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Homotransplantation of uterus and ovaries in dogs
Homotransplantation of uterus and ovaries in
dogs A preliminary report
ROBERT H. YONEMOTO, M.D., F.A.C.S. WILLIAM D. DU SOLD, M.D. ROBERT M. DELIMAN, M.D., F.A.C.S. Duarte, California An experimental technique f.or homotransplantation of the uterus and ovary by vascular anastomosis, in dogs, is described. Of 14 such homotransplantations, 5 were in male recipients. There were 6 immediate postoperative deaths and 8 long-term survivors. Viable uteri were found in 5 of the 8 long-term survivors when they were killed on a scheduled date. Detailed discussion on the rejection pattern, the uniqueness of the uterus as a fetus-harboring organ, and review of the literature is included. To our knowledge, homotransplantation of the uterus by vascular anastomosis has not been previously reported.
M u c H o F the work on uterine transplantation of the past was performed to investigate the uteroovarian cyclic function or to ameliorate traumatic amenorrhea. Numerous studies of suspension of uterine tissue, 4 endometrial tissue, 5• 24 • 28 uterine slices, 5 • 20 or the entire horn in a two-stage transplant procedure were carried out to determine the influence of the uterus on ovarian function. Various species of animals were subjected to this type of investigation. These included guinea pigs, 4 • 5· 8 • 15 • 20 rabbits,S• 24 • 28 mice,1 2 • 26 hamsters/• 22 and dogs.6, 1, 1• In these experiments either a portion of the uterus or the total uterus was implanted as a free graft intraperitoneally, intramuscularly, subcutaneously, or into the hamster's cheek pouch. The clinical application
for uterine transplant in the field of traumatic amenorrhea was summarized by Asherman1 in 1960. Bykow6 in 1927 successfully autotransplanted the uterus in dogs on three occasions by wrapping the uterus in the omentum after the uterus was resected free of its blood supply. Eight months following the reimplant, the uterus was found to be viable on exploration. Zhordania and Gotsiridze34• 35 in 1963 and 1964 utilizing dogs, rabbits, and ewes performed autotransplantation of the entire uterus with its adnexal organs utilizing similar techniques. Omentopexy for revascularization was used with 12 normal deliveries resulting out of 20 cases of probable pregnancies in the ewes. The distal end of the "internal genitals was sutured to the bottom of the pelvis restoring the patency of the cervix" in all these cases. Eraslan, Hamernik, and Hardy, 10 • 14 in 1964 and 1966, were first to perform autotransplantation of the uterus with its adnexal organ by vascular anastomosis in the canine species. They performed the operation on 18 nonpregnant female dogs, with
From Department of General and Oncologic Surgery, City of Hope Medical Center. Supported in part by the General Research Support Grant, National Institutes of Health, and the Saul C. Rockoff Fund.
1143
\u~HSI
1144 Yonemoto, Du Sold, and Deliman
evidence of patency of the vascular channels and ovarian function in the long-term survival group. In 3 dogs subsequent pregnancy ensued, with reported gestation and delivery in 2. The history of ovarian transplantation antedates that of the uterine transplant. Knauer18 ( 1896) and Grigor'e\' 11 ( 1897) demonstrated that ovarian autografts could survive in experimental animals for prolonged periods of time with occasional successful gestation in these animals. Much of the extensive experimental work performed during the early part of this century is well summarized by Martin,~ 1 who contributed considerable information from his own experimentation as well. From the clinical standpoint, aside from attempted rejuvenation, ovarian transplantation was performed basically to conserve or re-establish the physiologic state and menstruation after removal of the adnexal organ and to try to ameliorate the undesirable symptoms of menopause. Another goal of ovarian transplantation was to studv the aging process in animals. Martin 21 in 1922 summarized the status of homotransplantation and heterotransplantation up to that period hv stating, "'Vhile autotransplants give some evidence of success, homotransplants and heterotransplants give practically none at all.'' An extensive bibliography covering the first half of the twentieth century, both in the t
.\m.
J Obst.
J.J, J91J9
& ( ;ynt·r.
Material and methods
The animals utilized in this experiment were adult healthy mongrel dogs, fully immunized against distemper and hepatitis. All recipient dogs were started on Imuran 3 to 5 clays prior to operation. The usual dose was 5 mg. per kilogram per day, with a large booster the day of operation. There were 5 males and 9 females which sen.·ecl as recipients. Male dogs were g·iven stilbestrol in physiologic dose range in an attempt to improve the hormonal environment. All dogs were anesthetized by intrayenous Nembutal, and respiration was maintained via an endotracheal positive pressure respirator. A midline lower abdominal incision
Fig.
l. Vascni:Jr anatomy of the uterus and
ovaries.
