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The Manchester operation for uterine prolapse
International Journal of Gynecology and Obstetrics (2006) 92, 228 — 233
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CLINICAL ARTICLE
The Manchester operation for uterine prolapse A. Ayhan, S. Esin, S. Guven *, C. Salman, O. Ozyuncu Hacettepe University, School of Medicine, Department of Obstetrics and Gynecology, Ankara, Turkey Received 28 August 2005; received in revised form 27 November 2005; accepted 6 December 2005
KEYWORDS Manchester operation; Complications; Uterine prolapse
Abstract Objective: To evaluate the clinical characteristics, complications, and satisfaction scores of patients who underwent the Manchester operation. Methods: This retrospective observational study evaluated data from 204 women who underwent the Manchester operation at the Department of Obstetrics and Gynecology of Hacettepe University School of Medicine, Ankara, Turkey, from January 1985 to April 2004. Results: Mean age was 34.68 F 4.24 years and parity 2.47 F 0.96; 85.8% of the patients were premenopausal; 176 patients (86.28%) had grade 3 and 28 (13.72%) had grade 2 uterine prolapse; 95.1% of the patients had associated cystoceles and 51.3% had associated rectoceles; and 81.4% had urinary incontinence. Regarding early postoperative complications, 27 patients (13.23%) had febrile morbidity; retroperitoneal hematoma occurred in 1 patient (0.49%); urinary retention occurred in 45 patients (22.05%), and cervical stenosis occurred in 23 patients (11.27%). At 1 year, 1 patient had undergone abdominal hysterectomy because of unsuccessful cervical dilatation; and a mean of 3.6 years following the operation, 8 patients (3.9%) had undergone the tension-free vaginal tape procedure plus a vaginal hysterectomy for recurrent stress urinary incontinence and uterine prolapse. The mean satisfaction/acceptance score for the operation was 8.52 F 2.13 (range, 2— 10). Conclusion: A high degree of acceptance/satisfaction and a low morbidity rate show the Manchester operation to be a good option for the treatment of uterine prolapse in women who wish to keep their uterus. D 2005 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction
* Corresponding author. Mahmut Esat Bozkurt Caddesi No: 69/2 ONCEBECI, Ankara, Turkey. Tel.: +90 312 419 49 16; fax: +90 312 432 24 15. E-mail address: [email protected] (S. Guven).
With or without cystocele and/or rectocele, uterine prolapse, i.e., the descent of the uterus and cervix down the vaginal canal toward the introitus, causes great discomfort. Vaginal hysterectomy is the preferred procedure for the treatment of
0020-7292/$ - see front matter D 2005 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2005.12.002
The Manchester operation uterine prolapse, unless the patient is of reproductive age and wishes to remain fertile. In this case, the surgical procedures of choice are uteropexy or the Manchester—Fothergill operation. In the late 19th and early 20th century, 2 surgeons from Manchester, England, developed a successful technique for the correction of uterine prolapse [1]. Archibald Donald combined anterior and/or posterior colporrhaphy with amputation of the cervix into a single operation; later, W.E. Fothergill modified the technique, giving the anterior colporrhaphy incision a triangular shape with its base near the cervix and plicating the parametrium anterior to the cervix [1]. The operation has been known as the Manchester Donald— Fothergill operation but will be referred to as the Manchester operation. The aim of this study was to assess the early and late complications of the Manchester operation as well as the satisfaction scores of women who underwent it.
