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Van Dieren L, Tawa P, Coppens M, Naenen L, Dogan O, Quisenaerts T, Lancia HH, Oubari H, Dabi Y, De Fré M, Thiessen Ef F, Cetrulo CL, Lellouch AG. Acute Rejection Rates in Vascularized Composite Allografts: A Systematic Review of Case Reports. J Surg Res 2024; 298:137-148. [PMID: 38603944 DOI: 10.1016/j.jss.2024.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 01/20/2024] [Accepted: 02/29/2024] [Indexed: 04/13/2024]
Abstract
INTRODUCTION Vascularized Composite Allografts (VCA) are usually performed in a full major histocompatibility complex mismatch setting, with a risk of acute rejection depending on factors such as the type of immunosuppression therapy and the quality of graft preservation. In this systematic review, we present the different immunosuppression protocols used in VCA and point out relationships between acute rejection rates and possible factors that might influence it. METHODS This systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We systematically searched Medline (PubMed), Embase, and The Cochrane Library between November 2022 and February 2023, using following Mesh Terms: Transplant, Transplantation, Hand, Face, Uterus, Penis, Abdominal Wall, Larynx, and Composite Tissue Allografts. All VCA case reports and reviews describing multiple case reports were included. RESULTS We discovered 211 VCA cases reported. The preferred treatment was a combination of antithymocyte globulins, mycophenolate mofetil (MMF), tacrolimus, and steroids; and a combination of MMF, tacrolimus, and steroids for induction and maintenance treatment, respectively. Burn patients showed a higher acute rejection rate (P = 0.073) and were administered higher MMF doses (P = 0.020). CONCLUSIONS In contrast to previous statements, the field of VCA is not rapidly evolving, as it has encountered challenges in addressing immune-related concerns. This is highlighted by the absence of a standardized immunosuppression regimen. Consequently, more substantial data are required to draw more conclusive results regarding the immunogenicity of VCAs and the potential superiority of one immunosuppressive treatment over another. Future efforts should be made to report the VCA surgeries comprehensively, and muti-institutional long-term prospective follow-up studies should be performed to compare the number of acute rejections with influencing factors.
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Affiliation(s)
- Loïc Van Dieren
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Faculty of Medicine and Health Sciences, Antwerp, Belgium; Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Pierre Tawa
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, Massachusetts; Shriners Hospitals for Children-Boston, Boston, Massachusetts
| | - Marie Coppens
- Faculty of Medicine and Health Sciences, Antwerp, Belgium
| | - Laura Naenen
- Faculty of Medicine and Health Sciences, Antwerp, Belgium
| | - Omer Dogan
- Faculty of Medicine and Health Sciences, Antwerp, Belgium
| | | | - Hyshem H Lancia
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Haïzam Oubari
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Yohann Dabi
- Department of Obstetrics, Gynecology and Reproductive Medicine, Sorbonne University, Tenon Hospital (AP-HP), Paris, France
| | - Maxime De Fré
- Department of Plastic, Reconstructive and Aesthetic Surgery, Antwerp University Hospital, Antwerp, Belgium
| | - Filip Thiessen Ef
- Department of Plastic, Reconstructive and Aesthetic Surgery, Antwerp University Hospital, Antwerp, Belgium
| | - Curtis L Cetrulo
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, Massachusetts; Shriners Hospitals for Children-Boston, Boston, Massachusetts
| | - Alexandre G Lellouch
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, Massachusetts; Shriners Hospitals for Children-Boston, Boston, Massachusetts.
