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.