Volume 104 Number 8
Homotransplantation of uterus and ovaries m dogs
was used for both donor and recipient dogs. The donor specimen was prepared first by carefully dissecting out the main trunk of the common hypogastric artery and tracing it down to the uterine arteries. All other branches were divided and ligated (Fig. 1). The resulting arterial arcade with the uterus enveloped the sigmoid colon in such a fashion that the only manner in which the specimen could be delivered was by transecting the sigmoid colon. The uterine veins were exposed near the cervix and traced to the internal iliac vein and further to the junction of common iliac vein, where it was eventually divided. The dissection was tedious and the utmost care was needed to preserve the vascular tree. Distally the uterus was divided across the vagina and superiorly the cornua of the uterus were transected, thus excluding the ovaries, since ovarian arterial anastomosis was not deemed practical due to the small size of this vessel. However, in 5 later experiments, the ovaries were left attached to the uterine horn and were transplanted simultaneously, thus relying totally on the distal uterine artery which eventually formed an arcade with the ovarian artery to supply these
1145
structures. The donor specimen was delivered by dividing the common trunk of the hypogastric artery between two arterial clamps and by dividing the internal iliac veins at the junction of the external iliac veins. The specimen was quickly flushed with chilled Ringer's lactate solution containing heparin and transplanted into the recipient's pelvis. An end-to-end single-layer anastomosis of the common internal iliac artery with continuous 5-0 silk and an end-to-side anastomosis of the internal iliac veins to the common iliac vein on each side completed the procedure. Thus one arterial and two venous anastomoses were performed. When the recipient dog was a female, the vaginal cuff was anastomosed with continuous 2-0 chromic catgut sutures, but in the few instances when the recipient dogs were males the vaginal cuff was simply oversewn with 2-0 chromic catgut suture for hemostatic purposes. No effort was made to cover the uterus with the omentum. Postoperatively, Imuran was continued at a dose schedule of 3.0 to 5.0 mg. per kilogram per day except where falling white cell counts prevented its further use. All dogs received Combiotic for 5 days. Surviving
Table I. Uterine and ovarian homotransplantation in dogs Experiment No.
Sex
Days
Postoperative death group survival Female 94 2 Female 1 96 Male 3 110 Male 1 111 118 Male 5 Female 119 6 Survival group 95
Viable uterus
Ovarian transplant
Comment
No Yes Yes No Yes Yes
No No Yes No Yes Yes
Death due to hemorrhage Death due to hemorrhage Death due to evisceration Pregnant uterus. Hemorrhagic death Death due to intussusception Death due to hemorrhage Thrombosis of one uterine artery Horns partially necrotic Open biopsy 21 days Killed at 45 days Myometrium intact Endometrium remnants only Replaced by cystic mass Complete necrosis Complete necrosis Both uterine arteries patent Death from lmuran toxicity
Day killed
102
Male Female Female
21 14 45
Yes Yes Yes
No No No
106
Female
42
Yes
No
109 120 121
Female Male Female Female
17
No No No Yes
Yes No No Yes
103
122
37 49 11
1146 Yonemoto, Du Sold, and Deliman
August 15, 1969 Am ]. Obst. & Gynec.
animals were re-explored at 2 to 3 week intervals and biopsy of viable tissue was performed. All animals killed and all which died postoperatively were examined carefully to determine patency of vascular anastomosis, and tissue slides were prepared for microscopic examination.
walls, especially the venous anastomosis. The dog survived less than 24 hours and died from hemorrhage. Of the remaining 2 males, one showed partial survival of the transplant at 21 days when killed. Examination of the transplanted specimen revealed patency of the common internal iliac artery and one of the uterine arteries. The other revealed complete necrosis of the uterus with rejection when killed at 37 days. Since the number of male recipients was very small, no meaningful conclusions could be deduced from these experiments, when compared with the female recipients. Of the 9 female recipients, 3 died from postoperative hemorrhage. The remaining 6 survived from 11 to 49 days with varying success. In 2, complete necrosis of the uterus beyond recognition ensued and in 4- viable uterus was noted when killed or reoperated upon on a scheduled date. The animal killed at the end of 45 days (Experiment 102) showed a particularly favorable course which is outlined in Fig. 2. When re-explored at 21 days the uterus appeared enlarged and
Results !Table ll
Fourteen dogs served as reCipients for homotransplanted uteri. There were 5 males and 9 females. There were 6 deaths considered to be complications of the operation: 4 deaths from hemorrhage, 1 death from evisceration, and 1 death from intussusception. Three deaths were in the male dogs. One of these represented an unusual situation (Experiment 111). A pregnant animal served as a donor. That the animal was pregnant was unknown to us prior to the operation. Because of the size of the uterus with the embryos, only one uterine horn was removed and transplanted into the male recipient. The technique was very difficult because of the increased vascularity and attenuated vascular
UTERINE TRANSPLANT
~
~
WBC
AUTOPSY
BIOPSY. UTERUS
50,000
il!li
I MURAN
•
CORTISONE ACETATE
40,000
IMURAN mg. 400
30,000
20,000 200 10,000
0
-5
0
t
OPERATION
5
10
15
20
·-··
•., Ill
I
25
POST-OPERATIVE DAYS Fig. 2. Clinical course of dog in Experiment 102.
