The Manchester-Fothergill and the Elevate Posterior technique for the correction of a cervical elongation and large enterocele in a patient with bladder exstrophy and multiple surgeries

Abstract

Introduction and hypothesis: A 60-year-old woman presented with congenital bladder exstrophy, urinary incontinence since birth, and pelvic organ prolapse since the menopause at the age of 46 years.

Methods: The patient (gravida 2, para 2 by cesarean sections and tubal ligation) described an extensive past surgical history that included epispadias and neourethral procedures, anti-reflux surgery using the Lich-Grégoir technique, bilateral ureterosigmoidostomy achieving continence, uterine fixation after the Doléris operation, and neovaginal reconstruction. The physical examination revealed a fourth-degree enterocele with cervical elongation (POP-Q: Aa-2, Ba-2, C + 3, D + 4, gh:5, pb:2.5, Tvl:6, Ap + 3, Bp +6). Gynecological ultrasound and uro-CT were performed to ensure that the ureterosigmoidostomy had been successful, and CT-based 3D bone reconstructions were obtained to calculate the distance between the pubic rami and the ischial spines. Based on a literature review of the management options for these patients and the specific characteristics of our patient, a decision was made to perform trachelectomy (the Manchester technique with Fothergill stitches) and a polypropylene mesh placement with sacrospinous ligament anchor (Elevate Posterior® PC, AMS).

Results: Six months after the surgery, we observed good anatomical and functional results with significant improvement in the patient's quality-of-life scale score.

Conclusion: We believed that the vaginal approach was minimally invasive with a low risk of morbidity in our patient, who had a very altered anatomy, but produced a satisfactory functional result.