Robotic-assisted living-donor hysterectomy for uterus transplantation: a systematic review of surgical techniques, donor safety, and recipient outcomes

Uterus transplantation (UTx) has emerged as a promising treatment for women with absolute uterine factor infertility (AUFI), enabling pregnancy and live birth with their own genetic offspring. Living-donor uterus procurement remains the most technically demanding component of the procedure. Robotic-assisted donor hysterectomy has been introduced to improve surgical precision, reduce donor morbidity, and preserve graft quality, while recipient implantation is performed via laparotomy. This systematic review evaluated current evidence on robotic-assisted living-donor hysterectomy for UTx, focusing on surgical techniques, donor safety, recipient outcomes, and reproductive success. Databases and trial registries were searched from inception through June 2026. Six studies reporting 29 unique robotic-assisted living-donor hysterectomies across five countries met the inclusion criteria. All procedures used the da Vinci Xi robotic platform. Operative time and estimated blood loss decreased with increasing surgical experience, while major donor complications (Clavien-Dindo grade III or higher) were less frequent in later series. Among cases with reported follow-up, no graft loss was observed; restoration of menstruation, embryo transfer, clinical pregnancy, and live birth were achieved, including ten live births in the largest programme. Robotic-assisted living-donor hysterectomy for uterus transplantation appears technically feasible and has been associated with viable grafts and successful pregnancies in highly selected cases. However, major donor complications, including ureteric injury requiring reimplantation and bilateral oophorectomy, were observed, and the true incidence of donor morbidity remains uncertain. Current evidence remains limited to small observational studies, and these findings support careful evaluation within structured, multidisciplinary programmes and international registries rather than widespread expansion.