30
35
40
I
45
Volume 104 Number 8
Homotransplantation of uterus and ovaries in dogs
edematous. Direct biopsy was done which showed well-preserved architectural pattern of the endometrial lining in most areas (Fig. 3A), but the myometrium showed occasional perivascular collections of round cells, suggesting early rejection (Fig. 3, B). When killed at 45 days the uterus was found to have resumed its normal size and histologically a secretory phase of endometrium with a perfectly normal myometrium was noted (Fig. 3, C). No evidence of the rejection cells formerly seen at 21 days could be found in this specimen. The vaginal anastomosis was also intact and the vascular channels were found to be patent. Very few adhesions were noted and the uterus appeared grossly normal (Fig. 4). The five ovarian transplants were all done in dogs which did not survive beyond 17
1147
days. Three were in the short-term surviving group which died due to immediate postoperative complications. One dog was killed on the seventeenth postoperative day and was found to have complete necrosis of both the uterus and ovaries. The fifth dog died on the eleventh postoperative day from Imuran toxicity with an intact uterus as well as ovaries. The arterial arcade up to the ovaries was found to be patent. Fig. 5 is a photomicrograph of an ovarian transplant (Experiment 118). Comment The uniqueness of the uterus as the object of homotransplantation lies in the fact that this organ in a natural state is capable of harboring a foreign body, namely, a fetus, which is genetically different from the stand-
Fig. 3A. Experiment 102. Photomicrograph of uterine wall secured from open biopsy at 21 days. Good preservation of architectural pattern is noted with intact endometrium.
B
Fig. 3. B, Experiment 102. Photomicrograph from myometrium at 21 days with perivascular pyrinophilic round cell infiltration suggesting rejection. C. Experiment 102. Photomicrograph of uterine wall near horn, secured from specimen when dog was killed at 45 days. Normal endometrial lining and myometrium with no evidence of rejection is noted.
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Homotransplantation of uterus and ovaries in dogs
Fig. 4. Experiment 102. Gross appearance of uterus when dog was killed at 45 days. The Ellis clamps are placed on the cornu. ·
Fig. 5. Experiment 118. Viable ovary with active follicles.
1149
1150 Yonemoto, Du Sold, and Deliman
point of histocompatibility factors. The theory which considers the uterus as a "privileged site" is an attractive one, but there is strong evidence against it. 2 Extrauterine pregnancy to full term is known to occur both in man and in experimental animals. 16, 2s, 29, 3o, 31, 32, 33 The cheek pouch of the hamster, the brain and the anterior chamber of the eye are considered to be privileged sites but they are quite unique from the standpoint that the first two do not provide the inserted graft with a lymphatic drainage, and the anterior chamber of the eye is exempt from homograft reaction because of its absence of vascularity. Therefore, the uterus cannot be considered analogous to these privileged sites regarding tissue or organ transplants. Furthermore, decisive evidence that the uterus is not endowed with distinctive properties that make it a favorable site for
Am.
l
,\ugust 15, 1969 Obst. & Gyncc.
implantation of embryo is given by Schlesinger/7 who found that the reactivity of the uterus to implanted tumor tissue was much the same as other sites of the body. It appears probable that the reason is on the basis of complete separation of the two by a no nan tigenic trophoblast membrane"' and that the uterine tissue itself does not in any way possess a distinct antigenic peculiarity. The uterine tissue undoubtedly maintains a constant state of antigenicity whether gestational or in normal state. During the rejection phase we obst:>rved perivascular pyrinophylic round cell infiltration identical to that seen in other organs undergoing the rejection phenomenon. When full rejection ensues, sloughing of the f'lldometriallining first takes place. with resulting flattening of the endometrial layer (Fig. 6). The myometrium appears to have the greatest resistance to rejection, and it re·
Fig. 6. Experiment 118. Sloughing and flattening of endometrium from rejection. This dog died from intussusception on the fifth postoperative day but rejection was not controlled.
