If cervical elongation there than Fothergill ( Manchester repair ) is best for her otherwise if no elongation thanPosterior sling surgery by laparoscopy using tracker is equally good along with Antero- pasterior colpoperineorrhaphy. If she is from poor background non affording and follow up not possible than Vaginal hysterectomy with pelvic floor repair is best for her..
Partial removal of the cervix, , Laparoscopic hysteropexy, antero posterior colporraphy
I think if patient doesn't desire to keep her menstrual function the best choice is the vaginal hysterectomy, pelvic floor repair, and colpo-sacrospinal fixation but if she desires to keep it my option would be Fothergill(Manchester) surgery with pelvic floor repair and the colpo-sacrospinal fixation
At this age hysterectomy is not the best way forward .It will cause early menopause.Additionally ,there is usually pseudo-elongated cx .The proper solution is bilateral sacrohystopexy
I recommend to her operation "pelviscopic sacrohysteropexy(sacrocolpopexy) and anterior and posterior colporrhaphy".
Vaginal hysterectomy with suspension of the vaginal vault to the uterosacral ligaments. If there is associated prolapse of the anterior vaginal wall and the bladder, also anterior colporraphy-the pelvic floor muscles should be approximated and NOT JUST THE FASCIA. If elevation of the bladder results in urine leakage (tested during or before operation, by filling the bladder with 500 ml 0.9% physiological saline and elevating the bladder), the bladder neck should also be elevated, by using muscle and NOT FASCIA (The Kelly-Kennedy operation uses fascia with poor long-term results). If there is associated prolapse of the posterior vaginal wall and the rectum, a posterior colporraphy should be done, by approximating muscle. Meshes should be avoided, since they have a high risk of erosion, with consequent problems like a rectovaginal fistula. Stools must be kept soft after the operation. The ovaries should NOT be removed. The hysterctomy alone cannot cause early onset of the climacteric. Menopause means cessation of menstruation, which most women would prefer. With due respect- to do a sacrocolopexy makes no sense, since her family has been completed.
In a 30 year old woman, the hysterectomy is a big decision even if she has no plans of future pregnancy. There is no medical reason for this amputation. May I ask what does the patient want?
Of course if parity is completed and there is no desire to keep menstrual bleeding I think vaginal hysterectomy associated to pelvic floor repair as an appropiate procedure once the tissues will keep its weakness that was what permitted the prolapse and more to eliminate weight on them can be interesting. In other hand to keep the ovary I think there is no doubt at this condition once patient will have benefit to keep them as well as estrogen production
FOR ATTENTION: Veena Vidyasagar:
Dear Veena, What exactly do you mean by III degree UV prolapse, since their are two classifications, apart from the POP-Q classification. The most commonly used classification is: (i) First degree - the cervix has descended to at least to the level of the ischial spines, but not to the introitus; (ii) Second degree - the cervix appears at the intoitus; (iii)Third degree or procidentia - descent of the entire uterus through the introitus= the most common classification. Some classify this as descent of the cervix through the introitus and add procidentia as a Fourth degree. Obviously it is very important to know what we are dicussing - do you mean by III degree UV prolapse procidentia (I suspect so, becuase of the terminology you use) OR do you mean descent of only the cervix through the introitus. Thanks for your very interesting question - I look forward to your answer to my question. Kind regards, Prof Johan (JT) Nel.
Interesting discussion. I would be loathe to remove the uterus even if child-bearing is over at present. In addition to the value of menses & ovarian functions, the eventuality of her being divorced or becoming a widow has to be kept in mind as a possibility. Under those circumstances, she may wish to bear a child again!!
