Hysterectomy with vault suspension remains one of the most commonly performed procedures for pelvic organ prolapse (POP).(1) However, uterine preservation is increasingly preferred in young women, particularly when future fertility, body image, and hormonal considerations are important. The Manchester–Fothergill (MF) procedure is a well-established surgical option for isolated cervical elongation. When cervical elongation is associated with significant uterine descent, additional apical support is required.(2) This video demonstrates the surgical technique of combining Manchester–Fothergill repair with sacrospinous hysteropexy to manage third-degree uterovaginal prolapse with cervical elongation in a young woman desiring uterine conservation.

A 27-year-old multiparous woman (P4L3), with all previous deliveries vaginal, presented with complaints of a mass per vaginum and associated discomfort. Pelvic examination revealed POP-Q stage III uterovaginal prolapse, with the elongated cervix forming the leading point.
Several surgical options were evaluated. Sacrohysteropexy, although effective, involves mesh placement and carries mesh-related risks. Isolated sacrospinous hysteropexy does not adequately address cervical elongation. Sling-based uterine suspension procedures may not sufficiently correct stage III prolapse with significant cervical elongation. Vaginal hysterectomy with pelvic floor repair was not considered appropriate given the patient’s young age and preference for uterine preservation.
A combined approach was therefore planned to address both cervical elongation and apical descent, amputation of cervix to tackle cervical elongation and sacrospinous hysteropexy and plication of the Cardinal ligament with cervix to tackle descent i.e. Manchester-Fothergill repair combined with Sacrospinous hysteropexy. After spinal anaesthesia, patient was placed in lithotomy. A triangular portion of the anterior vaginal wall was excised, and the bladder was mobilised superiorly. The bilateral cardinal ligaments were identified, clamped, and sutured. Bilateral descending cervical vessels were ligated to minimize intraoperative bleeding. The cervix was amputated, leaving approximately 2.5 cm of cervical length. Permanent sutures were placed incorporating one cardinal ligament, the anterior cervical tissue, and the contralateral cardinal ligament, and tied centrally to restore cervical support (Manchester–Fothergill component).
Subsequently, the right pararectal space was dissected to expose the sacrospinous ligament. Two permanent sutures were placed through the sacrospinous ligament and anchored to the posterior aspect of the cervix to provide apical suspension (sacrospinous hysteropexy).
Reconstruction of the cervix was performed using Sturmdorf sutures placed at the 11 and 1 o’clock positions anteriorly and at 5 and 7 o’clock posteriorly to cover the raw cervical surface. The anterior vaginal wall was closed, followed by tying of the sacrospinous hysteropexy sutures to restore adequate apical support and vaginal axis.

The total operative time was 50 minutes, with an estimated blood loss of 150 ml. No intraoperative complications occurred. The patient had an uneventful postoperative recovery and was discharged on postoperative day two. At one-month follow-up, she reported complete resolution of symptoms. Pelvic examination demonstrated good apical support with no evidence of residual or recurrent prolapse.

Combined Manchester–Fothergill repair with sacrospinous hysteropexy is a safe, feasible, and effective uterine-preserving surgical option for young women with POP-Q stage III uterovaginal prolapse and cervical elongation. This approach simultaneously corrects cervical elongation and provides durable apical support while avoiding hysterectomy and mesh-related complications. It represents a valuable alternative in carefully selected patients seeking uterine conservation.

1.	deBoerTA, Slieker-TenHoveMC, BurgerCW, et al. The prevalence and factors associated with previous surgery for pelvic organ prolapse and/or urinary incontinence in a cross-sectional study in the Netherlands. Eur J Obstet Gynecol Reprod Biol. 2011;158(2):343-349. doi:10.1016/j.ejogrb.2011.04. 029
2.	Güler Çekiç S, Aktoz F, Urman B, Aydin S. A systematic review of uterine cervical elongation and meta-analysis of Manchester repair. Eur J Obstet Gynecol Reprod Biol. 2024 Sep;300:315-326. doi: 10.1016/j.ejogrb.2024.07.029.