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Homotransplantation of uterus and ovaries m dogs
tains its architectural structure the longest. Swelling of the uterus is noted during the early phase of the homograft rejection, much in the same manner as renal homograft rejection. The use of male recipients was forced upon us because of the scarcity of female dogs. Whether estrogen administration aids in maintaining a graft survival or not could not be ascertained from this small number of experiments, since only 2 male recipients survived sufficient length of time for evaluation. Halsted 13 laid down a principle that endocrine grafts would only take when the hormone secreted by the transplanted endocrine organ was absolutely deficient within the organism. If Halsted's law of depriva-
REFERENCES
1. Asherman, J. G.: ]. Obst. & Gynaec. Brit. Emp. 67: 228, 1960. 2. Billingham, R. E.: New England J. Med. 270: 667' 720, 1964. 3. Billingham, R. E., and Silvers, W. K.: J. Immunol. 85: 14, 1960. 4. Bradbury, J. T., Brown, W. E., and Gray, L. A.: Recent Progr. Hormone Res. 5: 151, 1950. 5. Butcher, R. L., Chu, K. Y., and Melampy, R. M.: Endocrinology 70: 442, 1962. 6. Bykow, S. G.: Monatsschr. Geburtsh. u. Gynak. 76: 186, 1927. 7. Cheval, M.: Proc. Roy. Soc. Med. 27: 1395, 1934. 8. Chu, J. P., Lee C. C., and You, S. S.: J. Endocrinol. 4: 392, 1946. 9. Duby, R. T., McDaniel, J. W., and Black, D. L.: Nature 205: 720, 1965. 10. Eraslan, S., Hamernik, R. J., and Hardy, J. D.: Arch. Surg. 92: 9, 1966. 11. Grigor'ev, cited by Demikhov, V. P.: Experimental Transplantation of Vital Organs, New York, 1962, Consultants Bureau Enterprises, Inc., p. 16. 12. Hall, G. ].: M. Rec. 139: 109, 1934. 13. Halsted, W. S.: J. Exper. Med. 11: 175, 1909. 14. Hamernik, R. J., Eraslan, S., and Hardy, J. D.: S. Forum 15: 383, 1964. 15. Hechter, 0., Fraenkel, M., Lev, M., and Soskin, S.: Endocrinology 26: 680, 1940. 16. Jarcho, J.: Am. J. Surg. 77: 273, 423, 1949. 17. Kakuschkin, N., and Bykow, S.: Monatsschr. Geburtsh. u. Gynak. 71: 181, 192.5. 18. Knauer, E.: Zentralb. Gynak. 20: 524, 1896.
1151
tion applies in the case of ovarian homotransplantation, additive estrogen therapy would be contraindicated. This remains to be seen. The sex-linked histocompatibility antigens would not interfere when uteri are transplanted into male recipients, smce transplantation antigen is located on the Y chromosome, 3 which is lacking in the female. Although there are reported cases of successful autotransplantation of the uterus by omentopexy, homotransplantation of the uterus by vascular anastomosis could be the only means by which successful end results can be achieved, in spite of the fact that preparation of the specimen is a time-consuming tedious task.
19. Krohn, P. L.: Transplantation Bull. 2: 15, 1955. 20. Loeb, L.: Am. J. Psycho!. 83: 202, 1927. 21. Martin, F. H.: Surg. Gynec. & Obst. 35: 573, 1922. 22. McDaniel, J. W., and Black, D. L.: Nature 202: 810, 1964. 23. Medawar, P. B.: Some Immunological and Endocrinological Problems Raised by Evolution of Viviparity in Vertebrates, in Society for Experimental Biology. Evolution (papers read at symposium of the Society held in collaboration with Genetical Society of Oxford in July, 1952), New York, 1953, Academic Press, Inc., Symposium No. 11, pp. 320-338. 24. Mishell, D. R., and Motyloff, L.: Endocrinology 28: 436, 1940. 25. Nicholas, J. S.: Anat. Rec. 58: 387, 1934. 26. Parfenoff, N.: Monatsschr. Geburtsh. u. Gynak. 88: 423, 1931. 27. Schlesinger, M.: J. Nat. Cancer Inst. 28: 927, 1962. 28. Sessums, J. V., and Murphy, D. P.: Surg. Gynec. & Obst. 56: 600, 1933. 29. Thiersch, J. B.: M. J. Australia 2: 127, 1941. 30. Thomas, R. C.: J. Obst. & Gynaec. Brit. Emp. 50: 189, 1943. 31. Waynforth, H. B.: J. Endocrinol. 33: 11, 1965. 32. Weiner, J. J.: Am. J. Surg. 65: 288, 1944. 33. Williams, C.: M. J. Australia 2: 326, 1941. 34. Zhordania, I. F., and Gotsiridze, 0. A.: Acta chir. plast. 6: 1, 1964. 35. Zhordania, I. F., and Gotsiridze, 0. A.: Internat. J. Fertil. 8: 849, 1963.
