Manchester-Fothergill Procedure
The Manchester-Fothergill procedure is a transvaginal uterus-preserving apical repair consisting of cervical amputation combined with plication of the uterosacral and cardinal ligaments onto the cervical stump to restore apical support while retaining the uterine body. It is particularly well-suited to symptomatic uterine prolapse with cervical elongation in patients who have completed childbearing.[1][2]
For the alternative uterus-preserving operation, see Sacrospinous Hysteropexy. For the post-hysterectomy vault analogue using the same uterosacral anchors, see Uterosacral Ligament Suspension (USLS). For the broader prolapse decision framework, see Prolapse Repair.
History and Definition
The procedure was first developed by Archibald Donald of Manchester, England in 1888, who combined anterior and posterior colporrhaphy with cervical amputation. William Fothergill modified the technique (1908) by adding the critical step of cardinal-ligament plication onto the anterior cervical stump.[3][4]
The AUGS / IUGA Joint Report on Terminology (2020) defined the Manchester procedure as amputation of the uterine cervix and plication of the uterosacral ligaments extraperitoneally above the remaining cervical stump.[2]
Historically underutilized in the United States, the operation has experienced a resurgence — particularly in Europe and Scandinavia — driven by the trend toward uterus-preserving surgery.[3][5]
Indications
- Symptomatic uterine prolapse (POP-Q stage ≥ 2), particularly with cervical elongation.[6]
- Patients who desire uterine preservation and have completed childbearing.[5]
- Uterine descent that does not protrude beyond the hymen — the best-studied population.[1]
- Failed conservative management (pessary, PFMT).
Relative contraindications
- Desire for future pregnancy — limited and concerning obstetric data; reserve for post-childbearing patients.[5]
- Suspected uterine or cervical malignancy.
- Prolapse of the uterine body significantly beyond the hymen (POP-Q point D at or beyond the hymen) — generally inappropriate for the Manchester procedure.[1]
- Abnormal uterine bleeding requiring further evaluation.
Surgical Technique
The operation is performed in dorsal lithotomy under regional or general anesthesia.[1][3][4]
- Anterior vaginal-wall incision. Circumferential incision around the cervix; vagina and bladder mobilized off the cervix and the uterosacral-cardinal ligament complex anteriorly and laterally.
- Ligament identification. Cardinal ligaments are clamped, cut, and ligated bilaterally; uterosacral ligaments are similarly identified.
- Cervical amputation. Cervix amputated at the desired level, removing the elongated portion. Specimen sent for histology — incidental abnormal cervical pathology was found in 4 of 164 specimens (2.4%) in the Enklaar 2023 RCT, including one CIN2.[1]
- Ligament plication.
- Uterosacral ligaments plicated extraperitoneally at the posterior aspect of the remaining cervical stump.
- Cardinal ligaments plicated and sutured to the anterior aspect of the cervical stump with overlapping sutures.
- Net effect: the cervix is pulled backward and upward into the pelvis, producing anteversion of the uterus.[4]
- Cervical reconstruction (Sturmdorf sutures). Posterior, then anterior Sturmdorf sutures cover the amputated cervical stump with vaginal mucosa and reconstruct the external os.[4]
- Concomitant compartment repair. Anterior and / or posterior colporrhaphy as needed; vaginal incision closed.
Outcomes — vs Sacrospinous Hysteropexy
The Enklaar 2023 multicenter RCT (n = 434) compared the two uterus-sparing operations for uterine descent not protruding beyond the hymen:[1]
| Endpoint | Manchester | Sacrospinous Hysteropexy | Notes |
|---|---|---|---|
| Composite success at 2 yr | 87.3% | 77.0% | Risk difference −10.3% (95% CI −17.8 to −2.8); sacrospinous hysteropexy did not meet noninferiority — supports superiority of Manchester |
| Reoperation for recurrence | 0% | 4.3% | — |
| PGI-I "very much improved" | ~80–82% | ~80–82% | Similar patient-reported global improvement |
| Anterior compartment recurrence | Lower | Higher | Manchester preserves physiological vaginal axis |
| Posterior compartment recurrence | Higher | Lower | Trade-off |
A British Society of Urogynaecology database study (n = 718 Manchester vs 2,384 sacrospinous hysteropexy) confirmed the RCT signal — significantly better PGI-I scores, lower symptomatic prolapse within 1 year (OR 0.36), and lower apical recurrence (OR 0.09) with the Manchester procedure.[7]
Outcomes — vs Vaginal Hysterectomy
A systematic review of 9 comparative studies (Tolstrup 2017):[8]
| Endpoint | Manchester | Vaginal Hysterectomy |
|---|---|---|
| Middle-compartment recurrence | Very rare | 4–7% |
| Reoperation rate | 3.3–9.5% | 9–13.1% |
| Operative time | Shorter | Longer |
| Blood loss | Lower | Higher |
| Bladder injury / infection | Less frequent | More frequent |
Medium- to Long-Term Outcomes
A 254-patient retrospective cohort of a modified Manchester procedure with median follow-up 4.18 yr (1–8.8 yr):[9]
- Subjective recurrence: 9.25%
- Surgical failure: 1.7%
- De novo SUI: 5.2%
- PGI-I satisfaction: 94.8%
- No severe complications beyond Clavien-Dindo grade III.
