The effectiveness of surgical correction of uterine prolapse: cervical amputation with uterosacral ligament plication (modified Manchester) versus vaginal hysterectomy with high uterosacral ligament plication

Abstract

Introduction and hypothesis: The objective of this study is to evaluate cervical amputation with uterosacral ligament plication (modified Manchester) and compare it to vaginal hysterectomy with high uterosacral ligament plication procedure with special regard to the middle compartment.

Methods: Consecutive women with pelvic organ prolapse who underwent either vaginal hysterectomy or a modified Manchester procedure were included. Assessments were made preoperatively and at 1-year follow-up, including physical examination with pelvic organ prolapse quantification standardised questionnaires (incontinence impact questionnaire, urogenital distress inventory, and defaecatory distress inventory).

Results: Between 2002 and 2007, 156 patients were included. Ninety-eight patients returned for a 1-year follow-up. In the modified Manchester group, we found no middle compartment recurrence versus two (4%) in the vaginal hysterectomy group. Anterior and posterior compartment prolapse recurrences (stage >or=2) were similar (approximately 50%). Considering operating time and blood loss, modified Manchester was more favourable. There was no difference in the pre- and postoperative subjective scores. The overall functional outcome was acceptable.

Conclusions: We found an excellent performance of both procedures regarding middle compartment recurrences.

Fig. 1

a Schematic diagram to illustrate the modified Sturmdorf suture on the posterior side after the amputation of the cervix. The suture starts at the left uterosacral ligament about 1 1/2 cm from the amputated cervix (1). With a deep bite through the cervix, it comes out close to the cervical canal (2). It then takes a superficial double bite through the posterior vaginal wall (3 and 4), after which, another deep bite through the cervix starting in or close to the cervical canal (5) comes out in the right uterosacral ligament around 1 1/2 cm from the amputated cervix (6). b After tying this suture, the two uterosacral ligaments (1 and 6) are united in the midline. There now is a double layer of epithelium between the ligaments. This technique shortens the uterosacral ligaments and thus elevates the uterus. It also partially closes the pouch of Douglas and, thus, has a preventive effect on the development of an enterocele. Posteriorly, the raw amputated surface of the cervix is now covered with vaginal epithelium (3 and 4)