Figure 1.
Uterine anatomy and vasculature at various stages of the graft-procurement procedure.
(a) Three abdominal retracting pads provided excellent exposure for microdissection of the sheep uterus, adnexa and their vasculature.
(b and c) The uterus and vessels before excision from the posterior surface (b) and the ventral surface(c).
(d) The excised uterus before transplantation.
(Hysterectomy was started with division of the round ligaments using a cautery. The broad ligament was opened, both the uterine arteries/ veins and both the utero-ovarian arteries/ veins along with both the ureters were carefully dissected from the peritoneal surface. The vessels were dissected free down to a level 20 mm distal to their branching from the internal iliac vessels. The large veins and arteries of the vagina and cervix were ligated and severed at the level of the planned transection of the vagina. The vagina was then divided approximately 5 mm caudal to the cervix. Eight atraumatic vascular clamps were applied to each uterine and utero-ovarian artery and vein, securing the proximal and distal ends of the uterine vasculature. Heparin was then administered. Finally, all the vessels were transected using microsurgical scissors, and total abdominal hysterectomy with oophorosalpingectomy was achieved.).
1, Left uterine horn; 2, left ovary; 3, left uterine artery; 4, left utero-ovarian artery; 5, left utero-ovarian vein; 6, suspensory ligament of left ovary; 7, corpus uteri; 8, cervix uteri.
Figure 2.
Changes in the vulvar skin due to resumption of ovarian cyclicity in the transplanted sheep.
(a) Appearance of the vulvar skin when the ewe is not in estrus.
(b) At 92 days after uterine transplantation, the vulvar skin of ewes 5 showed congestion, swelling and relaxation; which were signs of estrus. The same changes were observed on ewes 8 at 118 days after the transplantation. Thus, vulvar skin changes could be used as a non-invasive measure of successful transplantation.
Figure 3.
The excised uterus was transferred and preserved in a sterile basin, and then chilled in ice at 4°C.
Comparing with uterus in vivo, after perfusion of HTK renal preservation solution through the uterine arterial system, clear blanching of the uterine tissue was observed.
Significant uterine size difference when the uterine allotransplantation were carried out between a normal ewe (ewe 5) and a puerperous ewe which delivered two days before (ewe 6).
(a) Postpartum uterus of ewe 6; (b) normal uterus of ewe 5.
Figure 4.
Bicornuate transplanted uterus and sites of vascular anastomosis.
(a) Sites of utero-vaginal anastomosis and end-to-end vascular anastomoses.
1, Anastomosis site of left uterine artery; 2, anastomosis site of right utero-ovarian artery; 3, anastomosis site of right utero-ovarian vein; 4, anastomosis site of vagina.
(b) Comparing with Figure 3, after re-initiation of blood flow, the color of the uterus rapidly changed from pale to reddish.
Figure 5.
Blood gases and metabolite concentrations at different time points in venous blood samples obtained from the transplanted uterus during reperfusion.
(a), pH levels; (b), lactate concentrations; (c) ratio between pCO2 and pO2 were achieved from the transplanted sheep during the 180 min of reperfusion.
(d) Appropriate tacrolimus trough levels were achieved 15 days after uterin transplantation.
(e) Smooth postoperative temperature curve indicated reasonable immunosuppression and infection prevention.
Figure 6.
Exploratory laparoscopy performed 1 month after the transplantation procedure.
Macroscopically, normal-sized uterus with normal-sized ovaries were seen in the transplantated sheep.
1, transplanted uterus; 2, bladder; 3, Adhesions between the uterus and anterior peritoneum.
Figure 7.
Histological examination of various organs after uterine allotransplantation.
Light micrographs of uterine tissue (a and b).
S, stroma; G, endometrial gland; V, blood vessel.
Hematoxylin–eosin stain; magnification, (a) 100× and (b) 400×.
The area indicated by the arrow in (a) is shown at a higher magnification in (b). The arrows in (b) indicate neutrophilic granulocyte infiltration.
Light micrographs of (c) cervical and (d) ovarian tissue.
Hematoxylin–eosin stain; magnification, 100×.
The arrow in (c) shows typical cervical columnar epithelium.
The arrow in (d) shows a typical secondary follicle.
Light micrographs of (e) hepatic and (f) renal tissue.
Hematoxylin–eosin stain; magnification, 100×.
Both specimens have a normal appearance with few infiltrating neutrophils.