dogs A preliminary report
ROBERT H. YONEMOTO, M.D., F.A.C.S. WILLIAM D. DU SOLD, M.D. ROBERT M. DELIMAN, M.D., F.A.C.S. Duarte, California An experimental technique f.or homotransplantation of the uterus and ovary by vascular anastomosis, in dogs, is described. Of 14 such homotransplantations, 5 were in male recipients. There were 6 immediate postoperative deaths and 8 long-term survivors. Viable uteri were found in 5 of the 8 long-term survivors when they were killed on a scheduled date. Detailed discussion on the rejection pattern, the uniqueness of the uterus as a fetus-harboring organ, and review of the literature is included. To our knowledge, homotransplantation of the uterus by vascular anastomosis has not been previously reported.
M u c H o F the work on uterine transplantation of the past was performed to investigate the uteroovarian cyclic function or to ameliorate traumatic amenorrhea. Numerous studies of suspension of uterine tissue, 4 endometrial tissue, 5• 24 • 28 uterine slices, 5 • 20 or the entire horn in a two-stage transplant procedure were carried out to determine the influence of the uterus on ovarian function. Various species of animals were subjected to this type of investigation. These included guinea pigs, 4 • 5· 8 • 15 • 20 rabbits,S• 24 • 28 mice,1 2 • 26 hamsters/• 22 and dogs.6, 1, 1• In these experiments either a portion of the uterus or the total uterus was implanted as a free graft intraperitoneally, intramuscularly, subcutaneously, or into the hamster's cheek pouch. The clinical application
for uterine transplant in the field of traumatic amenorrhea was summarized by Asherman1 in 1960. Bykow6 in 1927 successfully autotransplanted the uterus in dogs on three occasions by wrapping the uterus in the omentum after the uterus was resected free of its blood supply. Eight months following the reimplant, the uterus was found to be viable on exploration. Zhordania and Gotsiridze34• 35 in 1963 and 1964 utilizing dogs, rabbits, and ewes performed autotransplantation of the entire uterus with its adnexal organs utilizing similar techniques. Omentopexy for revascularization was used with 12 normal deliveries resulting out of 20 cases of probable pregnancies in the ewes. The distal end of the "internal genitals was sutured to the bottom of the pelvis restoring the patency of the cervix" in all these cases. Eraslan, Hamernik, and Hardy, 10 • 14 in 1964 and 1966, were first to perform autotransplantation of the uterus with its adnexal organ by vascular anastomosis in the canine species. They performed the operation on 18 nonpregnant female dogs, with
From Department of General and Oncologic Surgery, City of Hope Medical Center. Supported in part by the General Research Support Grant, National Institutes of Health, and the Saul C. Rockoff Fund.
1143
\u~HSI
1144 Yonemoto, Du Sold, and Deliman
evidence of patency of the vascular channels and ovarian function in the long-term survival group. In 3 dogs subsequent pregnancy ensued, with reported gestation and delivery in 2. The history of ovarian transplantation antedates that of the uterine transplant. Knauer18 ( 1896) and Grigor'e\' 11 ( 1897) demonstrated that ovarian autografts could survive in experimental animals for prolonged periods of time with occasional successful gestation in these animals. Much of the extensive experimental work performed during the early part of this century is well summarized by Martin,~ 1 who contributed considerable information from his own experimentation as well. From the clinical standpoint, aside from attempted rejuvenation, ovarian transplantation was performed basically to conserve or re-establish the physiologic state and menstruation after removal of the adnexal organ and to try to ameliorate the undesirable symptoms of menopause. Another goal of ovarian transplantation was to studv the aging process in animals. Martin 21 in 1922 summarized the status of homotransplantation and heterotransplantation up to that period hv stating, "'Vhile autotransplants give some evidence of success, homotransplants and heterotransplants give practically none at all.'' An extensive bibliography covering the first half of the twentieth century, both in the t
.\m.
J Obst.
J.J, J91J9
& ( ;ynt·r.
Material and methods
The animals utilized in this experiment were adult healthy mongrel dogs, fully immunized against distemper and hepatitis. All recipient dogs were started on Imuran 3 to 5 clays prior to operation. The usual dose was 5 mg. per kilogram per day, with a large booster the day of operation. There were 5 males and 9 females which sen.·ecl as recipients. Male dogs were g·iven stilbestrol in physiologic dose range in an attempt to improve the hormonal environment. All dogs were anesthetized by intrayenous Nembutal, and respiration was maintained via an endotracheal positive pressure respirator. A midline lower abdominal incision
Fig.
l. Vascni:Jr anatomy of the uterus and
ovaries.
