: To evaluate the feasibility, surgical outcomes, and early graft function of the first four uterus transplantations performed in France using grafts retrieved from donors after brain death (DBD), and to describe the standardized 10-step surgical technique developed through this experience.

: Prospective inclusion of recipients within the TULIPE national uterus transplantation program. Four women with MRKH syndrome underwent UTx between 2025 and 2026 using grafts procured from DBD donors. Surgical procedures, ischemia times, perioperative events, postoperative graft perfusion, rejection episodes, and early functional outcomes were analyzed.

: All four grafts were successfully procured. Warm ischemia times ranged from 100 to 120 minutes, and total ischemia time decreased from 11 hours to 7 hours. The first graft was lost due to bilateral arterial thrombosis on postoperative day 1, associated with donor arterial atherosclerosis. Following technical refinements—including four venous outflows and graft stabilization prior to reperfusion—the second, third and fourth grafts demonstrated immediate and sustained perfusion. Menstruation resumed at 5 weeks, 22 days and 8 weeks, respectively. Two recipients experienced mild (grade 1) rejection episodes that resolved with corticosteroid therapy. No major long-term complications were identified.

: DBD-based uterus transplantation is feasible but was associated with a substantial rate of major complications in this early experience. Technical optimization improved perioperative outcomes, but larger series are needed before this approach can be considered safely integrated into established multi-organ procurement workflows. Technical optimization significantly improved perioperative outcomes and early graft function. These findings contribute to the standardization of UTx techniques and support further development of uterus transplantation programs.