As for the best conservative operation, my personal experience favors Shirodkar's sling, where the merselene tape is taken from sacral promontary/L5 to the upper part of cervix extraperitoneally & then on left side passing through a loop on psoas & behind the sigmoid mesentary & back to the sacral promontary/L5. The elongation of cervix also disappears over time once the cervix is brought to its normal position. A cervix of 4" became 1.5" in a span of 6 months on a case where there was a recurrence of prolapse after Purandare's sling surgery before. Shirodkar's sling is perhaps the most anatomically correct operation as it mimics the utero-sacral ligaments, the true support of the uterus. I have had fair experience of prolapse and among Manchester's, Purandare's, Khanna's, Vaginal sacropexy, and Shirodkar's, by far the most successful has been the Shirodkar's. Even subsequent child-births also do not lead to a recurrence!
Manchester operation vil by all means be the best solution for given situation.
Manchester repair
Amputate cervix
Attach cardinals to anterior surface of cervix
join uterosacrals
Will it be possible to restore the anatomy by Manchester operation in a case of Procidentia? It was described more than 100 years ago. ACOG and standard books (Robert Shaw) are saying that if uterus is preserved Manchester opn should not be done, it should be Sacrocolpohystopexy with anterior and posterior colporrhaphy. Evidences saying that immediate and late complications are more in manchester opn than s acrocolpohysteropexy. Unfortunately our respective teachers do not accept it.
dear dr.veena. i feel conservative surgical procedure is the best option for her. i would like to know her utero cervical length and cervical screening status for CIN.
If length is normal i prefer to go for site specific repair vaginally and laparoscopic khanna's sling with abdominal enterocele repair and sterilisation. if length needs amputation i would like to go for manchester with vaginal site specific repairs for cysto and rectocele and vaginal tubal ligation . and closure/ligation of the POD as high as possible.
Dear Sabita Saichandran,
Respectfully, I want to say that Purandare,s sling or anterior sling operation is not recommended due to lack of evidence. It should be sacro-colpo-hysteropexy with PFR. If manchester opn is tried then Shirodkar's modification of this opn can be tried which is the insertion of the US ligament infront of the cervix.
for u-v iiidegree prolapse I feel Manchester with ant and post colpoperineorraphy should be the choice.......sacropexy will not be useful if cervix is bad and elongated I am gynecologist in teaching hospital for last 38 years.......
Dear Sir,
If cervix is not elongated and it is only hypertrophied then what will be the therapy? Degree is used only in Beecham grading system (1980) that means fundus is outside introitus (Porges severity no longer used). Manchester-Fothergil opn is a charming opn for vaginal surgeon. Due to some unknown causes, evidences are in favor of scarocolpohysteropexy. What should be the answer? Answer should be evidence based or opinion based? If cervix is elongated and fundus is outside the introitus and family is completed then what will be option? Manchester opn was bound to do on that time as no other option was there. In my institution, our respected teacher do not like to do Manchester operation in third degree (Procedentia) prolapse. If manchester opn is tried then Shirodkar's modification of this opn can be tried which is the insertion of the US ligament infront of the cervix.
Dear SabitaChaichandran
How will you determine vaginal site specific defect for cysto and rectocele? Can you tell me the sensitivities of those procedure?
If uterovaginal prolapse how only sacropexy is going to help???this iiidegu-vprolase is shaws class........can I know?
I would opt for Shirodkar's abdominal sling operation. Manchester can damage the cervix & may lead to stenosis or incompetence. There is nothing like 'completing the family' in current scenario! The age of 30 is important, as she has almost 12-15 years of reproductive potential pending! She may lose a child or two, may remarry, after a divorce, or after getting widowed by god's providence! I have seen so many requests for fertility in such scenario. Again the sling is perhaps most anatomical in correcting the prolapse compared to all other options, where the post-op anatomical distortion from natural is significant, including the Manchester's. I hope that forum members are aware of this surgery. If not, please respond, and I will elaborate the surgical technique.
The cervix will become normal & the hypertrophy will diminish once it is placed in its normal position. I have observed this so many times. The most vivid one was a 4" long cervix (6" long Ut + Cervix) following a failed Purandare's sling. After a long deliberation and hesitation I opted for Shirodkar's sling. After 2 months the cervix was 2" long and after 6 months 1.5".
