
700
400
400
2100
600

2 × UV
2 × UV, 1 × UOV
2 × UV, 1 × UOV
2 × UV
2 × UV
2 × UV, 1 × UOV

No
No
No
No
Yes
No

ROBOT

2

12:30

400

2 × UV, 1 × UOV

No

ROBOT
ROBOT
ROBOT
ROBOT
ROBOT
ROBOT
ROBOT
OPEN
OPEN

3
4
5
6
7
8
1
1
2

11:30
12:30
11:30
11:30
11:30
10:00
6:00
5:45
7:21

N/R
N/R
N/R
N/R
N/R
N/R
100
400
1000

2 × UV, 2 × UOV
2 × UV, 1 × UOV
2 × UV, 2 × UOV
2 × UV, 2 × UOV
2 × UV, 2 × UOV
2 × UV, 1 × UOV
2 × OV
1 × UV, 1 × UOV
1 × UV, 1 × UOV

Yes
No
No
No
No
Yes
No
Yes
Yes

OPEN

3

6:41

1300

1 × UV, 1 × UOV

Yes

OPEN
OPEN
OPEN
OPEN
OPEN

4
5
6
7
8

6:40
6:34
7:07
6:38
6:12

1700
250
1100
600
400

2 × UOV
2 × UOV
1 × UV, 1 × UOV
2 × UV
2 × UOV

No
No
No
No
Yes

OPEN

9

7:34

750

1 × UV, 1 × UOV

No

OPEN

10

6:27

1500

2 × UVNo

China [10,20]
US (Dallas) [8,21–24]

Operative Complications(Grade *)Intraoperative ureteric injury(N/R)
Nocturia (1)Wound infection (2)Uterovaginal fistula (3b)None
Unilateral sensibility
impairment of the thigh (1)
None
None
None
None
None
None
Gluteal light pain when
walking (N/R)
N/R
Pressure alopecia (2)
N/R
N/R
N/R
Pyelonephritis (3b)NoneLeg/buttocks pain (1)UTI (2)
Vaginal cuff dehiscence (3b)Depression (2), UTI (2)UTI (2)
Faecal impaction (3b)Acute blood loss anaemia (2)UTI (2)None
Symptomatic anaemia (2),
UTI (2)
Acute blood loss anaemia(4a)Prolonged intubation (4a),UTI (2)

Discharge

Live Birth

N/R

N/A

6POD

Yes × 2

6POD

N/A

6POD

no

6POD

Yes × 2

6POD
6POD
6POD
6POD
6POD
N/R

Yes × 1
Yes × 2
Yes × 1
Yes × 1
N/A
N/R

5POD

Yes

N/R
N/R
N/R
N/R
N/R
N/R
5POD
6POD
6POD

N/A
N/R
N/R
N/R
N/R
N/A
Yes
N/A
N/A

6POD

N/A

5POD
7POD
5POD
5POD
6POD

Yes
Yes
Yes
Yes
N/A

5POD

Yes

8POD

N/R

Remarks

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6 of 11

Table 1. Cont.
Country

Czech [7,25,26]

Germany [27,28]

India [9,29]

Operation

No.

Surgical Time(h:min)Blood Loss(mL)

Preserved Vein

Graft Failure

Operative Complications(Grade *)Discharge

Live Birth

OPEN
OPEN

11
12

5:33
5:13

600
950

2 × UOV
1 × UV, 2 × UOV

No
Yes

None
Haemorrhage (N/R)

5POD
4POD

Yes
N/A

OPEN

13

6:10

800

1 × UV, 1 × UOVNo

UTI (2)

6POD

Yes

ROBOT

1

9:25

150

1 × UV, 2 × UOVNo

Temporary alopecia (1)

4POD

N/R

ROBOT

2

10:48

100

1 × UV, 2 × UOVN/RUreteral blood clot (3b)