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Veroux M, Scollo P, Giambra MM, Roscitano G, Giaquinta A, Setacci F, Veroux P. Living-Donor Uterus Transplantation: A Clinical Review. J Clin Med 2024; 13:775. [PMID: 38337468 PMCID: PMC10856556 DOI: 10.3390/jcm13030775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 01/22/2024] [Accepted: 01/27/2024] [Indexed: 02/12/2024] Open
Abstract
Uterus transplantation (UTx) is currently the only available treatment for absolute uterine factor infertility. More than 90 uterus transplantations have been performed worldwide, mostly from living donors. Living-donor (LD) UTx is a challenging surgical procedure since it poses ethical issues, and it is a high-risk and invasive surgery with higher hysterectomy-related risks compared to conventional hysterectomy. A total of 59 living-donor hysterectomies have been reported in the literature, including 35 performed with a laparotomic approach, 20 with a robotic approach and 4 with a laparoscopic approach. The mean donor age was 45.6 ± 9.1 years, and 22 were unrelated with the recipients, 34 were emotionally related (27 mothers, 5 sisters, 2 mother's sisters). The mean recipient age was 28.8 ± 4.5 years. Mayer-Rokitansky-Küster-Hauser syndrome was the most common indication for uterus transplant. Robotic living-donor hysterectomy had the longest operative time but resulted in a lower blood loss and postoperative stay compared to laparotomic and laparoscopic approaches. Twenty-nine births from LD-UTx have been reported, four after robotic living-donor hysterectomy and twenty-five after a laparotomic procedure. UTx is now an effective treatment for women with UFI. While living-donor UTx in some cases may be considered an experimental procedure, it offers the extraordinary possibility to give women the opportunity to have a pregnancy. Many efforts should be made to reduce the potential risks for donors, including the use of mini-invasive techniques, and the efficacy of UTx in the recipients, giving the potential harm of immunosuppression in a recipient of a non-life-saving organ.
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Affiliation(s)
- Massimiliano Veroux
- Vascular Surgery and Organ Transplant Unit, University Hospital of Catania, 95123 Catania, Italy; (M.M.G.); (G.R.); (A.G.); (F.S.); (P.V.)
| | - Paolo Scollo
- Maternal and Child Department, Obstetrics and Gynecology, Cannizzaro Hospital, 95123 Catania, Italy;
| | - Martina Maria Giambra
- Vascular Surgery and Organ Transplant Unit, University Hospital of Catania, 95123 Catania, Italy; (M.M.G.); (G.R.); (A.G.); (F.S.); (P.V.)
| | - Giuseppe Roscitano
- Vascular Surgery and Organ Transplant Unit, University Hospital of Catania, 95123 Catania, Italy; (M.M.G.); (G.R.); (A.G.); (F.S.); (P.V.)
| | - Alessia Giaquinta
- Vascular Surgery and Organ Transplant Unit, University Hospital of Catania, 95123 Catania, Italy; (M.M.G.); (G.R.); (A.G.); (F.S.); (P.V.)
| | - Francesco Setacci
- Vascular Surgery and Organ Transplant Unit, University Hospital of Catania, 95123 Catania, Italy; (M.M.G.); (G.R.); (A.G.); (F.S.); (P.V.)
| | - Pierfrancesco Veroux
- Vascular Surgery and Organ Transplant Unit, University Hospital of Catania, 95123 Catania, Italy; (M.M.G.); (G.R.); (A.G.); (F.S.); (P.V.)
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Ongun H, Celik K, Arayici S, Dogan NU, Mendilcioglu I, Ozkan O, Ozkan O. Miracles of science: Birth after uterus transplantation. J Obstet Gynaecol Res 2024; 50:5-14. [PMID: 37922953 DOI: 10.1111/jog.15825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 10/19/2023] [Indexed: 11/07/2023]
Abstract
AIM The concept of regaining childbearing ability via uterus transplantation (UTx) motivates many infertile women to pursue giving birth to their own children. This article provides insight into maternal and neonatal outcomes of the procedure globally and facilitates quality of care in related medical fields. METHODS The authors searched ISI Web of Science, MEDLINE, non-PubMed-indexed journals, and common search engines to identify peer-review publications and unpublished sources in scientific reference databases. RESULTS The feasibility of the procedure has been proven with 46 healthy children in 88 procedures so far. Success relies upon dedicated teamwork involving transplantation surgery, obstetrics and reproductive medicine, neonatology, pediatrics, psychology, and bioethics. However, challenges exist owing to donor, recipient, and fetus. Fetal growth in genetically foreign uterine allograft with altered feto-maternal interface and vascular anatomy, immunosuppressive exposure, lack of graft innervation leading to "unable-to-feel" uterine contractions and conception via assisted reproductive technology create notable risks during pregnancy. Significant portion of women are complicated by at least one or more obstetric problems. Preeclampsia, gestational hypertension and diabetes mellitus, elevated kidney indices, and preterm delivery are common complications. CONCLUSIONS UTx has short- and long-term satisfying outcome. Advancements in the post-transplant management would undoubtedly lead this experimental procedure into mainstream clinical practice in the near future. However, both women and children of UTx need special consideration due to prematurity-related neonatal problems and the long-term effects of transplant pregnancy. Notable health risks for the recipient and fetus should be discussed with potential candidates for UTx.