2. Methods The 204 available records of 232 eligible women who underwent the Manchester operation at the Department of Obstetrics and Gynecology of Hacettepe University School of Medicine, Ankara, Turkey, from January 1985 to April 2004 were reviewed. The institutional ethics board approved the study. The degree of prolapse had not been reported at the time of surgery for most patients, either by the pelvic organ prolapse quantitation (POP-Q) classification proposed by the International Continence Society—which standardizes terminology for female pelvic organ prolapse and pelvic floor dysfunction— or by any of the more commonly accepted standards. Therefore, the level of descent was graded on a scale of 0 to 4, with grade 0 referring to no prolapse; grade 1, prolapse half-way to the hymen; grade 2, at the hymen; grade 3, half-way out of the hymen; and grade 4, total prolapse (i.e., procidentia). Patients with procidentia were excluded from this retrospective study. No patients had a history of pelvic surgery. Endometrial biopsies were performed in all patients preoperatively and no sample revealed hyperplasia or neoplasia. Preoperative cervical Pap smear results were normal for all patients. All Manchester operations were performed with a few modifications by the same pelvic surgeon team. The components of the standard Manchester operation are diagnostic curettage; detachment, suturing, and reattachment of both cardinal and uterosacral ligaments to the anterior aspect of the
229 uterine isthmus; amputation of the cervix; and covering of the cervical stump with vaginal mucosa, as per the Sturmdorf technique. Tubal ligation was performed concomitantly via posterior colpotomy in 82 patients (40.2%) who no longer desired to become pregnant. No patients underwent culdoplasty. Of the 166 patients with urinary stress incontinence, 160 (96.3%) underwent the standard Kelly—Kennedy plication procedure and 6 (3.7%) the tension-free vaginal tape (TVT) procedure along with the standard plication. A vaginal pack was placed into the vagina and removed on the second postoperative day. The urethral catheter was removed on the second postoperative day as well. If the patient had urinary retention, she was recatheterized, and if the residual urine volume was greater than 100 mL, the catheter was left in place for 3 days. During this period, the patient was taught to perform bladder exercises. If her condition persisted, 25 mg/day of bethanechol chloride (Myocholin; Glenwood, Essen, Germany) was prescribed. Febrile morbidity was defined as a temperature higher than 38.3 8C on a single occasion or 38.0 8C or higher on 2 occasions more than 24 h after surgery. Cervical stenosis was suspected in patients with pelvic pain, hypomenorrhea or amenorrhea, and negative results for blood pregnancy tests. It was confirmed if a Hegar dilator 3 mm or less in diameter could not be passed through the cervix, and by transvaginal sonography. Following confirmation of the diagnosis of cervical stenosis, patients underwent cervical dilatation with Hegar dilators. Six weeks and 6 months after surgery, all patients underwent pelvic examinations by the same surgeon team to determine whether the uterine prolapse and the cystocele or rectocele had improved. All patients were asked by questionnaire about their satisfaction with and acceptance of the Manchester operation at a median of 60 months (range, 4—228 months) after the procedure. They were asked to scale their degree of satisfaction from 0 (lowest) to 10 (highest). The statistical software SPSS for Windows, version 10.0 (SPSS, Chicago, Illinois) was used to perform the statistical analyses. The v 2, t, and Mann—Whitney U tests were used, and P b.05 was considered significant.
3. Results A total of 232 patients underwent the Manchester operation from January 1985 to April 2004 but data
230
A. Ayhan et al.
were available of only 204. Mean F SD age at the time of surgery was 34.68 F 4.24 years (range, 18— 53 years) and mean F SD parity was 2.47 F 0.96 (range, 0—5). Twenty-nine patients (14.2%) were postmenopausal at the time of surgery. The patients’ demographic and clinical characteristics are shown in Table 1. In 187 (91.6%) of the patients, the main complaint was pelvic pressure and a feeling of dragging. In addition, 166 patients (81.4%) had urinary incontinence and 72 (35.2%) had defecation dysfunction. All had symptomatic genital prolapse, which was the main indication for surgery. Preoperative pelvic examination findings and urogynecological results are also shown in Table 1. Only 1 (1.22%) of the 82 patients who underwent tubal ligation concomitantly with the Manchester operation became pregnant, and she gave birth to a healthy full-term baby via cesarean section. There were no complications during the initial surgery, but the recanalization of the left fallopian tube was observed on cesarean section.
Table 1 Demographic characteristics and operative factors of 204 women who underwent the Manchester operation* Variable Age at time of diagnosis Parity, No. Length of operation, min Intraoperative blood loss, mL Length of hospitalization, d Menopausal status Premenopausal Postmenopausal Systemic disease None Chronic obstructive pulmonary disease Chronic constipation Degree of uterine prolapse Grade 2 Grade 3 Associated cystocele None Grade 1 Grade 2 Grade 3 Incontinence None Stress incontinence Urge incontinence Mixed Associated rectocele None Grade 1 Grade 2 Grade 3
34.68 F 4.24 (18—53) 2.4 F 0.96 (0—5) 85.37 F 42.63 (40—120) 247.35 F 97.20 (50—750) 5.40 F 3.68 (1—42) 176 (85.8) 28 (14.2) 201 (98.5) 1 (0.5) 2 (1.0) 28 (13.7) 176 (86.3) 10 28 151 15
(4.9) (13.7) (74.0) (7.4)
38 91 10 65
(18.6) (44.6) (4.9) (31.9)
99 14 67 24
(48.7) (6.8) (32.8) (11.7)
* Values are given as mean F SD (range), or number (%).
