Manchester Repair as A Uterine Preservation Surgery
Received Date: June 05, 2019; Published Date: July 01, 2019
Uterine preservation surgery in uterovaginal prolapse is beginning to be relooked at more vigorously now. The need for uterine preservation surgery is for the reasons of desire for future fertility, maintaining sexual function and sense of identity for the woman. Incontinence and pelvic organ prolapse (POP) have an impact on sexuality. Observational prospective longitudinal cohort study to evaluate the impact of uterus preservation after POP repair on sexual function demonstrated that POP plays a role in female sexual dysfunction and uterus sparing surgery is associated with a greater improvement in sexual function . However, the uterine conserving surgery does have its contraindications such as history of current or recent cervical dysplasia, abnormal menstrual bleeding, postmenopausal bleeding and other endometrial pathology. In these cases, therefore conservation of the uterus would not be advocated.
The conservative options such as pelvic floor exercises and the use of vaginal support pessary can be attempted if surgical option is not suitable or required to be delayed. Among the common uterine preservation surgery is the Manchester repair, Hysterosacrocolpopexy and Sacrospinous hysteropexy.
Hysterosacrocolpopexy is performed by abdominal approach either via open, laparoscopic or robotic technique. The vaginal approach is either by the Manchester operation or the sacrospinous hysteropexy.
The Manchester operation or also known as Fothergill operation is an old operation first introduced in 1888 in Manchester, England by Dr Archibald Donald. It was later combined into a single procedure by Dr William Fothergill who subsequently reported the procedure . The indication for this surgical option is mainly cervical elongation and also as a uterine conserving surgery for young women who wish to maintain their reproductive capacity. It is also can be performed for women with uterine prolapse who prefer to conserve their uterus.
The procedure generally requires amputating the cervix after detaching the uterosacral ligaments. This is followed by reattachment of the uterosacral ligaments to the remnant cervical stump. Studies have shown that the Manchester procedure is equally effective when compared with vaginal hysterectomy in regard to not only anatomical outcome but with less morbidity [3,4]. Liebergall-Wischnitzer M, et al  concluded in a study that the modified Manchester procedure including reconstructive surgery for women with cervix elongation, with or without POP, prevented recurrent uterine prolapse. The surgery was also well received in terms of patient’s satisfaction, quality of life, and sexual function .
In a review in our own centre, we found that it is a useful surgery for Stage 1and2 (POP-QICS) uterine prolapse. There were minimal complications and lesser risk of recurrence. (Manchester repair for Uterine conservation-A 3year experience in Penang Hospital S Balakrishnan, Dass AK, Rahman A. Dept of O&G, Penang Hospital, Penang, Malaysia presented in the IUGA /ICS 2010). Tolstrup CK, et al  found that the anatomical recurrence rate was 4-7 % after vaginal hysterectomy, whereas recurrence was very rare after the Manchester procedure6. It is therefore a good option for younger women with uterine prolapse. One of the main reasons for uterine preservation surgery is to maintain reproductive capacity. There is always a possibility for the women to get pregnant, but a theoretical risk of premature delivery does exist. Tipton RH, et al  described 5 women after Manchester procedure who wished to conceive (out of 82 women) of which 2 of them had uneventful pregnancies. 1 patient unfortunately suffered a miscarriage and 2 did not conceive. The risk of premature delivery is unknown, but it is postulated that it is possibly higher with cervical amputation .
In another review by Hopkins MP, et al.  it was advised that patients who had undergone a Manchester operation can develop disease in the retained uterine corpus. This should be considered in the differential diagnosis of a pelvic mass in a patient with previous Manchester surgery. They describe 3 cases of pelvic mass after this surgery. There was a patient with a well-differentiated adenocarcinoma in the retained uterine corpus, another patient had retained blood-filled corpus with an early-stage fallopian tube cancer. The last patient had a retained corpus was distended and filled with mucoid material .
The Manchester repair for uterine preservation for prolapse is a good option for patients with need for reproductive needs as well as for patients who wished to retain their uterus. It is a useful technique which appears to be making a comeback among the urogynecology surgeons. It is generally found to be equally effective as vaginal hysterectomy and repair for uterine prolapse. The risks and complications rate are either equal or even less than vaginal hysterectomy. Successful pregnancy after this procedure has been described albeit possible antenatal problems such as premature delivery. It should be an option given to a patient presenting with uterine prolapse wishing for surgical correction.
Conflict of Interest
No conflicts of interest.
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