Graft Hysterectomy After Uterus Transplantation With Robotic-assisted Techniques.

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; IO, intraoperative; LOS, length of stay; NA, not available; OT, operative time; PO, postoperative; UTx, uterus transplantation; –, not applicable. Although an open and laparoscopic GH technique has been described,4,5 we report 2 cases of GH performed with a complete robotic approach. Compared with standard and laparoscopic hysterectomy, additional concerns were initially related to the compact and dense adhesions that may form around any transplanted organ. In reality, postoperative adhesions did not constitute a significant problem except for long operative times compared with standard hysterectomy. Because no attempt needs to be made to completely dissect and extract the graft vessels in their entirety, the plane of dissection remains close to the uterine parenchyma, allowing for a safe dissection. No vascular staplers were necessary, and the entire GH could be completed with the robotic vessel sealer. One of the advantages of the robot-assisted approach may be better control of hemostasis to the detriment of longer operation compared with the open and laparoscopic technique. It is possible that with increasing confidence, the operative time and hospital stay will significantly decrease; already the second case was completed in a shorter time (194 versus 297 min). Compared with open and laparoscopic approach proposed by Brucker et al, we perceive surgical advantages such as better operative field vision and superior intraoperative maneuverability because of the dexterity of the robotic arms, especially in the context of complex adhesion. There were also direct patient benefits, like less postoperative pain, a short length of stay, and overall perceived faster recovery. Interestingly, the fact that the robotic approach gives the impression of a less invasive surgical procedure, whereas in reality, the magnitude of the GH remains the same as in the open approach and constitutes a mitigating factor for the emotional distress of the removal of the uterus. In conclusion, we have shown that robotic hysterectomy after UTx is feasible and safe in selected patients. Previous pelvic surgery is not a contraindication for a minimally invasive approach. The robotic technique and 3-dimensional magnification can be beneficial especially in the narrow operative pelvic field, with a possible better view compared to open access. Furthermore, the transition from an open approach to a robotic approach seems possible and safe, as described in other surgical fields.6