Volume 104 Number 8
Homotransplantation of uterus and ovaries m dogs
was used for both donor and recipient dogs. The donor specimen was prepared first by carefully dissecting out the main trunk of the common hypogastric artery and tracing it down to the uterine arteries. All other branches were divided and ligated (Fig. 1). The resulting arterial arcade with the uterus enveloped the sigmoid colon in such a fashion that the only manner in which the specimen could be delivered was by transecting the sigmoid colon. The uterine veins were exposed near the cervix and traced to the internal iliac vein and further to the junction of common iliac vein, where it was eventually divided. The dissection was tedious and the utmost care was needed to preserve the vascular tree. Distally the uterus was divided across the vagina and superiorly the cornua of the uterus were transected, thus excluding the ovaries, since ovarian arterial anastomosis was not deemed practical due to the small size of this vessel. However, in 5 later experiments, the ovaries were left attached to the uterine horn and were transplanted simultaneously, thus relying totally on the distal uterine artery which eventually formed an arcade with the ovarian artery to supply these
1145
structures. The donor specimen was delivered by dividing the common trunk of the hypogastric artery between two arterial clamps and by dividing the internal iliac veins at the junction of the external iliac veins. The specimen was quickly flushed with chilled Ringer's lactate solution containing heparin and transplanted into the recipient's pelvis. An end-to-end single-layer anastomosis of the common internal iliac artery with continuous 5-0 silk and an end-to-side anastomosis of the internal iliac veins to the common iliac vein on each side completed the procedure. Thus one arterial and two venous anastomoses were performed. When the recipient dog was a female, the vaginal cuff was anastomosed with continuous 2-0 chromic catgut sutures, but in the few instances when the recipient dogs were males the vaginal cuff was simply oversewn with 2-0 chromic catgut suture for hemostatic purposes. No effort was made to cover the uterus with the omentum. Postoperatively, Imuran was continued at a dose schedule of 3.0 to 5.0 mg. per kilogram per day except where falling white cell counts prevented its further use. All dogs received Combiotic for 5 days. Surviving
Table I. Uterine and ovarian homotransplantation in dogs Experiment No.
Sex
Days
Postoperative death group survival Female 94 2 Female 1 96 Male 3 110 Male 1 111 118 Male 5 Female 119 6 Survival group 95
Viable uterus
Ovarian transplant
Comment
No Yes Yes No Yes Yes
No No Yes No Yes Yes
Death due to hemorrhage Death due to hemorrhage Death due to evisceration Pregnant uterus. Hemorrhagic death Death due to intussusception Death due to hemorrhage Thrombosis of one uterine artery Horns partially necrotic Open biopsy 21 days Killed at 45 days Myometrium intact Endometrium remnants only Replaced by cystic mass Complete necrosis Complete necrosis Both uterine arteries patent Death from lmuran toxicity
Day killed
102
Male Female Female
21 14 45
Yes Yes Yes
No No No
106
Female
42
Yes
No
109 120 121
Female Male Female Female
17
No No No Yes
Yes No No Yes
103
122
37 49 11
1146 Yonemoto, Du Sold, and Deliman
August 15, 1969 Am ]. Obst. & Gynec.
animals were re-explored at 2 to 3 week intervals and biopsy of viable tissue was performed. All animals killed and all which died postoperatively were examined carefully to determine patency of vascular anastomosis, and tissue slides were prepared for microscopic examination.
walls, especially the venous anastomosis. The dog survived less than 24 hours and died from hemorrhage. Of the remaining 2 males, one showed partial survival of the transplant at 21 days when killed. Examination of the transplanted specimen revealed patency of the common internal iliac artery and one of the uterine arteries. The other revealed complete necrosis of the uterus with rejection when killed at 37 days. Since the number of male recipients was very small, no meaningful conclusions could be deduced from these experiments, when compared with the female recipients. Of the 9 female recipients, 3 died from postoperative hemorrhage. The remaining 6 survived from 11 to 49 days with varying success. In 2, complete necrosis of the uterus beyond recognition ensued and in 4- viable uterus was noted when killed or reoperated upon on a scheduled date. The animal killed at the end of 45 days (Experiment 102) showed a particularly favorable course which is outlined in Fig. 2. When re-explored at 21 days the uterus appeared enlarged and
Results !Table ll
Fourteen dogs served as reCipients for homotransplanted uteri. There were 5 males and 9 females. There were 6 deaths considered to be complications of the operation: 4 deaths from hemorrhage, 1 death from evisceration, and 1 death from intussusception. Three deaths were in the male dogs. One of these represented an unusual situation (Experiment 111). A pregnant animal served as a donor. That the animal was pregnant was unknown to us prior to the operation. Because of the size of the uterus with the embryos, only one uterine horn was removed and transplanted into the male recipient. The technique was very difficult because of the increased vascularity and attenuated vascular
UTERINE TRANSPLANT
~
~
WBC
AUTOPSY
BIOPSY. UTERUS
50,000
il!li
I MURAN
•
CORTISONE ACETATE
40,000
IMURAN mg. 400
30,000
20,000 200 10,000
0
-5
0
t
OPERATION
5
10
15
20
·-··
•., Ill
I
25
POST-OPERATIVE DAYS Fig. 2. Clinical course of dog in Experiment 102.
