Standardization of back-table technique for uterus transplantation.

Objective: To present a standardized back-table technique for uterus transplantation (UTx).

Design: Step-by-step description of surgical technique and live-action narrated surgical footage showing back-table technique in UTx.

Subjects: Uterus transplantation has become a viable option for patients with absolute uterine factor infertility and their families. After performing 20 research cases, our institution has conducted UTx in 13 patients, and over 100 cases have been performed worldwide. Uterus transplantation is now considered technically feasible, with a high live birth rate after successful graft survival.

Intervention: The transplantation of a uterus involves three separate surgical components: living or deceased uterus retrieval; back-table preparation of the uterine graft; and implantation of the uterine graft in the recipient. The living donor hysterectomy and implantation of the uterus in the recipient can be seen in separate videos. The back-table process is critically important in transplant surgery. After the uterus is removed from the donor, organ perfusion, vascular preparation, and marking are essential for ensuring a smooth transition to recipient surgery. In this video, we demonstrate our standardized back-table technique. Currently, there are no articles in gynecology focused solely on back-table techniques. When selecting a potential donor, factors such as age, body mass index, general health, and obstetric and surgical history are considered. Once a candidate is deemed suitable, in-person screening includes blood tests, imaging studies, and mental health evaluations. Preoperative imaging provides valuable information on the condition of the uterine vascularity, which is crucial given the complexity and variability of pelvic vessels. Once the uterus is removed from a living or deceased donor, it is immediately placed on ice and flushed with cool preservation fluid on the back-table. Back-table procedures average 0.5-1 hours and includes the following: perfusion; preparation of the arteries; preparation of the veins; ligation of the base of the fallopian tubes; and four-point suturing of the vagina, as well as (optional) cervical cerclage. Preparing the veins is a key part of the back-table process, especially when the vessel diameters are small, necessitating conjoining. Additionally, because the uterus is a mobile organ located between the bladder and rectum, it is essential to assess the shape and positioning of the vessels that will be anastomosed to avoid torsion during the uterine-vessel anastomosis. We believe that our method will be useful for many institutions that wish to initiate UTx programs.

Main Outcome Measures: Uterine graft viability and recipient pregnancy outcome.

Results: No surgical complications occurred. The postoperative course was uneventful, with early mobilization. The length of hospital stay was 5 days. The uterus was successfully implanted with successful pregnancy outcome.

Conclusion: Our standardized back-table technique minimizes harm to the recipient. Furthermore, the technique does not compromise the uterine graft function. Further studies and more educational content using video will be key to the widespread adoption of uterine transplantation.