A Retrospective Observational Study on the Outcomes and Efficacy of the Manchester Procedure as a Uterine-Sparing Surgery for Uterovaginal Prolapse

Introduction

More than 10% of women undergo surgical intervention for uterovaginal prolapse.^1,2 Despite this high prevalence, there is no international unanimity on the surgical approach to management of uterovaginal prolapse. ² Vaginal hysterectomy has been the conventional surgical treatment, but it is associated with increased blood loss, morbidity, duration of surgery, and postoperative recovery time.^1–4 It has also been proposed that the extensive pelvic floor dissection involved during hysterectomy may increase the risk of de novo urinary incontinence, bladder and sexual dysfunction.

Many women wish to conserve their uteri. For premenopausal women, this can be due to eagerness to conserve reproductive function. For other women, it might be because the presence of the uterus plays a role in their gender identity, self-esteem, sexual function, and general psychologic well-being.^5–8 Various uterine-sparing procedures have evolved for women who want to conserve their uteri. ¹

The Manchester procedure is one such technique. It was first performed in 1888 by Donald in Manchester, where the cotton mills employed a large proportion of female labor and the incidence of uterine prolapse was high. ⁹ The procedure involves amputation of the cervix combined with anterior and posterior colporrhaphy, and fashioning of the neocervix. Elongation of the cervix is often associated with pelvic organ prolapse (POP) and needs correction. Fothergill suggested transfixation of the cervical stump to the cardinal ligaments, which helps by uplifting and anteverting the uterus by pulling back the cervix into the pelvis. This also stretches the anterior vaginal wall, which plays an important role in correcting cystoceles. He also emphasized excluding uterine pathology before undertaking the procedure. The combined procedure is known as the Manchester–Fothergill operation.^1,2,9–13 The cure rates of this procedure in various studies has been reported to be from 92% to 95.7%, and it was associated with lower blood loss than vaginal hysterectomy with pelvic floor repair.^14–16

Materials and Methods

A retrospective evaluation was conducted of women who underwent the Manchester procedure in the Department of Urogynaecology of K.K. Women's and Children's Hospital, Singapore, from November 2002 to July 2015. The case notes were retrieved and the preoperative demographic parameters, grade of prolapse, and intraoperative details were evaluated. Postoperative complications, recurrence of symptoms or prolapse noted on examination, and pregnancy outcomes were also assessed.

Results

Fifty-seven women underwent the Manchester procedure from November 2002 to July 2015. It was possible to retrieve case notes for 55 of these 57 patients. The average age and parity of the patients were 41.3 years and 2, respectively. Three patients (5.4%) were nulliparous, 4 (7.3%) were postmenopausal, and 51 (92.7%) were sexually active. Four patients (7.3%) were keen on having future fertility (Table 1).

Table 2 shows the preoperative grades of uterovaginal prolapse assessed by the Baden–Walker prolapse quantification system. According to this system, 98.2% of the patients had grade 2 or higher-grade cervical descent and 21 (38.2%) had elongation of the cervix. Fourteen patients had concomitant stress urinary incontinence (SUI).

The average duration of the surgery was 46 minutes, and the average blood loss was 31.8 mL. There were no intraoperative complications (Table 3).

Five patients (9.1%) had excessive bleeding per vaginum within 2 weeks of the procedure. Of these patients, 2 had reactionary hemorrhage of ∼500 mL within 6 hours of surgery. Both of these patients underwent examination under anesthesia and were found to have bleeding due to slipped ligatures from the cardinal ligaments. The cardinal ligaments were reclamped and ligated, and the bleeding was controlled. One patient had excessive bleeding per vaginum 5 days postoperatively, and 2 patients had excessive bleeding per vaginum 14 days postoperatively, most likely due to infection. The bleeding in all these patients was between 100 mL and 150 mL. These patients were managed conservatively with vaginal packing with acriflavine-soaked gauze and oral antibiotics. Four patients (7.3%) had voiding dysfunction postoperatively and required indwelling catheters for up to 2 weeks (Table 4).

There were no long-term complications. Four patients (7.3%) conceived after the procedure, of whom 2 underwent elective cesarean section at 36 weeks. One patient had an emergency caesarean section at 28 weeks for preterm premature rupture of the membranes with transverse lie, and the fourth patient underwent a termination of pregnancy at 10 weeks for an unwanted pregnancy. Twenty-three of 39 patients (59%) completed 5 years of postoperative follow-up. Two patients complained of occasional SUI on follow-up, and none had recurrences of prolapse noted on examination (Table 5).