30
35
40
I
45
Volume 104 Number 8
Homotransplantation of uterus and ovaries in dogs
edematous. Direct biopsy was done which showed well-preserved architectural pattern of the endometrial lining in most areas (Fig. 3A), but the myometrium showed occasional perivascular collections of round cells, suggesting early rejection (Fig. 3, B). When killed at 45 days the uterus was found to have resumed its normal size and histologically a secretory phase of endometrium with a perfectly normal myometrium was noted (Fig. 3, C). No evidence of the rejection cells formerly seen at 21 days could be found in this specimen. The vaginal anastomosis was also intact and the vascular channels were found to be patent. Very few adhesions were noted and the uterus appeared grossly normal (Fig. 4). The five ovarian transplants were all done in dogs which did not survive beyond 17
1147
days. Three were in the short-term surviving group which died due to immediate postoperative complications. One dog was killed on the seventeenth postoperative day and was found to have complete necrosis of both the uterus and ovaries. The fifth dog died on the eleventh postoperative day from Imuran toxicity with an intact uterus as well as ovaries. The arterial arcade up to the ovaries was found to be patent. Fig. 5 is a photomicrograph of an ovarian transplant (Experiment 118). Comment The uniqueness of the uterus as the object of homotransplantation lies in the fact that this organ in a natural state is capable of harboring a foreign body, namely, a fetus, which is genetically different from the stand-
Fig. 3A. Experiment 102. Photomicrograph of uterine wall secured from open biopsy at 21 days. Good preservation of architectural pattern is noted with intact endometrium.
B
Fig. 3. B, Experiment 102. Photomicrograph from myometrium at 21 days with perivascular pyrinophilic round cell infiltration suggesting rejection. C. Experiment 102. Photomicrograph of uterine wall near horn, secured from specimen when dog was killed at 45 days. Normal endometrial lining and myometrium with no evidence of rejection is noted.
Volume 104 Number 8
Homotransplantation of uterus and ovaries in dogs
Fig. 4. Experiment 102. Gross appearance of uterus when dog was killed at 45 days. The Ellis clamps are placed on the cornu. ·
Fig. 5. Experiment 118. Viable ovary with active follicles.
1149
1150 Yonemoto, Du Sold, and Deliman
point of histocompatibility factors. The theory which considers the uterus as a "privileged site" is an attractive one, but there is strong evidence against it. 2 Extrauterine pregnancy to full term is known to occur both in man and in experimental animals. 16, 2s, 29, 3o, 31, 32, 33 The cheek pouch of the hamster, the brain and the anterior chamber of the eye are considered to be privileged sites but they are quite unique from the standpoint that the first two do not provide the inserted graft with a lymphatic drainage, and the anterior chamber of the eye is exempt from homograft reaction because of its absence of vascularity. Therefore, the uterus cannot be considered analogous to these privileged sites regarding tissue or organ transplants. Furthermore, decisive evidence that the uterus is not endowed with distinctive properties that make it a favorable site for
Am.
l
,\ugust 15, 1969 Obst. & Gyncc.
implantation of embryo is given by Schlesinger/7 who found that the reactivity of the uterus to implanted tumor tissue was much the same as other sites of the body. It appears probable that the reason is on the basis of complete separation of the two by a no nan tigenic trophoblast membrane"' and that the uterine tissue itself does not in any way possess a distinct antigenic peculiarity. The uterine tissue undoubtedly maintains a constant state of antigenicity whether gestational or in normal state. During the rejection phase we obst:>rved perivascular pyrinophylic round cell infiltration identical to that seen in other organs undergoing the rejection phenomenon. When full rejection ensues, sloughing of the f'lldometriallining first takes place. with resulting flattening of the endometrial layer (Fig. 6). The myometrium appears to have the greatest resistance to rejection, and it re·
Fig. 6. Experiment 118. Sloughing and flattening of endometrium from rejection. This dog died from intussusception on the fifth postoperative day but rejection was not controlled.
