Graft Hysterectomy After Uterus Transplantation With Robotic-assisted Techniques

摘要

Uterus transplantation (UTx) is a temporary transplant, and graft hysterectomy (GH) is planned either at the time of delivery or at a later date.1,2 When the GH is delayed, it can be done either with an open or minimally invasive technique. Twenty patients, part of the Dallas UtErus Transplant Study and approved by the ethics committee and institutional review board of the Baylor University Medical Center in 2015 (clinical trial NCT02656550), underwent UTx between September 2016 and October 2019. To date, we performed 17 GH, 6 of these at a separate encounter after delivery. In 2 of these cases, a robotic-assisted approach (January 2020 and January 2021, respectively) was used. The robotic GH is performed using a da Vinci Xi robotic platform alternating between a 0° and a 30° scope. The patient is placed in the modified ski position in the Bluefin stirrups. A 5-mm laparoscopic optical port, 3 cm below the left costal margin in the midclavicular line, is used to obtain pneumoperitoneum. Four robotic ports are used. The port sites are 7 cm lateral to the umbilicus on the left side of the abdomen (8 mm), below the umbilicus (8 mm), and 7 cm lateral to the umbilicus on the right side of the abdomen (8 mm). The last 8-mm port is placed in the right lower quadrant. The patient is then placed in a deep Trendelenburg position. A uterine manipulator (Rumi II Koh-Efficient Uterine Manipulator; CooperSurgical, Trumbull, CT) is placed. Bilaterally, the residual round ligaments (if intact) are severed. The vesicouterine peritoneum is then incised and the bladder is dissected off the lower uterine segment, cervix, and upper vagina. The uterine veins and arteries are carefully skeletonized, dissecting enough perivascular tissue to allow for Hem-o-lock placement proximally and for the utilization of the vessel sealer distally. An anterior vaginotomy is created along the Koh ring with monopolar scissors. This is carried circumferentially around the Koh ring until the uterus and cervix are amputated from the vagina. These are then placed in an Endo-Catch bag and brought out through the vagina. The vaginal cuff is closed with a suture in a running continuous fashion. Tables 1 and 2 summarize patients' characteristics and postoperative data. Neither robotic case was converted to open access nor required an intraoperative, postoperative blood transfusion, or intensive care unit. With 38 and 26 mo follow–up, respectively, neither of the patients experienced any complication related to the GH. TABLE 1. - Characteristics of patients with a transplanted uterine graft who underwent hysterectomy with robotic approach Casea Date Approach Age (y) Donor Recipient graft time (d) Live births (n) Concomitant surgery at hysterectomy BMI (kg/m2) Indication for hysterectomy Type of maintenance IS Days off IS before GH 13 1/21/20 Robotic 33 LD 407 1 BS 31 Patient preference AZA, Envarsus 7 15 1/12/21 Robotic 33 LD 345 1 27 Organ rejectionb AZA, Prograf 53 aThe cases are numbered based on the date of UTx and study recruitment.bWorsening kidney function requiring cessation of IS, with subsequent organ rejectionAKI acute kidney injury; AZA, azathioprine; BMI, body mass index; BS, bilateral salpingectomy; CS, cesarean section; DD, deceased donor; GF, graft failure; GH, graft hysterectomy; HS, hysterectomy; IS, immunosuppression; LD, living donor; UAT, uterine artery thrombosis; UTx, uterus transplantation; UVT, uterine vein thrombosis. TABLE 2. - Intraoperative and postoperative outcomes after robotic GH in UTx patients Indication Case OT (min) Specimen weight (g) Blood loss (mL) Transfusion (units): IO/PO Conversion Total LOS (d) ICU LOS (d) CD complication grade (type) Day of PO complication: onset- resolution Pregnancy (n) Same time as delivery Aftersuccessfulbirth 13 (robotic) 194 116 60 0/0 0 1 0 1 (bladder cramping) 1-1 1 0 15 (robotic) 297 290 300 0/0 0 2 0 1 (nausea) 1-1 1 0 CD, Clavien-Dindo classification3; GH, graft hysterectomy; ICU, intensive care unit;