Discussion

The aim of surgical treatment of POP is to repair the anatomy of the vagina and to enhance urinary, bowel, and sexual function. ⁴ The need for hysterectomy in cases of uterine prolapse becomes less obvious in the absence of uterine pathology. ¹⁷ Diwan et al. reported that patients who underwent hysterectomy had an increased incidence of de novo urinary incontinence, bladder dysfunction, prolapse recurrence, and sexual dysfunction. ¹ The risk of unexpected gynecologic pathology in women wishing to conserve their uteri at the time of prolapse surgery is low.^18,19 Manchester repair is ideal for patients with cervical elongation who wish to conserve their uteri, as the procedure involves cervical amputation.

Berger et al. found that cervical elongation is found in 40% of women with anterior predominant POP. These women will have a higher risk of recurrence of prolapse if treated with procedures—such as sacrospinous hysteropexy—not involving cervical amputation. ²⁰ Tolstrup et al. reviewed the Manchester procedure versus vaginal hysterectomy, and reported operating times in the range of 62.4–110 minutes and mean blood losses in the range of 191–408 mL for the Manchester procedure in 5 studies. ² Other studies comparing vaginal hysterectomy to the Manchester procedure also found a significantly shorter operating time and lower blood losses associated with the latter surgery.^21–23

There were no intraoperative complications in the current study. Ahyan et al. reported bladder perforation in 2 patients (0.02%), postoperative fever in 27 (23.3%), retroperitoneal hematoma in 1 (0.49%), and urinary retention in 45 of 204 patients (22.05%). ³ Tolstrup et al. reported a 0%–0.4% incidence of bladder injury and a 0.4%–1% incidence of bowel injury in their review. ² The risk of intraoperative bladder injury was found to be low (0%–1%) in a review by Dietz et al. of 573 women who underwent the procedure. ²⁴

Alkış et al. studied 49 patients who underwent the Manchester–Fothergill procedure and reported 1 case of an intraoperative complication (2%)—a bladder perforation in a patient with concomitant anterior colporrhaphy and tension-free vaginal tape—and 1 case of postoperative urinary retention (2%). ¹⁷ Tolstrup et al. reported a postoperative hemorrhage rate of 0%–3% after the Manchester procedure in 4 studies. ² Conger and Keettel reported that postoperative urinary retention was the most frequent postoperative complication; this occurred in 15.2% of 960 patients, and these patients needed an indwelling catheter for 9 or more days. ¹⁵ Thomas et al. reported no intraoperative complications in 88 patients who underwent the procedure, but also reported that a high proportion of patients (17.1%) had postoperative voiding dysfunction. ¹⁴ de Boer et al. reported a 11% incidence of this problem, ²¹ while Thys et al. reported a 34% incidence of postoperative urinary retention. ²²

Alkış et al. reported a low rate of recurrence of prolapse (1 of 24 patients; 4.1%) noted on follow-up examinations up to 5 years. Nineteen of these 24 patients (79.1%) had no complaints. ¹⁷ Four complained of urinary incontinence. In a study of 431 patients, Oversand et al. reported a 13.3% recurrence of stage 2 or more prolapse at a 1 year postoperative follow up, a 3% incidence of de novo SUI, and a 2.8% 5-year reoperation rate. ¹² Subjective satisfaction rate in the Oversand study at a 1-year follow up was 95%. ¹²

Ayhan et al. reported an 11% incidence of hematometra due to cervical stenosis requiring cervical dilatation. ³ Cervical stenosis after the Manchester procedure can mask the symptoms of endometrial malignancy, such as postmenopausal bleeding. Hopkins et al. reported 3 patients with uterine disease (2 with cancer) after the Manchester procedure in women who assumed that their uteri had been removed during prolapse surgery, thus delaying the diagnosis. ²⁵

Rouzi et al. reported that 2 of 7 women who underwent the Manchester procedure in their case series conceived subsequently and had normal vaginal deliveries. ²⁶

The drawbacks of the current study were its retrospective nature and its low follow-up rates.

Conclusions

The Manchester procedure could be considered in women with uterovaginal prolapse who want to conserve their uteri for various reasons in view of this operation's low complication and prolapse recurrence rates.