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Affiliation(s)
- Hakan Ongun
- Department of Pediatrics, Division of Neonatology, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - Kiymet Celik
- Department of Pediatrics, Division of Neonatology, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - Sema Arayici
- Department of Pediatrics, Division of Neonatology, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - Nasuh Utku Dogan
- Department of Obstetrics and Gynecology, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - Inanc Mendilcioglu
- Department of Obstetrics and Gynecology, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - Ozlenen Ozkan
- Department of Plastic and Reconstructive Surgery, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - Omer Ozkan
- Department of Plastic and Reconstructive Surgery, Akdeniz University Faculty of Medicine, Antalya, Turkey
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Brännström M, Racowsky C, Carbonnel M, Wu J, Gargiulo A, Adashi EY, Ayoubi JM. Uterus transplantation: from research, through human trials and into the future. Hum Reprod Update 2023; 29:521-544. [PMID: 37328434 PMCID: PMC10477946 DOI: 10.1093/humupd/dmad012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 03/29/2023] [Indexed: 06/18/2023] Open
Abstract
Women suffering from absolute uterine factor infertility (AUFI) had no hope of childbearing until clinical feasibility of uterus transplantation (UTx) was documented in 2014 with the birth of a healthy baby. This landmark accomplishment followed extensive foundational work with a wide range of animal species including higher primates. In the present review, we provide a summary of the animal research and describe the results of cases and clinical trials on UTx. Surgical advances for graft removal from live donors and transplantation to recipients are improving, with a recent trend away from laparotomy to robotic approaches, although challenges persist regarding optimum immunosuppressive therapies and tests for graft rejection. Because UTx does not involve transplantation of the Fallopian tubes, IVF is required as part of the UTx process. We provide a unique focus on the intersection between these two processes, with consideration of when oocyte retrieval should be performed, whether, and for whom, preimplantation genetic testing for aneuploidy should be used, whether oocytes or embryos should be frozen and when the first embryo transfer should be performed post-UTx. We also address the utility of an international society UTx (ISUTx) registry for assessing overall UTx success rates, complications, and live births. The long-term health outcomes of all parties involved-the uterus donor (if live donor), the recipient, her partner and any children born from the transplanted graft-are also reviewed. Unlike traditional solid organ transplantation procedures, UTx is not lifesaving, but is life-giving, although as with traditional types of transplantation, costs, and ethical considerations are inevitable. We discuss the likelihood that costs will decrease as efficiency and efficacy improve, and that ethical complexities for and against acceptability of the procedure sharpen the distinctions between genetic, gestational, and social parenthood. As more programs wish to offer the procedure, we suggest a scheme for setting up a UTx program as well as future directions of this rapidly evolving field. In our 2010 review, we described the future of clinical UTx based on development of the procedure in animal models. This Grand Theme Review offers a closing loop to this previous review of more than a decade ago. The clinical feasibility of UTx has now been proved. Advancements include widening the criteria for acceptance of donors and recipients, improving surgery, shortening time to pregnancy, and improving post-UTx management. Together, these improvements catalyze the transition of UTx from experimental into mainstream clinical practice. The procedure will then represent a realistic and accessible alternative to gestational surrogacy for the treatment of AUFI and should become part of the armamentarium of reproductive specialists worldwide.
