Hypothesis / aims of study
Manchester operation for elongation of the uterine cervix was first described by Archibald Donald from Manchester England in 1888 and modified later by William Edward Fothergill in 1915 (1). The surgery was designed to treat symptomatic cervical elongation in the presence of mild uterine prolapse. The Manchester operation is a minimally invasive procedure that enables uterine preservation and thus keeping the possibility of future pregnancy and childbirth.
Following the 2019 FDA's warning regarding the use of mesh for pelvic organ prolapse (POP) repair, there has been a growing interest in classical surgical techniques that use native tissue, such as Manchester operation. However, data regarding the efficacy and safety of the Manchester operation are extremely scarce and there is a real need to get up-to-date data.
The aim of the present study was to investigate the efficacy, complications, and clinical outcomes of Manchester operation for women with POP mainly related to elongation of the uterine cervix.
Study design, materials and methods
A retrospective cohort study of all Manchester operations that were done between 2010 and 2019 in a single Urogynecology and Pelvic Floor Reconstruction unit of a tertiary hospital. The study was approved by the local IRB. The major surgical steps of the Manchester operation include amputation of the cervix, suspension of the cervical stump by suturing the cut ends of Cardinal Ligaments in front of cervix (Fothergill sutures), and formation of a posterior vaginal flap into the cervix (Sturmdorf suture) for re-epithelialization of the cervical canal. Care is taken through surgery to keep the cervical canal open.
Medical records of all patients who underwent Manchester operation were reviewed. Demographic and surgical data were collected in real time and stored in a computerized database. The computerized medical charts were reviewed for general characteristics, such as age, body mass index (BMI), parity, smoking status, postmenopausal status, POP staging, and surgical data including duration of operation, blood loss during surgery, length of hospital stay, early and late postoperative complications, as well as follow up visits.
Results
Overall, 35 patients (mean age 54.2 ± 10.5 years) underwent Manchester operation between 2010 and 2019. Demographic and clinical characteristics of the patients are presented in table 1. Of the 35 patients, 34 had significant elongation of the uterine cervix. One other patient was scheduled for vaginal hysterectomy but due severe pelvic adhesions the procedure was converted to Manchester operation. Twenty-five patients (71%) underwent a concomitant repair such as anterior colporrhaphy, posterior colporrhaphy, or mid urethral sling procedure (TVT-O).
There were no intraoperative complications. The Operation time for patients who underwent Manchester operation only, was less than 30 minutes. Mean hemoglobin levels before and after surgery were not significantly different (12.17±1.2 g/dl versus 11.02±1 g/dl, respectively). One patient underwent surgical revision 24 hours after surgery for increased vaginal bleeding and the anterior aspect of the cervical stump was re-sutured. Mean Hospital stay was 48 hours.
There were four cases of late postoperative complications: one patient had vesicovaginal fistula that was diagnosed two months postoperatively. The second patient underwent drainage of hamatometra three months postoperatively with complete recovery thereafter. The third patient presented with abdominal pain and fever six months after surgery. Ultrasound examination revealed heterogeneous contents within the uterus. The presumed diagnosis was pyometra. The patient underwent a failed hysteroscopic attempt to drain the uterus under anesthesia and therefore total abdominal hysterectomy was undertaken. The forth patient presented nine months after surgery with small bowel evisceration through the posterior vaginal fornix. This complication was probably due to significant underweight (BMI 19) and poor tissue healing.
Interpretation of results
Manchester operation seems to be an effective and safe alternative procedure for the treatment of POP caused by true cervical elongation. The surgery is short, blood loss is minimal and without any significant early complications. In addition, the surgery enables uterine preservation in women who are interested in this option. However, there may be significant complications during the first year after surgery, especially hamatometra or pyometra due to post-operative cervical stenosis. It is therefore important, that the surgery will be carried out with a strict technique and skilled surgeons who are capable to manage unique postoperative complications.