Classification and treatment of vaginal strictures at the donor-recipient anastomosis after uterus transplant

Objective To describe the incidence and management of vaginal stricture after uterus transplants (UTx) in the United States, to propose a grading system to classify stricture severity, and to identify risk factors for stricture formation. Design Prospective cohort study. Subjects Recipients undergoing UTx from 2016 to 2023 at Baylor University Medical Center at Dallas, Cleveland Clinic, University of Pennsylvania, and University of Alabama at Birmingham were monitored postoperatively with regular pelvic exams. Stricture was defined as vaginal narrowing less than 3 cm in patients with graft survival of at least 7 days. Exposure Demographic and surgery characteristics. Main Outcome Measures Stricture development and severity (Grade 1 for diameter 2 to <3 cm, Grade 2 for 1 to <2 cm, or Grade 3 for <1 cm). Results Of the 45 UTx from 2016 to 2023 (16 deceased donor, 29 living donor), 3 were excluded from the analysis due to graft loss within 7 days. Of the 42 remaining recipients, 39 (92.9%) had Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome and 3 (7.1%) had a prior hysterectomy. Twenty-eight UTx recipients (66.7%) developed postoperative vaginal strictures with median time to stricture of 33 days (interquartile range 19 to 53 days). Most strictures were of moderate severity, with 4 strictures (14.3%) categorized as Grade 1, 19 (67.9%) as Grade 2, and 5 (17.9%) as Grade 3. History of MRKH and preoperative recipient vaginal length were significant risk factors for stricture, after adjustment for donor and recipient age and BMI, anastomosis technique, total ischemia time, center, and year. Patients with longer preoperative vaginal length had a lower risk of stricture (HR 0.45, 0.29-0.70). Severity grading of the stricture was associated with effectiveness of a non-operative treatment approach (p=0.018, Grade 1 vs. Grade 3). No patients with Grade 3 strictures improved with self-dilation alone; all required surgical repair and/or dilation under anesthesia. Conversely, for Grade 1 or 2 strictures, self-dilation alone was successful in 47.8% (11/23), and no Grade 1 strictures required surgical repair. Conclusions Vaginal stricture is a common postoperative complication after UTx, affecting over 65% of recipients. Short preoperative vaginal length and history of Müllerian agenesis in the recipient are significant risk factors. Vaginal self-dilation was effective for some mild to moderate strictures, though dilation under anesthesia or surgical repair was required in most cases.