Analysis of Two Reperfusion Techniques in Uterine Transplantation in an Experimental Model

Introduction: Uterine transplantation was developed for the treatment of absolute uterine factor infertility. As it is a new modality of transplantation, there is still room for technical improvement. A factor that impacts graft survival in organ transplantation is the warm ischemia time. In uterine transplantation specifically, at least two vascular anastomoses are performed on each side of the uterus, and the graft revascularization takes place when the vascular clamps of the arteries and veins are released on both sides simultaneously. For this reason, the warm ischemia time in uterine transplant is expected to be considerably long. The purpose of this study was to compare the sequential technique of uterine graft revascularization, which aims to reduce the warm ischemia time of the procedure, with the simultaneous revascularization technique.

Material And Methods: For the procedure, the uterine auto-transplantation technique was performed using 10 non-pregnant adult ewes weighing about 45 kg, divided into two groups: simultaneous revascularization group (5 animals) and sequential revascularization group (5 animals). To evaluate the groups, we analyzed the procedure and warm ischemia times, graft macroscopy, hemodynamic, laboratory, and histological parameters of the uterus.

Results: The sequential revascularization technique group had similar surgical procedure times, and the warm ischemia time was significantly shorter with medians of 32 min in the sequential group vs 72 min in the simultaneous group (p < 0.008). The graft macroscopy and hemodynamic, laboratory, and histological parameters evaluated were similar between the groups.

Conclusions: The sequential revascularization technique proved to reduce the warm ischemia time in the sheep uterine auto-transplantation model without compromising graft viability.

Citing Articles

A decade of human uterus transplantation.

Brannstrom M Acta Obstet Gynecol Scand. 2025; 104(3):434-436.

PMID: 39968606 PMC: 11871116. DOI: 10.1111/aogs.15080.

Analysis of two reperfusion techniques in uterine transplantation in an experimental model.

Macedo Arantes R, Ejzenberg D, Tanigawa R, da Silva Neto A, de Martino R, Galvao F Acta Obstet Gynecol Scand. 2024; 104(3):474-482.

PMID: 39402719 PMC: 11871109. DOI: 10.1111/aogs.14979.

References

Sirivatanauksorn Y, Taweerutchana V, Limsrichamrern S, Kositamongkol P, Mahawithitwong P, Asavakarn S . Recipient and perioperative risk factors associated with liver transplant graft outcomes. Transplant Proc. 2012; 44(2):505-8. DOI: 10.1016/j.transproceed.2012.01.065. View

Robertson F, Bessell P, Diaz-Nieto R, Thomas N, Rolando N, Fuller B . High serum Aspartate transaminase levels on day 3 postliver transplantation correlates with graft and patient survival and would be a valid surrogate for outcome in liver transplantation clinical trials. Transpl Int. 2015; 29(3):323-30. DOI: 10.1111/tri.12723. View

Zitkute V, Kvietkauskas M, Leber B, Strupas K, Stiegler P, Schemmer P . Ischemia and reperfusion injury in uterus transplantation: A comprehensive review. Transplant Rev (Orlando). 2020; 34(3):100550. DOI: 10.1016/j.trre.2020.100550. View

Wu M, Yiang G, Liao W, Tsai A, Cheng Y, Cheng P . Current Mechanistic Concepts in Ischemia and Reperfusion Injury. Cell Physiol Biochem. 2018; 46(4):1650-1667. DOI: 10.1159/000489241. View

Tennankore K, Kim S, Alwayn I, Kiberd B . Prolonged warm ischemia time is associated with graft failure and mortality after kidney transplantation. Kidney Int. 2016; 89(3):648-58. DOI: 10.1016/j.kint.2015.09.002. View

Brannstrom M, Belfort M, Ayoubi J . Uterus transplantation worldwide: clinical activities and outcomes. Curr Opin Organ Transplant. 2021; 26(6):616-626. DOI: 10.1097/MOT.0000000000000936. View

Macedo Arantes R, Nacif L, Pinheiro R, Rocha-Santos V, de Martino R, Waisberg D . Novel Technique in a Sheep Model of Uterine Transplantation. Transplant Proc. 2020; 52(5):1399-1401. DOI: 10.1016/j.transproceed.2020.02.040. View

Dahm-Kahler P, Wranning C, Lundmark C, Enskog A, Molne J, Marcickiewicz J . Transplantation of the uterus in sheep: methodology and early reperfusion events. J Obstet Gynaecol Res. 2008; 34(5):784-93. DOI: 10.1111/j.1447-0756.2008.00854.x. View

Cicinelli E, Einer-Jensen N, Galantino P, Alfonso R, Nicoletti R . The vascular cast of the human uterus: from anatomy to physiology. Ann N Y Acad Sci. 2005; 1034:19-26. DOI: 10.1196/annals.1335.002. View

10.

Matoba Y, Kisu I, Sera A, Yanokura M, Banno K, Aoki D . Current status of uterine regenerative medicine for absolute uterine factor infertility. Biomed Rep. 2019; 10(2):79-86. PMC: 6341411. DOI: 10.3892/br.2019.1182. View

11.

Macedo Arantes R, Ejzenberg D, Tanigawa R, da Silva Neto A, de Martino R, Galvao F . Analysis of two reperfusion techniques in uterine transplantation in an experimental model. Acta Obstet Gynecol Scand. 2024; 104(3):474-482. PMC: 11871109. DOI: 10.1111/aogs.14979. View

12.

Milliez J . Uterine transplantation FIGO Committee for the Ethical Aspects of Human Reproduction and Women's Health. Int J Gynaecol Obstet. 2009; 106(3):270. DOI: 10.1016/j.ijgo.2009.03.045. View

13.

Brannstrom M . Current status and future direction of uterus transplantation. Curr Opin Organ Transplant. 2018; 23(5):592-597. DOI: 10.1097/MOT.0000000000000568. View

14.

Marasco S, Kras A, Schulberg E, Vale M, Lee G . Impact of warm ischemia time on survival after heart transplantation. Transplant Proc. 2012; 44(5):1385-9. DOI: 10.1016/j.transproceed.2011.12.075. View

15.

Brannstrom M, Diaz-Garcia C, Johannesson L, Dahm-Kahler P, Bokstrom H . Livebirth after uterus transplantation - Authors' reply. Lancet. 2015; 385(9985):2352-3. DOI: 10.1016/S0140-6736(15)61098-4. View

16.

Fageeh W, Raffa H, Jabbad H, Marzouki A . Transplantation of the human uterus. Int J Gynaecol Obstet. 2002; 76(3):245-51. DOI: 10.1016/s0020-7292(01)00597-5. View

17.

Brannstrom M, Johannesson L, Dahm-Kahler P, Enskog A, Molne J, Kvarnstrom N . First clinical uterus transplantation trial: a six-month report. Fertil Steril. 2014; 101(5):1228-36. DOI: 10.1016/j.fertnstert.2014.02.024. View

18.

Diaz-Garcia C, Akhi S, Martinez-Varea A, Brannstrom M . The effect of warm ischemia at uterus transplantation in a rat model. Acta Obstet Gynecol Scand. 2012; 92(2):152-9. DOI: 10.1111/aogs.12027. View

19.

Shockley M, Arnolds K, Beran B, Rivas K, Escobar P, Tzakis A . Uterine viability in the baboon after ligation of uterine vasculature: a pilot study to assess alternative perfusion and venous return for uterine transplantation. Fertil Steril. 2017; 107(4):1078-1082. DOI: 10.1016/j.fertnstert.2017.01.014. View