Introduction
Absolute uterine factor infertility (AUFI) includes congenital uterine malformation and 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; and Asherman’s syndrome, in which the endometrium is adhered.2
A new transplantation technique, uterine transplantation (UTx), has been clinically applied 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 team reported the first live birth after UTx.4 Since then, UTx has been applied clinically in many countries, and there have been some reports of live births from women who have undergone 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, as by the Swedish team that obtained the first live birth after UTx. The procedure has become the gold standard for UTx living-donor surgery.6 When the UV is used, the surgical 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 of vessels, the procedure is sometimes difficult, resulting in longer surgical time and massive haemorrhage. 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 (Fig. 1).8 When these veins are used, the surgical 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 initially performed using an open approach, but recently there have been reports of laparoscopic9 and robot-assisted approaches10 for donor surgery.
In this review of the literature, we report on the differences in surgical and clinical outcomes by the variation of surgical approach and the preserved veins in UTx living-donor surgery.