“This is how we do it” Anaesthesia for uterine transplant and associated surgeries: the Australian-Swedish collaborative protocol

Uterine transplantation represents a groundbreaking fertility treatment for individuals with uterine factor infertility. Since the first successful live birth from uterine transplantation in 2014, surgical technique and outcomes have been widely reported yet published anaesthetic guidance remains limited. Australia's first uterine transplantation was performed in early 2023 at the Royal Hospital for Women, Sydney, Australia. Anaesthesia for uterine transplantation is complex, requiring multidisciplinary planning. Donor hysterectomy is an extended procedure (8 to 12 h) involving radical dissection, anticoagulation, thromboembolic prophylaxis, and postoperative pain control, with epidural analgesia. Recipient surgery, while shorter (4 to 7 h), demands coordination between surgical teams to minimise graft ischaemia time and optimise immunosuppressant administration. Aseptic technique and haemodynamic monitoring are critical components of perioperative care. Following uterine transplantation, recipients may require anaesthesia for cervical biopsies for rejection surveillance or for embryo transfer. These procedures may be prior to, or during pregnancy. Obstetric anaesthetic considerations include the impact of immunosuppression, heightened risks of preeclampsia and acute kidney injury and preterm delivery, and requirements for perioperative planning of caesarean section. Elective and emergency caesarean deliveries can be successfully managed with combined spinal-epidural anaesthesia, with special attention to haemorrhage risk and postoperative analgesia. The final stage of the uterine transplantation pathway is graft hysterectomy, performed electively following completed fertility treatment or for medical indications. This review outlines the anaesthetic considerations for uterine transplantation and all related surgeries, providing insights into perioperative planning, multidisciplinary collaboration, and evolving protocols drawing on the experience at the Royal Hospital for Women. The uterine transplants referred to in this paper were part of a clinical trial, registration number ACTRN12622000917730, Ethics approval 2019/ETH13038.