Pelvic organ prolapse (POP) is defined by ICS as the descent of one or more of the anterior vaginal wall, posterior vaginal wall, the uterus, or the apex of the vagina (vaginal vault after hysterectomy)
The estimated lifetime risk for pelvic organ prolapse surgery is 11% to 20%. (1) The primary surgical approach for pelvic organ prolapses is transvaginal. (1) Vaginal hysterectomy is one of the classical surgeries to treat uterine prolapse. In the present era, surgical techniques that preserve the uterus are getting more common.
Not all patients with uterine prolapse, experience descent of the uterine body. Cervical elongation can cause uterine prolapse without descent of the uterus.  In such patients Level I support is intact, compared to that in uterine descent patients. “True cervical elongation” can be differentiated from uterine descent by pelvic examination. 
When the D point of the Pelvic Organ Prolapse Quantification (POP-Q) system is high and C point is below the hymen, the etiology of uterine prolapse is related to cervical elongation rather than uterine descent.
 Manchester operation is a surgery which involves excision of the cervix and suture of cervical stump to the cardinal ligament. Manchester operation preserves the uterine body; therefore, it is effective in correcting uterine prolapse caused by true cervical elongation.
The aim of the study was to evaluate the clinical outcomes of Manchester operation in patients with true cervical elongation in terms of POP-Q staging, PFDI-20 scores, and POP SS scores.

This study was a retrospective study conducted on 5 women in reproductive age group who underwent Manchester surgery for uterine prolapse with true cervical elongation at a tertiary care hospital from January 2022 to December 2022. Data was retrieved for these patients from OT records and admission case sheets. Informed written consents were taken for all the patients. Presenting complaints, examination findings were noted. Preoperative POP-Q and PFDI-20 (Pelvic floor distress inventory) score and POP-SS (Pelvic organ Prolapse- symptom score) was noted from the pre-operative case sheets.
Intraoperative case sheets were studies to assess the operating time, blood loss, intra-op and immediate post-op complications if any . Following Manchester procedure, amputated cervix was sent for Histo-pathological examination. Patients were reviewed at 6- and 12-months post-surgery. PFDI-20 score, and POP-SS score was calculated at 6 and 12 months. Patients were examined and anatomical success was defined as POP-Q stage 0 to 1.

The mean age of the patients was 28.4 + 2.41 years. Among the 5 patients, 3 patients (60%) were P2L2, and rest 2 patients (40%) were P3L3. 
Chief complaint of all the 5 patients was mass descending through the vagina (100%). Associated symptoms were heaviness or dullness in the pelvic area, urinary urgency, increased frequency of micturition, constipation, bowel urgency.  None of the patients had urinary incontinence. 1 patient (20%) required manual digitation for urination. 
On Examination, all the 5 patients (100%) had POP-Q stage III prolapse with ‘C’ as the leading point. All the 5 patients had cervical elongation with mean infra-vaginal cervical length 0f 6.6 + 0.8 cm.  None of the patients had cystocele or rectocele.
Mean preop POPDI-6, CRAD-8, UDI-6, PFSI-20, POP SS are given in table no 1.
Mean operating time was 48 + 4 minutes. Average blood loss in all 5 case was <100 ml.
There were no intra-op or immediate post operative complications in any of the 5 patients. The Post operative period was uneventful all the 5 patients and all the patients were discharged in stable condition.
Histo-pathology of amputated cervix all the 5 patients was normal.
Patients were reviewed 2 weeks post-surgery. There were no fresh complains at that time. Then patients were reviewed at 6 and 12 months respectively. None of the patients had cervical stenosis post-surgery.
Post 6 and 12 months, patients were reviewed, examination was done, POP-Q noted, and PFDI-20 and POP SS scores were calculated.
Mean POP-Q score at 6 and 12 months was <= stage 1. At 12 months, in 2 patients (40%) POPQ was stage 1 and in 3 patients (60%) POP-Q was stage 0

In our study, there was statistically significant difference in the PFSI-20 and POP SS scores at 6 and 12 months respectively which shows that there is significant improvement in the symptoms after the surgery. The POP-Q stage at 12 months was <= stage 1 showing that there was anatomical success of the Manchester’s surgery. There were no major intra-op and post-operative complications and there was no case reported of cervical stenosis.
In a study conducted by Yun Jin Park et al (2), it showed that Manchester surgery is less extensive, operating time is less and it minimizes damage to surrounding structures.
In a study done by Maryam et al (3), it was demonstrated that Manchester procedure does adequate apical correction, it is associated with low rates of recurrent pelvic organ prolapse surgery, symptomatic recurrence, and low surgical morbidity compared to other surgical methods.

Manchester surgery is an effective procedure in terms of anatomical outcome for uterine prolapse caused by true cervical elongation. The observed anatomical changes in the apical compartment correlated well with the symptom of bulging. It meets our requirement of preserving the uterus. It is a safe surgical option for young women with prolapse with true cervical elongation in whom the family is complete.
We believe uterus -sparing pelvic organ prolapse surgery will retain its place in future, since the risk of vault prolapse is known to be substantially higher after uterus removal.

Enklaar RA, Schulten SFM, van Eijndhoven HWF, et al. Manchester Procedure vs Sacrospinous Hysteropexy for Treatment of Uterine Descent: A Randomized Clinical Trial. JAMA. 2023;330(7):626–635. doi:10.1001/jama.2023.13140
Park YJ, Kong MK, Lee J, Kim EH, Bai SW. Manchester Operation: An Effective Treatment for Uterine Prolapse Caused by True Cervical Elongation. Yonsei Med J. 2019 Nov;60(11):1074-1080.
Maryam Deldar Pesikhani, Zinat Ghanbari, Tahereh Eftekhar, Maryam Kazemi, Saina Nassiri, Farideh Sabzi Shahrbabaki, Marjan Ghaemi. Long-term outcomes and quality of life after Manchester procedure for pelvic reconstructive surgery in women with cervical elongation,European Journal of Obstetrics & Gynecology and Reproductive Biology.Volume 289,2023,Pages 152-157.