Technical Refinements in Brain-dead Donor Uterus Transplantation: Lessons From the 3 First Cases in France.

Background: Uterus procurement from brain-dead donors during multiorgan procurement for uterus transplantation (UTx) presents a technical challenge because the uterus is not a vital organ and also because of the need to harvest uterine and ovarian veins for transplantation. The aim of this article is to describe the technical refinements in uterus procurement from brain-dead donors during multiorgan procurement and evaluate their impact on graft viability in UTx. Methods: According to a prospective interventional study within a national multiorgan procurement network, we described uterus procurement during multiorgan retrieval with protocol modifications between the first and second procedures, including bilateral femoral artery cannulation for pelvic perfusion and in situ identification of uterine and pelvic vessels before cold flushing. The main outcomes were the feasibility of procurement, graft viability, surgical parameters (ischemia times, operative duration), and short-term graft outcomes. Results: Among 8 evaluated recipients, 3 UTx procedures from brain-dead donors were performed. The first transplantation resulted in early graft loss because of bilateral arterial thrombosis requiring graft explantation on postoperative day 1. The second and third transplantations demonstrated sustained graft viability with normal perfusion on Doppler imaging up to 2 and 7 mo, resumption of menstruation, and only 1 episode of mild rejection responsive to corticosteroids. Technical refinements reduced back-table complexity and operative time (5 h 40 min versus 4 h 15 min) and enabled improved venous outflow through additional anastomoses. Bilateral femoral artery cannulation allowed effective pelvic perfusion without interfering with standard multiorgan procurement. Conclusions: UTx from brain-dead donors is feasible within a multiorgan procurement setting. Bilateral femoral cannulation combined with in situ vascular identification improves graft preparation and may enhance reproducibility without compromising retrieval of vital organs. These refinements represent important steps toward standardization of deceased donor UTx.