Complications
Cervical stenosis — characteristic procedure-specific complication
| Population | Rate |
|---|---|
| JAMA RCT (Enklaar 2023) | 0.9% (1/106 procedures)[1] |
| Most series | 0.7–3.3%[1][5] |
| Younger women (older series) | Up to 11%, but treatment required in only 0.5% |
May present as postmenopausal bleeding (hematometra) or dysmenorrhea.[1]
Other complications[5][9][10]
| Complication | Rate / note |
|---|---|
| Urinary retention | ~7.5% (Chen 2025)[9] |
| Postoperative fever | ~5.1%[9] |
| UTI | ~1.2%[9] |
| Bladder injury | Rare; isolated case reports[10] |
| Hemorrhage / hematoma | Low across all studies[5] |
| Posterior compartment recurrence | Higher than after sacrospinous hysteropexy, but typically stage 2 (not beyond the hymen) and not yet associated with reoperation difference[1] |
| Abnormal cervical histology on amputated specimen | 2.4% (Enklaar 2023, including 1 CIN2)[1] |
Cost-Effectiveness
An economic evaluation alongside the JAMA RCT showed Manchester was significantly less expensive than sacrospinous hysteropexy from a societal perspective — mean cost difference €1,458 lower (95% CI −2,746 to −171) with no significant QALY difference.[11]
Fertility and Pregnancy Considerations
The Manchester procedure should be reserved for women who have completed childbearing. The 2026 systematic review concluded that pregnancy data after the procedure are limited and concerning.[5]
- Risk of cervical stenosis impairing conception.
- Risk of cervical incompetence and preterm delivery, by analogy with trachelectomy data for cervical cancer.[12]
- Successful pregnancies after the procedure are limited to case reports.[13]
Special Indication — Cervical Elongation Without Uterine Descensus
The Manchester procedure is also effective for isolated cervical elongation without true uterine body descent. A 36-patient series demonstrated significant improvements in POP-Q, P-QoL, and PISQ-12, with only one anterior-compartment reoperation and no serious complications.[6]
Advantages and Disadvantages
| Advantage | Disadvantage |
|---|---|
| Superior 2-yr composite success vs sacrospinous hysteropexy[1] | Higher posterior compartment recurrence vs sacrospinous hysteropexy[1] |
| Preserves the uterine body | Cervical stenosis 0.7–3.3%[1] |
| Maintains physiological vaginal axis (no posterior deflection)[1] | Not appropriate for women desiring future pregnancy[5] |
| Lower anterior compartment recurrence than sacrospinous hysteropexy[1] | Not suitable for higher-stage prolapse (uterine body beyond the hymen)[1] |
| Shorter operative time and lower EBL than vaginal hysterectomy[8] | Ongoing endometrial surveillance required |
| Lower cost than sacrospinous hysteropexy[11] | Many surgeons lack training and familiarity[3][14] |
| Native tissue — no mesh | — |
| Histology of amputated cervix offers incidental pathology screening[1] | — |
Key Principles
- Manchester-Fothergill is a uterus-preserving native-tissue apical operation combining cervical amputation with cardinal- and uterosacral-ligament plication onto the cervical stump.[1][2]
- Reserve for women who have completed childbearing — pregnancy data are limited and concerning.[5]
- Best-studied indication is uterine descent not beyond the hymen with cervical elongation; not for high-stage descent.[1]
- Superior composite success vs sacrospinous hysteropexy at 2 yr (87.3% vs 77.0%; Enklaar 2023) and at scale (BSUG database).[1][7]
- Lower cost than sacrospinous hysteropexy with similar QALYs (€1,458 less per case).[11]
- Trade-off: lower anterior compartment recurrence but higher posterior recurrence vs sacrospinous hysteropexy.[1]
- Cervical stenosis is the characteristic complication (~1%); always send the amputated specimen for histology.[1]
- Many surgeons lack training in the technique — a gap in contemporary urogynecologic surgical education despite the evidence base.[3][14]
Videos
References
1. Enklaar RA, Schulten SFM, van Eijndhoven HWF, et al. Manchester procedure vs sacrospinous hysteropexy for treatment of uterine descent: a randomized clinical trial. JAMA. 2023;330(7):626-635. doi:10.1001/jama.2023.13140.