Dr. Prabhat Mondal - can you give a link to ACOG document? Or give aq gist of what you wish us to take note of!
Dear Parul Kotdawala
This is my opinion. This is not fact. If I honestly say that I like Manchester operation. It is very interesting opn to me than VH. But I will never do the operation in third degree prolapse (Procedentia). During Manchester operation we (our teachers in my institution) try to determine the length of cervix whatever the portion of cervix (intravaginal or supravagina). When we do VH in Procedentia we think this uterus is quite impossible to preserve the uterus by Manchester operation. I do not understand when I read the Robert Shaw's gynecology. Clearly they recommended that if uterus has to be preserved it should not be Manchester operation but it should be hysteropexy but the indication of this operation (pinpoint indications) are not mentioned. When I read the ACOG (ACOG Practice Bulletin No. 85: Pelvic organ prolapse) guideline I was puzzled. But it is evidenced best. We have to honor it. The guide line was bases on most of the retrospective series. However, it was published on 2007. I think we have to wait for new one. Some portion I am quoting
O. Alternative operations for uterine preservation in women with prolapse include uterosacral or sacrospinous ligament fixation by the vaginal approach, or sacral hysteropexy by the abdominal approach.
O. Hysteropexy should not be performed by using the ventral abdominal wall for support because of the high risk for recurrent prolapse, particularly enterocele.
In this guide line Manchester operation was not mentioned. presently its indication has been changed depending on practice. We perform when family is complete or after simultaneous tubectomy Anterior sling operation we performed and got best result is not recommended due to lack of evidence. I think if we perform this operation to an women and failed then how can we justify if she demanded the evidence.
Once again this is my opinion not fact. When I do comment it is always evidenced based because I am junior, many respective teachers and specialist give their experience in this site.
Dear Prabhat Mandal
This is an open forum and you should not feel diffident in expressing your views and thoughts. In fact you have tried to look up many resources before putting up your views!! I salute you for that. As for the ACOG guidelines; I am not sure what a 'hysteropexy' means!? But probably it means a sling operation & Shirodkar's is a posterior sling. I hope that you have seen that surgery! I have performed it in 40+ cases, and with gratifying results. The surgery is a bit complex compared to other surgeries, but is perhaps the best available as on today in terms of results & in terms of non-recurrence!
A senior colleague (retired professor) from Ahmedabad - Dr. Narayan Patel, who makes videos of operative procedures, has recorded this surgery & he does sell video collection.
Big, hypertrophied Cervix has to be thoroughly investigated to rule out any pre malignant lesions. Only later we have to decide on the surgical treatment. Age alone should not be the only criteria for conservative surgeries.
Consider laparoscopic/abdominal sacrohysteropexy. Vaginal procedures may cause sexual dysfunction unfortunately.
laproscopic purandare's sling works better for such cases
but a hypertrophied cervix I presume that pap smear is normal
After all answers presented here I think once there are many optional technics for these problems, each surgeon should use that he has more knowledge and confiability because all of them can present good results for the patients
1st, find the anatomical cause of the prolapse (generally lax uterosacral and cardinal ligaments) and in this vase, an elongated cervix, then restore the anatomy
Balance is important.
Rx depends on the patient's condition, what is available, risks and benefits.
Laparoscopic SCP can create massive problems such as bowel adhesions (2%) and subsequent difficulties with evacuation of urine and feces. Even a 2% risk is unaccceptable if a simpler safer option is available.
Alternatives
Consider a Manchester Repair. Amputate the cervix. This will get rid of at least half the protrusion.
Make a transverse incision at the vesicouterine junction.
