In our department, the MP has been the chosen technique for cervical elongation for many years. In sexually active women, we recommend reconstruction of the perineal body without involving the levator ani muscles to reduce the dyspareunia risk. We, therefore, set out to evaluate anatomical and subjective POP-related quality of life 12 months after the MP. Additionally, we aimed to assess whether postoperative anatomical success was correlated with the subjective outcome or not.

Women with apical compartment prolapse up to stage 3 due to cervical elongation but with no previous prolapse surgery were considered eligible for the study. Patients were excluded if they had previously undergone a hysterectomy (total or subtotal), or if the preoperative evaluation (including transvaginal ultrasound and on the indication, endometrial biopsy) revealed coexisting indications for hysterectomy, such as endometrial pathology. In the case of adnexal pathology, evaluation and treatment for this condition had to be concluded before POP surgery.

Manchester procedure
We recommend the MP as the standard treatment for apical compartment prolapse up to stage 3 due to cervical elongation in patients who desire uterus preservation and do not have any contraindications for uterine conservation. For these patients’ concomitant colporrhaphy, reconstruction of the perineal body, and apical suspension procedures such as sacrospinous fixation was performed if indicated. 

Although MP can be performed in more severe apical prolapses, the preferred procedure at our department for the few POP patients evaluated for surgery (< 10%)  with a true apical prolapse (>stage 3) and not cervical elongation alone, is hysterectomy in combination with either sacrospinous fixation, uterosacral ligament suspension or sacrocolpopexy. Therefore, women with apical prolapse > stage 3, were not included in this study. The position of the uterine corpus was evaluated on palpation (during the patient Valsalva maneuver or by cervical traction) by identifying the cervicouterine junction, as well as the position of the posterior fornix.  
Following cervical amputation, a Hegar dilatator in the cervical canal prevents accidental closure while reconstructing the portio with modified Sturmdorf sutures. In recent publications, the term MP is often used without including a reconstruction of the perineal body,  possibly omitted to avoid dyspareunia. 

In this study, we reconstructed the perineal body if it is reduced in height and thickness, as described in the original papers on the procedure. The rationale was such anatomical changes would result in a change of the vaginal axis and a subsequent loss of support for the apical compartment.  

Evaluation tools
Demographic data such as age, body mass index (BMI), and obstetrics data such as gravida and delivery type were obtained via a questionnaire. Clinical examinations including POP-Q measurements [15] were performed at baseline and 12 months after the surgery. Also, the women completed the Pelvic Floor Disability Index (PFDI-20)  and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) at the baseline and 12 months after the surgery.

33 participants were recruited in the study. Significant anatomical improvements were obtained in all compartments after the surgery. After 12 months in POP-Q examination, the mean (±SD) of Ba was changed from +1.82 (±1.71) to −1.18 (±1.50), C was changed from −1.25 (±2.81) to −6 (±1.82), and D from −6.30 (± 1.42) to −7.1 (±1.25) respectively (P<0.001). POP-Q stage 0–1 was obtained inof7% in the apical compartment (C < −1), but only in 45.4% in the anterior compartment (Ba < −1).  A significant reduction in symptom scores was obtained for PFDI-20 (P< 0.01) and PISQ-12 (P=0.011).

This study is one of the very few prospective studies evaluating the MP. We were able to demonstrate that the procedure gives adequate apical correction, by recent publications comparing MP with vaginal hysterectomy.

This study shows that the MP provides sufficient apical compartment support and appropriate subjective outcomes at 12-months of follow-up, whereas the less optimal anatomical outcomes in the anterior compartment might still consider a challenge. The observed anatomical changes in the apical compartment correlated well with the changes in the sole symptom of bulging, whilst the anatomical changes in the anterior compartment also associated with the overall changes in urinary distress and POP symptoms. Less appropriate anatomical outcome in the anterior compartment did not seem to affect subjective satisfaction, implying that the aim of operation in the anterior compartment should be to decrease the prolapse to above the level of the hymen, not inescapably aiming for stage 0–1. Furthermore, the perineal body restoration may be having reduced the potential negative subjective effects owing to a less optimal anatomical anterior wall repair.