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Affiliation(s)
- Mats Brännström
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Stockholm IVF-EUGIN, Stockholm, Sweden
- Department of Obstetrics, Gynecology and Reproductive Medicine, Hospital Foch, Suresnes, France
| | - Catherine Racowsky
- Department of Obstetrics, Gynecology and Reproductive Medicine, Hospital Foch, Suresnes, France
- Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Marie Carbonnel
- Department of Obstetrics, Gynecology and Reproductive Medicine, Hospital Foch, Suresnes, France
- University Versailles, Saint-Quentin en Yvelines, France
| | - Joseph Wu
- Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Antonio Gargiulo
- Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Eli Y Adashi
- Department of Medical Science, Brown University, Providence, RI, USA
| | - Jean Marc Ayoubi
- Department of Obstetrics, Gynecology and Reproductive Medicine, Hospital Foch, Suresnes, France
- University Versailles, Saint-Quentin en Yvelines, France
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Carbonnel M, Karpel L, Corruble N, Legendri S, Pencole L, Cordier B, Racowsky C, Ayoubi JM. Transgender Males as Potential Donors for Uterus Transplantation: A Survey. J Clin Med 2022; 11:jcm11206081. [PMID: 36294400 PMCID: PMC9605112 DOI: 10.3390/jcm11206081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 09/25/2022] [Accepted: 10/11/2022] [Indexed: 11/16/2022] Open
Abstract
Uterus transplantation is a new treatment for patients with absolute uterine infertility that is conducted in order to enable them to carry their own pregnancy. One of the limitations for its development is donor availability. Some transgender males undergo a hysterectomy in the gender-affirming surgery process, and might be interested in donating their uterus for transplantation. In this manuscript, we report the results of a survey designed to determine the attitudes of such individuals regarding donation of their uterus for this purpose. Over 32 years (January 1989-January 2021), 348 biological women underwent hysterectomy at our hospital as part of gender-affirming surgery. The survey was sent to 212 of the 348 prospective participants (for 136, we lacked postal or email addresses). Among the 212 surveys sent, we obtained responses from 94 individuals (44%): 83 (88.3%) stated they would agree to donate, of whom 44 would do so for altruism, 23 for the usefulness of the gesture and 16 out of understanding of the desire to have a child; 63 (75.5%) wanted to know the recipient and 45 (54.2%) wanted to know the result of the donation. According to this survey, a high proportion of transgender males surveyed would be interested in donating their uterus for uterus transplantation.
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Affiliation(s)
- Marie Carbonnel
- Department of Obstetrics and Gynecology, Foch Hospital, 40 Rue Worth, 92150 Suresnes, France
- Medical School, University of Versailles, Saint-Quentin-en-Yvelines, 55 Avenue de Paris, 78000 Versailles, France
- Correspondence:
| | - Léa Karpel
- Department of Obstetrics and Gynecology, Foch Hospital, 40 Rue Worth, 92150 Suresnes, France
| | - Ninon Corruble
- Department of Obstetrics and Gynecology, Foch Hospital, 40 Rue Worth, 92150 Suresnes, France
| | - Sophie Legendri
- Department of Obstetrics and Gynecology, Foch Hospital, 40 Rue Worth, 92150 Suresnes, France
| | - Lucile Pencole
- Department of Obstetrics and Gynecology, Foch Hospital, 40 Rue Worth, 92150 Suresnes, France
| | - Bernard Cordier
- Department of Psychiatry, Hospital Foch, 40 Rue Worth, 92150 Suresnes, France
| | - Catherine Racowsky
- Department of Obstetrics and Gynecology, Foch Hospital, 40 Rue Worth, 92150 Suresnes, France
- Department of Psychiatry, Hospital Foch, 40 Rue Worth, 92150 Suresnes, France
- Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | - Jean-Marc Ayoubi
- Department of Obstetrics and Gynecology, Foch Hospital, 40 Rue Worth, 92150 Suresnes, France
- Medical School, University of Versailles, Saint-Quentin-en-Yvelines, 55 Avenue de Paris, 78000 Versailles, France
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Le Gal C, Carbonnel M, Balaya V, Richard C, Gelin V, Galio L, Sandra O, Hersant B, Bosc R, Charton J, Chavatte-Palmer P, Vialard F, Coscas R, Ayoubi JM. Analysis of Predictive Factors for Successful Vascular Anastomoses in a Sheep Uterine Transplantation Model. J Clin Med 2022; 11:jcm11185262. [PMID: 36142908 PMCID: PMC9503062 DOI: 10.3390/jcm11185262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 07/27/2022] [Accepted: 09/02/2022] [Indexed: 11/16/2022] Open
Abstract
Uterine transplantation is becoming an increasingly realistic therapeutic for uterine infertility. Surgical training on large animal models such as sheep is a prerequisite for establishing a program in humans. The objective of our study was to analyze the predictive factors for successful vascular anastomoses. We performed 40 autotransplants that involved end-to-side anastomoses from the uterine to the external iliac vessels. We analyzed vessel results in terms of success or failure; a total of 78.7% of arterial and 82.9% of venous anastomoses were successful in the immediate postoperative period. In multivariate analysis, independent factors associated with immediate successful vein anastomoses were as follows: a short warm ischemia time (<2 h, OR = 0.05; 95% CI [0.003−0.88], p = 0.04), the absence of any anastomotic complications (OR = 0.06; 95% CI [0.003−0.099], p = 0.049), and their realization by a vascular surgeon (OR = 29.3; 95% CI [1.17−731.9], p = 0.04). Secondly, we showed that an increase in lactate levels greater than 2.72 mmol/L, six hours after reperfusion was predictive of failure, with a sensibility of 85.7% and a specificity of 75.0%. In order to perfect the management of vascular anastomoses by a vascular surgeon, training on animal models and in microsurgery are mandatory in establishing a uterine transplantation program in humans.