Dissect bladder off CX. This will take the ureters away from the next step which is to use a large strong needle and dig into the tissues 1 cm lateral to the cervix. These contain the torn and laterally displaced cardinal ligaments (CL). Bring the tissues across onto the anterior lip of CX and suture there firmly. If the two CL ends can be approximated without tension, even better.
Then make a transverse incision 3cm below CX. Take a wide sweep laterally and approximate the tissues using a large strong needle. This will automatically shorten the uterosacrals and liift the uterus further.
Do a cystoscopy and check that the ureters are functioning.
Peter Petros
Manchester fothergil operation would be appropriate for this patient.
Once again I agree with Peter. It's an elongated/hypertrophied cervix, so it's not a real procidentia. Not a real apical prolapse. D point may be really negative in these cases.
Long term SCP results recently presented by the late report of CARE trial showed that lots of long term complication may show up. Starting from a 10% mesh erosion rate.
My choice. Go vaginally, a well done Manchester procedure as suggested.
Dear Carlos Sarsotti,
You are focusing on elongated cervix or minimal d point descent. In that case, Manchester technique is appropriate. But to replace procidentia, it could be sacrospinohysteropexy vaginally, or sacrocolpohysteropexy abdominally but never manchester.
Hi Prabhat! thanks for your answer. And I agree with you then in that case. Our choice is anterior and posterior sacrospinoushysteropexy using a 14 x 1,5cm sling type mesh + classic repairs which are already published and with videos available on the web.. If the cervix is hypertrophic then we resect the cervix. Like a "Manchester/Hysteropexy". This has been our standard of care for years even in postmenopausal ladies as in our country the uterus is a valuable and more than 80% of women request uterine preservation. Vaginally will be for sure less invasive. Anyway if the TVL is larger than 12 our choice is SCHP open, laparoscopic or even robotic if the patient can afford the robot. Our large case series of SSFHysteropexy shows that after C+12cm results are not that good and after 14 really bad. In all these case SCHysteropexy is our choice
Thanks Dr. Sarsotti,
I really appreciate your explanation. Actual management goes towards the urogynecology. Thanks once again for your support.
Thanks Prabhat!. And I really appreciate you asking about uterine preservation. For years no one wanted to discuss this topic, as hysterectomy was mandatory though nobody could explain why were doing it… Even those whose were repeating all the time that as D. Nichols said that the uterus is "a victim" "a silent bystander"… kept removind it. 15 years ago we sent a paper to AUGS about SSFhysteropexy using only sutures (which didn't work..) and was rejected because of being unethical. Uterine preservation was unethical in the US by that dates.
Right now we are in the middle of a protocol comparing VH + classic SSF + repairs vs SSF hysteropexy + repairs for Stages IIIC+5 and higher up to IVC +12. But I think there should be something like an international protocol about this as we live in a global world by now for any stages that deserve treatment for apical descents. Have a nice weekend.
Pseudoprolapse better treated by fathergill`soperation . True uterine prolapse better by sacrocolpopexy or sacrospinous fixation.
Dear Dr. Bakul Leuva,
I told this in this forum. But I did not try it. Yet I have to collect the original article from BJOG.
Why do not you try the CESA-VASA technique.Is more comprehinsive that the vaginal approach is likly to recure in young age vaginal prolapse and abdominal surgery is more useful.Also,lokking to the bigger pic. what is the urinary complaint of this lady?
I feel in this case Manchester with Anterior and posterior colpoperiniorraphy will be right choice.i agree with peter petros and Dr.Dilip Bhavtankar.
I agree to Johan Nel mainly when family is completed as in this ask
4th November 2014
Thanks Claudio,
In the years when my father trained in England and Ireland to become an Obstetrician & Gynaecologist (1952-1956), he was taught this operation. Subsequently he had a massive practice in Cape Town, South Africa and I frequently assisted him with his beautiful operations. It then became known that by removing the cervix, as in the Manchester-Fothergill operation, infertilty is actually caused, since the cervical mucus is necessary for penetration of sperm cells.