6POD

N/R

ROBOT

3

12:10

200

1 × UV, 2 × UOVN/RBilateral ureteral injury (3b)

3POD

N/R

ROBOT

4

9:27

20

2 × UV, 2 × UOV

N/R

None

4POD

N/R

ROBOT

5

12:03

100

3 × UOV

N/R

None

3POD

N/R

OPEN

1

5:20

100

2 × UV, 2 × OV

No

None

7POD

N/R

OPEN

2

6:10

800

2 × UV, 2 × OV

No

None

7POD

N/R

OPEN

3

7:10

100

2 × UV, 2 × OVNoClimacteric symptoms (N/R)

6POD

N/R

OPEN

4

5:30

100

2 × UV, 2 × OV

YesBladder hypotonia (3a)

11POD

N/A

OPEN

5

5:30

1000

2×UV, 2×OV

No

OPEN

1

12:07

100

2 × UVNo

Ureter laceration (3a)Climacteric symptoms (N/R)
None

OPEN

2

13:06

N/R

UV ‡

N/A

Hydronephrosis (3b)

N/R

N/A

OPEN
OPEN
OPEN
LAP
LAP
LAP
LAP

3
4
5
1
2
3
4

9:03
10:24
9:11
4:00
4:00
2:40
3:20

100
100
100
100
100
100
100

1 × UV, 1 × OV
2 × UV, 1 × UOV
2 × UV, 2 × UOV
1 × or 2 × UV, 2 × OV §1 × or 2 × UV, 2 × OV §2 × OV
2 × OV

No
No
No
No
No
No
No

None
None
None
None
None
None
None

12 days†
14 days †14 days †
7POD
7POD
6POD
6POD

Yes
N/A
N/A
N/R
N/R
N/R
N/R

9POD

Yes

11 days †YesRemarks

Not
anastomosed
UV
Not
anastomosed
UV
Not
anastomosed
UV
There were 2 left
UOV
Not
anastomosed
UV
Not
anastomosed
UV
Not
anastomosed
UV
Not
anastomosed
OVNo
transplantation
performed* Clavien-Dindo classification; † Hospital stay; ‡ Number of removed UV not reported; § Used 1 x UV on No. 1 or No. 2 case. OPEN, open approach; N/R, not reported; UV, uterine vein; N/A, not applicable;
UOV, utero-ovarian vein; POD, postoperative day; ROBOT, robot-assisted approach; OV, ovarian vein; UTI, urinary tract infection; LAP, laparoscopic approach.

J. Clin. Med. 2021, 10, 349

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Table 2. Operative and clinical data for each operative approach with or without using the uterine vein.
OPEN
UV (+)
n29
Surgical time
8:45 ± 2:39
(h:min) *Blood loss
711 ± 586(mL) *
Discharge
6.3 ± 1.4
(POD)
Complications
17 (58.6%)(n,%)
Graft failure
8 (28.6%) †(n,%)
Live birth
13 (46.4%)(n,%)

UV (−)LAP
Total

UV (+)UV (−)

ROBOT
Total

UV (+)UV (−)

Total

4

33

2

2

4

12

2

14

6:14 ± 0.26

8:26 ± 2:47

4:00 ± 0:00

3:00 ± 0.20

3:30 ± 0.33

11:19 ± 1:08

9:01 ± 3:01

10:59 ± 1:45

738 ± 569

715 ± 584

100 ± 0100 ± 0100 ± 0245 ± 197

100 ± 0209 ± 182

5.8 ± 0.8

6.2 ± 1.3

7.0 ± 0.0

6.0 ± 0.0

6.5 ± 0.5

4.4 ± 1.0

4.0 ± 0.0

4.3 ± 1.0

2 (50.0%)

19 (57.6%)

0 (0.0%)0 (0.0%)0 (0.0%)6 (50.0%)0 (0.0%)6 (42.9%)

1 (25.0%)

9 (28.1%) †0 (0.0%)0 (0.0%)0 (0.0%)2 (16.7%)

0 (0.0%)2 (14.3%)

3 (75.0%)

16 (48.5%)

0 (0.0%)0 (0.0%)0 (0.0%)1 (8.3%)

1 (50.0%)

2 (14.3%)* Mean ± SD; † Not including 1 case in which uterine transplantation was not performed. OPEN, open approach; LAP, laparoscopic
approach; ROBOT, robot-assisted approach; UV, uterine vein; POD, postoperative day.

