DUETS (Dallas UtErus Transplant Study): The role of imaging in uterus transplantation

Abstract

Objective: Uterus transplantation is rapidly becoming a viable clinical option for women with uterine-factor infertility and a desire for parenthood. Radiological imaging plays a central role in selecting the optimal living donors for uterus transplantation and serves to exclude any pathology and evaluate the uterine vasculature. The latter is the most important variable in the ultimate technical success of the uterus transplant. In this first report of imaging in the setting of uterus transplantation, we report our experience with living-donor selection, and the evolution of the imaging techniques that ultimately allowed a significant improvement in donor selection and transplant outcome. We also suggest a framework for preoperative imaging in uterus transplantation. Methods: Between 2016 and 2018, 27 potential living donors were evaluated by imaging prior to uterine donation for uterus transplantation. Predonation imaging included a screening chest radiograph, dual-phase computed tomography (CT) angiograms of the abdomen and pelvis in the arterial and venous phases and pelvic sonography with Doppler. Seventeen potential donors additionally underwent multiphasic pelvic MR angiograms. The imaging performed was meant to display features of the vascular anatomy relevant for uterus transplantation. Results: Out of the 27 potential live donors who were evaluated by imaging, 9 eventually donated their uterus for transplantation. The most frequent reason for exclusion was suboptimal quality of the vessels (33%), including small uterine arteries, the presence of atherosclerosis or small size/poor quality of the uterine or utero-ovarian veins, or both. The next most common reason was voluntary patient withdrawal or failure to complete the evaluation process (28%). Three potential donors (16.6%) were rejected for uterine factors, fibroids, and/or adenomyosis. Other reasons for donor rejection included ABO incompatibility and unfavorable psychological evaluation. Conclusion: Diagnostic imaging plays a crucial role in selecting appropriate potential donors, screening prospective recipients, planning the graft procedure, and following up on any graft or nongraft-related complications in both the donor and recipient after the transplantation procedure is performed. Contrast-enhanced CT and MR angiographies have complementary roles, especially when evaluating the donor for adequacy of the arterial and venous supply to the uterine graft and the experience gained from our series indicates that the inclusion of both modalities contributed directly to successful uterus transplant graft survival by selecting patients with favorable arterial and venous vasculature.

Uterus Transplantation with Live Donors: Screening Candidates in One French Center

“…Conventional arteriography was added in later LD trials including in ours, which seem necessary to evaluate the uterine artery status of LD [5]. Suboptimal quality of vessels could be a major reason of potential D exclusion [40]. History of at least one normal pregnancy, without recurrent miscarriages seems to be a reasonable precaution for LD.…”

Human uterine vasculature with respect to uterus transplantation: A comprehensive review

“…and Mahmood et al ., 85,86 computed tomography angiography produced an accurate assessment of the arterial vasculature but was unsatisfactory in determining the diameter and length of the venous outflow 85 . MRA with venous phase is reported to provide better imaging of the venous outflow 85,86 . Doppler ultrasound is better utilized in a postoperative follow‐up of the perfusion than it is in donor assessment.…”

“…82 Precise evaluation, and proper donor selection might produce better outcomes. 82,84 According to Testa et al and Mahmood et al, 85,86 computed tomography angiography produced an accurate assessment of the arterial vasculature but was unsatisfactory in determining the diameter and length of the venous outflow. 85 MRA with venous phase is reported to provide better imaging of the venous outflow.…”

“…85 MRA with venous phase is reported to provide better imaging of the venous outflow. 85,86 Doppler ultrasound is Figure 4 A schematic figure of the human uterine graft after retrieval. The graft is procured with both uterine arteries including the segments of the internal iliac arteries, uterine veins including the segments of the internal iliac veins, and ovarian veins, that is, the graft was procured from a deceased donor.…”

Human Uterus Transplantation from Living and Deceased Donors: The Interim Results of the First 10 Cases of the Czech Trial

“…Whereas all of the LDs were assessed using CTA, only three of five DDs were evaluated in this manner. Magnetic resonance angiography (MRA) is reported to achieve better results in the assessment of uterine veins [ 9 , 20 ]. However, none of the donors presented was evaluated with MRA during the first half of the study.…”