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Affiliation(s)
- Claire Le Gal
- UVSQ, INRAE, BREED, Paris-Saclay University, 78350 Jouy-en-Josas, France
| | - Marie Carbonnel
- UVSQ, INRAE, BREED, Paris-Saclay University, 78350 Jouy-en-Josas, France
- Department of Gynecology and Obstetrics, Foch Hospital, 92150 Suresnes, France
- Correspondence:
| | - Vincent Balaya
- Department of Gynecology and Obstetrics, Foch Hospital, 92150 Suresnes, France
| | - Christophe Richard
- UVSQ, INRAE, BREED, Paris-Saclay University, 78350 Jouy-en-Josas, France
- National Veterinary School, BREED, 94700 Maisons-Alfort, France
- MIMA2 Platform, INRAE, 78350 Jouy-en-Josas, France
| | - Valerie Gelin
- UVSQ, INRAE, BREED, Paris-Saclay University, 78350 Jouy-en-Josas, France
- National Veterinary School, BREED, 94700 Maisons-Alfort, France
- MIMA2 Platform, INRAE, 78350 Jouy-en-Josas, France
| | - Laurent Galio
- UVSQ, INRAE, BREED, Paris-Saclay University, 78350 Jouy-en-Josas, France
- National Veterinary School, BREED, 94700 Maisons-Alfort, France
| | - Olivier Sandra
- UVSQ, INRAE, BREED, Paris-Saclay University, 78350 Jouy-en-Josas, France
- National Veterinary School, BREED, 94700 Maisons-Alfort, France
| | - Barbara Hersant
- Department of Maxillofacial and Plastic & Reconstructive Surgery, Henri Mondor University Hospital, 94000 Creteil, France
| | - Romain Bosc
- Department of Maxillofacial and Plastic & Reconstructive Surgery, Henri Mondor University Hospital, 94000 Creteil, France
| | - Johanna Charton
- Department of Vascular Surgery, Amboise Pare University Hospital, AP-HP, 92100 Boulogne-Billancourt, France
| | - Pascale Chavatte-Palmer
- UVSQ, INRAE, BREED, Paris-Saclay University, 78350 Jouy-en-Josas, France
- National Veterinary School, BREED, 94700 Maisons-Alfort, France
| | - François Vialard
- UVSQ, INRAE, BREED, Paris-Saclay University, 78350 Jouy-en-Josas, France
- National Veterinary School, BREED, 94700 Maisons-Alfort, France
- Department of Genetics, Medical Biology Laboratory, Poissy-St Germain en Laye University Hospital, 78300 Poissy, France
| | - Raphael Coscas
- Department of Vascular Surgery, Amboise Pare University Hospital, AP-HP, 92100 Boulogne-Billancourt, France
- UMR 1018, Inserm-Paris11-CESP, Versailles Saint-Quentin-en-Yvelines University, 78000 Versailles, France
| | - Jean-Marc Ayoubi
- UVSQ, INRAE, BREED, Paris-Saclay University, 78350 Jouy-en-Josas, France
- Department of Gynecology and Obstetrics, Foch Hospital, 92150 Suresnes, France
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