4. Discussion
Laparoscopic and robot-assisted approaches may contribute to less invasive livingdonor surgery in UTx in the same way that they have led to less invasive surgery for otherdiseases. Similarly, the use of the OV or UOV for drainage, without UV, may also contributeto less invasive living-donor surgery.
Although UTx is an option for the treatment of AUFI, there are still some issues to besolved. UTx is a non-vital organ transplantation and can be considered a transplantation
to improve quality of life, but it requires a lot of surgical burden to the donors and therecipients. There are at least four operations in the UTx: uterus explantation in the donor,
uterus implantation in the infertile woman, caesarean section after pregnancy with the aidof assisted reproductive technologies, and hysterectomy after completed family planning.
Surgery for living donors takes a long time and causes a large amount of blood loss, whichplaces a heavy burden on the living donor. Surgical invasion of the recipient may be
acceptable since infertility is seen as a disease that causes a great psychological burden.
However, the living donor is a completely healthy person. The burden for living donors of
UTx must be reduced as much as possible.
One of the reasons for the high invasiveness of donor surgery is the difficulty in handling the complex venous system around the uterus. As the veins around the uterus makea network surrounding the ureter, they are difficult to isolate in the narrow operative fieldof the pelvic floor without sustaining damage. As a solution to this challenge, techniques
in which the OV and/or UOV are used, instead of the UV, as drainage veins have beendeveloped. In the UTx cases included in this review, only the UOV and OV were used,instead of the UV in each approach of living-donor surgery. With the exception of the open
approach, the blood loss tended to be lower in non-UV preserved cases than in the UV
preserved cases. This suggests that not using the UV may contribute to a less invasive
living-donor surgery for UTx.
On the other hand, there are concerns about the use of the UOV and OV as drainage
veins. One of the concerns is whether these veins are sufficient for blood flow in thegestational uterus. Many pregnancies and live births have been reported after radical
trachelectomy (RT), a fertility preservation treatment for cervical cancer in which thevenous blood flow of the uterus is dependent on the UOV and OV, as well as UTx, using the
UOV and OV only [30]. Considering this fact, the venous flow required by the gestational
uterus is preserved even if only the UOV and OV are used as drainage veins. In addition,
considering that there have already been reports of live births in UTx without using the
UV as a drainage vein [8,20], the use of the UOV and OV should be considered as an
option for living-donor surgery. In the case of the use of the OV as a venous vessel on the

