The Manchester Procedure is a uterine sparing technique for uterine descensus often associated with Cystocele. Originally described by Archibald Donald, the procedure was later modified by Edward Fothergill and is often referred to as the Manchester Fothergill Procedure. Patients with true uterine descensus with a level 1 support system has failed and also present with cervical prolapse, often accompanied by additional prolapse in compartments, including the vault. This is differentiated from an isolated cervical prolapse due to hypertrophy where the cervix is exteriorized and the vault is well supported. Both may present with similar symptoms and may on the surface appear the same. The Manchester Procedure is ideal for patients with significant comorbidities that may preclude a more invasive procedure by offering decreased operative time, decreased intraoperative blood loss, and offers shorter recovery period. This case typifies the patient with significant cervical hypertrophy with a well-supported vault. This is a young, sexually active premenopausal female. Note the large, patchy-less cervix that is typical of these patients with minimal, if any, vault descensus. The procedure is begun by identifying important anatomic landmarks, uterocervical ligaments, the posterior cul-de-sac, and the vesicle-uterine fold. The utero-cervical junction between the lower uterine segment and the cervix is identified. This will be the level of amputation. The cervix to be amputated is first circumscribed with a boby cautery. The vesicle-uterine fold is then identified, and the bladder is bluntly dissected off the lower uterine segment. The bladder is then retracted anteriorly out of harm's way. The cervix is then skeletonized to the level of the utero-sacral and cardinal ligaments. Hemostasis is maintained with electrocautery. A colpotomy is performed to enter the posterior cul-de-sac. The utero-sacral ligaments are then identified, transected, and suture-ligated using delayed abdorbable suture and tagged for later use. The cardinal ligament is transected and tagged in a similar fashion. This is performed on the contralateral side as well. Adequate mobility of the supporting ligaments is essential as they will be used to suspend the uterus. The cervix is then amputated. The utero-sacral and cardinal ligaments are then fixated to the contralateral anterior aspect of the lower uterine segment and tagged. Prior to tying the suspensory ligaments, the cervical os is identified with a uterine sound and stay sutures are used to approximate the vaginal mucosa to the cervical canal in a circumferential fashion. Next, the utero-sacral cardinal ligament complexes are brought across the anterior surface of the cervix and secured to the contralateral aspect of the lower uterine segment. This creates a firm ligamentous band in front of the lower uterine segment. As a result, the lower uterine segment is held posteriorly, thus bringing the fundus anteriorly. Next, the previously placed stay sutures within the cervical os are then tied. Additional sutures are placed circumferentially to allow for canalization. This is crucial to maintain a patent cervical canal and allow for drainage. At the conclusion of the case, the uterus is well supported and repositioned within the pelvis, providing excellent vault support as well as supporting the anterior compartment. Additional prolapse compartments, including posterior coporaphy, may be performed if indicated. A retrospective review of six patients who underwent the Manchester procedure for isolated cervical hypertrophy was performed. All patients had greater than grade 3 cervical prolapse. Two patients had previous failed attempts within a 12-month period. Concomitant procedures include posterior coporaphy with perineurophy, vaginal interstitial repair, as well as anti-incontinence procedures. Postoperative anatomic findings demonstrated maintenance of total vaginal length with marked improvement in point C value from minus 1 centimeter to minus 8 centimeters. And restoration of anterior wall support demonstrated by a mean postoperative point VA of minus 2.4. All patients in this series were satisfied with the procedure, reporting either greatly improved or cured on self-assessment. Our experience with the Manchester procedure has yielded excellent anatomic outcomes without complications. The Manchester procedure is an often overlooked and safe alternative to hysterectomy for patients desiring uterine preservation. For more information visit www.osho.com

Manchester Procedure

uterine sparing technique

Cystocele

comorbidities

anatomic outcomes