The fact is also that IIIrd degree UV-prolapse is extremely rare in women who have not had children.
In the case mentioned by Veena, the answer is therefore vaginal hysterectomy with anterior and posterior repair.
The patient must be properly informed, followed by written informed consent.
Poverty should play no role in the decision, since all patients should be treated by the best available method.
Kind regards,
The uterus is suspended proximally by uterosacral ligaments (USL) posteriorly, cardinals (CL) laterally and the fascial attachments of vagina to ATFP anteriorly. From a biomechanical and bioengineering perspective alone, the uterus is needed as part of the structural support system as it acts like the keystone of an arch. There is also recent work which suggests that the there is a greater incidence of prolapse and symptoms such as nocturia in patients who have had prior hysterectomy.
An anatomical explanation for this is that CLs and USLs proximally are supplied by the descending branch of the uterine artery. Cutting this during VH may cause atrophy in the proximal parts of USL and CL. In short, from a structural perspective alone, the uterus should be preserved if possible.
I agree that a Manchester is not optimal and that some type of tape applied to the suspensory ligaments is the ultimate way to reinforce them.
That is why I applied the TVT neoligament principle to the infracoccygeal sacropexy operation in the early 1990s. It was a great operation which basically reinforced the USLs. Unfortunately initially Tyco marketed it with a multifilament tape which produced a higher rate of erosions.
More recently, we have been using the TFS minisling which can repair all 4 suspensory ligaments plus perineal body.
For a history of how the neoligament principle was developed and the application of tapes to incontinence and prolapse, see
Petros PE, Papadimitriou J Evolution of Midurethral and Other Mesh Slings – A Critical Analysis. Neurourol Urodyn. 2012 Sep 21. doi: 10.1002/nau.22308.
Uterus is suspended from behind by uterosacral ligament. Proximally by pubocervical ligament and laterally by cardinal ligament. It is level one support. Direction of vagina during erect posture and nerve supply to levator ani muscle are very important along with length of genital hiatus. Weakness, damage to nerve supply of levator ani muscle are the main culprit. Until or unless US or cardinal ligament gets traction they usually does not lengthen. Whatever the procedure or material, level one and two have to be reconstructed. Either hight US suspension or sacrospinous suspension is essential.
Dear Prabhat
If "Weakness, damage to nerve supply of levator ani muscle are the main culprit." how do you explain a >90% cure rate for apical uterine prolapse by repair of only cardinal and uterosacral ligaments?
Above all the explanation have been taken from articles published in 'Clinical obstetrics and gynecology'. Congenital weakness, acquired weakness, reconstruction causes anatomical correction as well as structural integrity is maintained by reattachment and fibrosis. I am explaining like this
In case of Sacrospinous fixation by polyglycoloic acid suture. Its tensile strength decreases within 60 to 70 days. How can it prevent apical prolapse? Whereas failure rate is only 10% if done correctly.
Every operation in the pelvic floor addresses ligaments or fascia.
'Clinical obstetrics and gynecology' is just somebody's opinion. It is important to maintain a critical attitude.
re Sacrospinous fixation by polyglycolic acid suture.
I have never performed this operation so I cannot reasonably comment
However, it is a fact the 100 year old Manchester Operation still works quite well.
In my experience, it works by formation of scar tissue which prevents the prolapse
In other words, the dissection creates trauma and scar tissue
The sutures support the tissues while the scar cross-bonds over a period of 4-6 weeks
Thanks. What you said I mean it.
The Journal does not say the opinion exclusively. I always try to read the references also. Delancy's explanation is no longer an opinion, it is evidence-based.
Above your explanation is very helpful to me to express my opinion more exclusively.
In my opinion, Manchester Operation works well if properly done and is indicated [ second degree uterine descent with supravaginal elongation of cervix and obviously, if woman does not want further baby]. This is my opinion, and I follow it.
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