Background/Objectives: Uterus transplantation (UTx) has evolved into a clinical reality for women with absolute uterine infertility. The international experience with UTx has predominantly utilized living donor grafts—and strategies to minimize harm to donors remain paramount. Robotic living donor hysterectomy represents a minimally invasive approach to facilitate rapid donor recovery, improve pelvic visualization and operative access, and maintain UTx recipient outcomes. The aim of this study is to describe donor, recipient, graft, and pregnancy outcomes after adoption of a robotic living donor hysterectomy program. Methods: The Dallas UtErus Transplant Study (DUETS) incorporated a robotic living donor hysterectomy operative protocol, including transvaginal extraction, from April 2019. Prospectively collected data were analyzed, and a case series presented, to describe donor intra- and post-operative outcomes and recipient intra-operative outcomes, graft viability, established pregnancies, and live births. Early cases were compared to later cases to better describe the learning curve associated with the technique. Results: Sixteen robotic living donor hysterectomies were performed with 100% graft viability after implantation demonstrated by myometrial flow and onset of menses. Early experience (eight cases) demonstrated two cases of ureteric injury. Later experience (eight cases) demonstrated a reduction in operative time (11 h 10 min vs. 6 h 38 min), with no ureteric injuries and a reduction in major operative morbidity from 25% to 12.5% (Clavien–Dindo grade ≥3). At the time of reporting, nine successful live births have occurred, with six ongoing pregnancies. Conclusions: Robotic living donor hysterectomy represents a safe approach to minimize donor harm without compromising UTx recipient, graft, and pregnancy-related outcomes. A learning curve is demonstrated with the adoption of the novel technique—with particularly care required to prevent ureteric injuries, and ongoing vigilance and reporting necessary given the small case numbers of robotic living donor hysterectomy reported internationally.

Background.: Normothermic regional perfusion (NRP) is an organ procurement technique developed for donation after circulatory death (DCD). NRP is associated with better liver transplant outcomes and allows increased risk thresholds for medically complex DCD donors. DCD donors on extracorporeal membrane oxygenation (ECMO) are a category of medically complex donors lacking significant reported experience. Objectives.: This brief report describes the utilization of liver grafts from ECMO-DCD donors using an NRP procurement technique. Methods.: Retrospective analysis of donor and recipient outcomes in 3 cases following abdominal DCD-NRP with ECMO cannula exchange to an NRP circuit. Existing cannulas and tubing can be used for NRP inflow, outflow, or both depending on the configuration. Results.: All donors were older than the age of 50 y and had a functional warm ischemia time of <30 min. NRP duration ranged from 66 to 134 min. All 3 donors demonstrated lactate clearance while on NRP. Recipient age ranged from 52 to 68 and model for end-stage liver disease scores were 22, 26, and 7. All had a 1-d intensive care unit stay and 5- to 7-d total hospital length of stay. One of the 3 recipients had a biliary anastomotic stricture. Conclusions.: This report demonstrates the technical and clinical feasibility of liver transplantation from ECMO-DCD-NRP donors. Preoperative planning for the utilization of existing cannulas, the addition of needed inflow or outflow, and circuit exchange logistics is essential for a smooth transition to NRP in these cases.