2. International Urogynecological Association / American Urogynecologic Society. Joint report on terminology for surgical procedures to treat pelvic organ prolapse. Int Urogynecol J. 2020;31(3):429-463. doi:10.1007/s00192-020-04236-1.
3. Marquini GV, de Jarmy di Bella ZIK, Sartori MGF. The Manchester-Fothergill technique: browsing in the cutting-edge art gallery. Int J Gynaecol Obstet. 2022;156(1):10-16. doi:10.1002/ijgo.13706.
4. Walsh CE, Ow LL, Rajamaheswari N, Dwyer PL. The Manchester repair: an instructional video. Int Urogynecol J. 2017;28(9):1425-1427. doi:10.1007/s00192-017-3284-9.
5. Elissaoui S, Issaoui ME, Klarskov N, Husby K. The Manchester procedure: a systematic review of recurrence, perioperative measures, and financial cost, and a scoping review of sexual dysfunction, gynecologic cancer, and obstetric outcomes. Acta Obstet Gynecol Scand. 2026. doi:10.1111/aogs.70209.
6. Doganay M, Tugrul D, Ersak B, et al. A blind spot: Manchester-Fothergill operation for cervical elongation without uterine descensus. Eur J Obstet Gynecol Reprod Biol. 2022;271:83-87. doi:10.1016/j.ejogrb.2022.02.001.
7. Tan ACC, Latthe P. The outcomes of the Manchester procedure versus sacrospinous ligament hysteropexy for uterine prolapse: a study of the British Society of Urogynaecology database. Int Urogynecol J. 2024;35(7):1469-1475. doi:10.1007/s00192-024-05826-z.
8. Tolstrup CK, Lose G, Klarskov N. The Manchester procedure versus vaginal hysterectomy in the treatment of uterine prolapse: a review. Int Urogynecol J. 2017;28(1):33-40. doi:10.1007/s00192-016-3100-y.
9. Chen Y, Xu S, Luo N, Du L. Medium- to long-term follow-up study on modified Manchester procedure for pelvic organ prolapse. Int Urogynecol J. 2025. doi:10.1007/s00192-025-06237-4.
10. Alkış I, Karaman E, Han A, Gülaç B, Ark HC. The outcome of Manchester-Fothergill operation for uterine descensus repair: a single center experience. Arch Gynecol Obstet. 2014;290(2):309-14. doi:10.1007/s00404-014-3200-1.
11. Schulten SFM, Enklaar RA, Weemhoff M, et al. Economic evaluation of Manchester procedure versus sacrospinous hysteropexy: a follow-up analysis of a randomized clinical trial. PLoS One. 2025;20(11):e0336030. doi:10.1371/journal.pone.0336030.
12. Kyrgiou M, Mitra A, Arbyn M, et al. Fertility and early pregnancy outcomes after treatment for cervical intraepithelial neoplasia: systematic review and meta-analysis. BMJ. 2014;349:g6192. doi:10.1136/bmj.g6192.
13. Skiadas CC, Goldstein DP, Laufer MR. The Manchester-Fothergill procedure as a fertility sparing alternative for pelvic organ prolapse in young women. J Pediatr Adolesc Gynecol. 2006;19(2):89-93. doi:10.1016/j.jpag.2006.01.004.
14. Enklaar RA, Essers BAB, Ter Horst L, Kluivers KB, Weemhoff M. Gynecologists' perspectives on two types of uterus-preserving surgical repair of uterine descent: sacrospinous hysteropexy versus modified Manchester. Int Urogynecol J. 2021;32(4):835-840. doi:10.1007/s00192-020-04568-y.