Volume 104 Number 8
Homotransplantation of uterus and ovaries m dogs
tains its architectural structure the longest. Swelling of the uterus is noted during the early phase of the homograft rejection, much in the same manner as renal homograft rejection. The use of male recipients was forced upon us because of the scarcity of female dogs. Whether estrogen administration aids in maintaining a graft survival or not could not be ascertained from this small number of experiments, since only 2 male recipients survived sufficient length of time for evaluation. Halsted 13 laid down a principle that endocrine grafts would only take when the hormone secreted by the transplanted endocrine organ was absolutely deficient within the organism. If Halsted's law of depriva-
REFERENCES
1. Asherman, J. G.: ]. Obst. & Gynaec. Brit. Emp. 67: 228, 1960. 2. Billingham, R. E.: New England J. Med. 270: 667' 720, 1964. 3. Billingham, R. E., and Silvers, W. K.: J. Immunol. 85: 14, 1960. 4. Bradbury, J. T., Brown, W. E., and Gray, L. A.: Recent Progr. Hormone Res. 5: 151, 1950. 5. Butcher, R. L., Chu, K. Y., and Melampy, R. M.: Endocrinology 70: 442, 1962. 6. Bykow, S. G.: Monatsschr. Geburtsh. u. Gynak. 76: 186, 1927. 7. Cheval, M.: Proc. Roy. Soc. Med. 27: 1395, 1934. 8. Chu, J. P., Lee C. C., and You, S. S.: J. Endocrinol. 4: 392, 1946. 9. Duby, R. T., McDaniel, J. W., and Black, D. L.: Nature 205: 720, 1965. 10. Eraslan, S., Hamernik, R. J., and Hardy, J. D.: Arch. Surg. 92: 9, 1966. 11. Grigor'ev, cited by Demikhov, V. P.: Experimental Transplantation of Vital Organs, New York, 1962, Consultants Bureau Enterprises, Inc., p. 16. 12. Hall, G. ].: M. Rec. 139: 109, 1934. 13. Halsted, W. S.: J. Exper. Med. 11: 175, 1909. 14. Hamernik, R. J., Eraslan, S., and Hardy, J. D.: S. Forum 15: 383, 1964. 15. Hechter, 0., Fraenkel, M., Lev, M., and Soskin, S.: Endocrinology 26: 680, 1940. 16. Jarcho, J.: Am. J. Surg. 77: 273, 423, 1949. 17. Kakuschkin, N., and Bykow, S.: Monatsschr. Geburtsh. u. Gynak. 71: 181, 192.5. 18. Knauer, E.: Zentralb. Gynak. 20: 524, 1896.
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tion applies in the case of ovarian homotransplantation, additive estrogen therapy would be contraindicated. This remains to be seen. The sex-linked histocompatibility antigens would not interfere when uteri are transplanted into male recipients, smce transplantation antigen is located on the Y chromosome, 3 which is lacking in the female. Although there are reported cases of successful autotransplantation of the uterus by omentopexy, homotransplantation of the uterus by vascular anastomosis could be the only means by which successful end results can be achieved, in spite of the fact that preparation of the specimen is a time-consuming tedious task.
19. Krohn, P. L.: Transplantation Bull. 2: 15, 1955. 20. Loeb, L.: Am. J. Psycho!. 83: 202, 1927. 21. Martin, F. H.: Surg. Gynec. & Obst. 35: 573, 1922. 22. McDaniel, J. W., and Black, D. L.: Nature 202: 810, 1964. 23. Medawar, P. B.: Some Immunological and Endocrinological Problems Raised by Evolution of Viviparity in Vertebrates, in Society for Experimental Biology. Evolution (papers read at symposium of the Society held in collaboration with Genetical Society of Oxford in July, 1952), New York, 1953, Academic Press, Inc., Symposium No. 11, pp. 320-338. 24. Mishell, D. R., and Motyloff, L.: Endocrinology 28: 436, 1940. 25. Nicholas, J. S.: Anat. Rec. 58: 387, 1934. 26. Parfenoff, N.: Monatsschr. Geburtsh. u. Gynak. 88: 423, 1931. 27. Schlesinger, M.: J. Nat. Cancer Inst. 28: 927, 1962. 28. Sessums, J. V., and Murphy, D. P.: Surg. Gynec. & Obst. 56: 600, 1933. 29. Thiersch, J. B.: M. J. Australia 2: 127, 1941. 30. Thomas, R. C.: J. Obst. & Gynaec. Brit. Emp. 50: 189, 1943. 31. Waynforth, H. B.: J. Endocrinol. 33: 11, 1965. 32. Weiner, J. J.: Am. J. Surg. 65: 288, 1944. 33. Williams, C.: M. J. Australia 2: 326, 1941. 34. Zhordania, I. F., and Gotsiridze, 0. A.: Acta chir. plast. 6: 1, 1964. 35. Zhordania, I. F., and Gotsiridze, 0. A.: Internat. J. Fertil. 8: 849, 1963.