J. Clin. Med. 2021, 10, 349

8 of 11premenopausal donor, where ovariectomy is inevitable, should be discussed. In an ASRM
statement on UTx, it is described that it is generally not recommended to use the ovarian
vessels if this results in the loss of ovaries in premenopausal women [31].
Laparoscopic and robot-assisted approaches have advantages, such as improved
magnification and small, minimally invasive wounds. These characteristics are being
applied to clinical practice in UTx with the possibility of contributing to less invasive
living-donor surgery. Previous reports comparing laparoscopic and open approaches forradical hysterectomy, in which the uterine artery and veins are handled as well as UTx
living-donor surgery, have reported less intraoperative blood loss with the laparoscopic
approach than with open approach [32]. In addition, the robot-assisted approach has
already been used in other organ transplant surgeries [33]. It has already contributed tominimizing invasive living-donor surgery and is, therefore, considered feasible. In thisreview, the laparoscopic and robot-assisted living-donor UTx operations also tended toreduce blood loss compared to the open approach. There was also a tendency for patientsto be discharged earlier with the robot-assisted approach than with the open approach.
These findings suggest that the laparoscopic and robot-assisted approaches may contributeto less invasive UTx in the future.
On the other hand, the disadvantages and complications of laparoscopic and robotassisted approaches need to be considered. Fourteen cases of robot-assisted surgeries
were reported, but the average operative time was longer than that of the open approach.
Robotic-assisted procedure has not been standardized yet, and the robot-assisted approachdiffers depending on each center. Therefore, it is not possible to clearly state why roboticassisted approach takes longer than the open approach at the moment. Temporary alopecia
has been reported as a complication related to intraoperative positioning in robot-assisted
approach [24]. In addition, the main goal of UTx is to achieve live birth after transplantation.
Although many live births have been reported for the open approach, partly because of thesmall number of procedures performed, only two live births have been reported for thelaparoscopic and robot-assisted approach UTx. A long-term report on mental status afterUTx [17] found no clear results on how live birth affects mental status, but it is thoughtthat live birth could affect the mental status of living donors. Although minimally invasive
techniques for living donors are required, these need to be developed with the objectivesof UTx in mind.
The open approach has a higher incidence of surgical complications and graft failure
than minimally invasive approaches. However, the open approach has been performed
since the inception of UTx, and surgical outcomes from that time are also included inthis review. In addition, the robot-assisted approach is utilized in countries that perform
more UTx by the open approach by surgeons who have sufficient experience with UTx
surgery. The differences in clinical and operative outcomes between each approach may
be influenced by these factors, which do not lead directly to the conclusion that the open
approach is inferior to minimally invasive approaches. Further accumulation of data thatregards the clinical outcome of each approach is essential.
UTx from deceased donors has been clinically applied as a fundamental solution to
the risks of living donors, and there are reports of live births after UTx from deceased
donors [34,35]. To investigate UTx from a deceased donor, basic research has also been
conducted [36]. However, this technique has challenges such as hormone replacement
therapy for postmenopausal donors and difficulties in assessing the detailed uterine vasculature. The effects of these factors on graft implantation and live birth need to be examined.
There are also many issues that need to be considered, such as what criteria are suitablefor deceased donors for UTx and what surgical procedures for organ harvesting, such as
hysterectomy, may be appropriate.
Limitations are present in this review. As this is a retrospective review, various
confounding factors may be included, and it is not possible to say directly which approachis superior. Statistical comparisons with laparoscopic and robot-assisted approaches are
particularly difficult to conduct because of the small number of procedures performed.

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In addition, this review only included original articles that met the inclusion criteria
retrieved by PubMed. However, there are some articles that include unpublished data,such as live birth after laparoscopic UTx in India, and some press releases about theimplementation of UTx in other countries [5,37,38]. If such information is included, theresults may differ from those of this review.
This literature review on UTx living-donor surgical approaches, preserved veins, andoperative and clinical outcomes was conducted with a focus on the laparoscopic approachand robot-assisted approach. Laparoscopic and robot-assisted approaches may contributeto less invasive living-donor surgery in UTx in the same way that they have led to lessinvasive surgery for other diseases. Similarly, the use of the OV or UOV as a drainage vein,
without UV, may also contribute to less invasive living-donor surgery. However, there
are few reports of live birth—the ultimate goal of UTx—with these new techniques. The
application of these techniques needs to be thoroughly discussed.
Author Contributions: I.K. and K.B. conceived the idea for the review. Y.M. and I.K. reviewed theliterature and wrote the manuscript. D.A. reviewed and edited the manuscript. All authors haveread and agreed to the published version of the manuscript.
Funding: This study was supported by the Seiichi Imai Memorial Foundation.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Data available in a publicly accessible repository.
Conflicts of Interest: The authors declare no conflict of interest.

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