Tubal ligation was performed again with the Pomeroy technique. The operative factors are outlined in Table 1. Bladder perforation occurred during surgery in 2 patients (0.98%). Regarding early postoperative complications, 27 patients (13.23%) experienced febrile morbidity; 1 patient (0.49%) developed a postoperative retroperitoneal hematoma, which was managed conservatively; 45 patients (22.05%) developed urinary retention postoperatively, of whom 20 (9.80%) required 25 mg/day of bethanechol chloride for 1 week. Twenty-three patients (11.27%) developed cervical stenosis, and cervical dilatation under general anesthesia was performed for symptomatic and therapeutic relief. Of these patients, 12 (5.88%) required cervical dilatation once; because of recurrence, 5 (2.45%) required it twice, 3 (1.47%) required it 3 times, and 3 (1.47%) required it 4 times. One year after the Manchester operation, 1 patient (0.49%) underwent abdominal hysterectomy because of recurrent cervical stenosis after cervical dilatation failed 4 times. A mean of 3.6 years following the Manchester operation, only 8 patients (3.9%) experienced recurrent uterine prolapse. All 8 patients, who were older than 40 years, initially presented with grade 3 prolapse and now had grade 2 prolapse. The clinical risks and the risk of another prolapse recurrence following conservative surgery or with medical therapy were discussed with these patients. After giving informed consent, they underwent vaginal hysterectomy plus the TVT procedure for recurrent stress urinary incontinence. Moreover, another 3 patients (1.47%) who had recurrent grade 3 cystocele plus grade 2 rectocele also underwent further anterior and posterior colporrhaphy. In this study, performing tubal ligation concomitantly with the Manchester operation did not yield statistically significant differences in mean operating time, blood loss, length of hospital stay, satisfaction scores, or rates of early or late complications (P N.05) (Table 2). Furthermore, age at diagnosis, parity, and presence of urinary incontinence did not cause statistically significant differences in the mean satisfaction scores of patients (Table 3). Malignant mesothelioma developed in 1 patient 6 years after the operation, and she died 1 year after diagnosis; renal oncocytoma developed in 1 patient, who underwent nephrectomy; but no gynecologic malignancy developed in any of the patients following the operation. The mean satisfaction/acceptance score for the Manchester operation was 8.52 F 2.13 (range, 2—
The Manchester operation Table 2 ligation*
231
Comparison of operative variables for the Manchester operation with or without concomitant tubal
Variable
MO (n = 122)
MO + TL (n = 82)
P value
Mean hospital stay, d Mean operation time, min Mean blood loss, mL Postoperative complications, % Hematoma formation Urinary infection
5.35 F 4.25 71.43 F 17.55 185.18 F 74.44
5.47 F 2.63 95.56 F 102.53 222.10 F 124.97
.82 .29 .22
0.8 12.5
0 11.0
NA .47
Abbreviations: MO, Manchester operation; NA, not applicable; TL, tubal ligation. * Values are given as mean F SD unless otherwise indicated.
10). The median postoperative follow-up was 5 years (range, 4 months to 19 years).
4. Discussion Approximately half of all parous women have loose pelvic floor support and some degree of uterine prolapse, but only 10% to 20% of these women seek medical attention [2,3]. Uterine prolapse increases with parity, age, genetic predisposition, and traumatic delivery [3,4]. The lifetime risk for a parous woman to undergo surgery for pelvic organ prolapse or incontinence is 11% by the age of 80 years [5]. Treatment modalities for uterine prolapse are complex, and they include nonsurgical procedures (such as pelvic floor exercises and placement of pessaries) and surgical procedures (such as vaginal hysterectomy, the Manchester operation, anterior and/or posterior colporrhaphy, and uteropexy). The failure of nonsurgical treatment and the need for a definitive therapy make surgery the appropriate choice for the correction of pelvic support defects [6]. The vaginal route is preferable to the abdominal route for uterine prolapse treatment. For the Table 3 Distribution of satisfaction scores (from 0 to 10) according to clinical characteristic* Characteristic
Satisfaction scores
Age at diagnosis, y V30 7.80 F 2.24 N30 8.59 F 2.10 Parity, No. V2 8.78 F 1.96 N2 8.22 F 2.27 The choice of surgical therapy MO 8.53 F 2.12 MO + TL 8.50 F 2.13 Associated urinary incontinence Yes 8.44 F 2.11 No 8.77 F 2.14
P value .11
.06
.91
.35
Abbreviation: MO, Manchester operation; TL, tubal ligation. * Values are given as mean F SD.
definitive treatment of uterine prolapse, hysterectomy is commonly required; however, in patients who want to retain their uterus, the Manchester operation may be the option of choice [6]. In this study, 85.8% of the women were premenopausal, which suggests that younger patients with uterine prolapse who want to retain their uterus prefer to undergo the Manchester operation. Vaginal hysterectomy seems to be favored over other methods, including the Manchester operation, for the treatment of uterine prolapse [7]. However, a question that needs to be answered is whether it is necessary to remove the uterus when there is no uterine disease. Women may be at increased risk for new-onset urinary incontinence, bladder dysfunction or prolapse, and sexual dysfunction—including problems with achieving orgasm—following hysterectomy [8], and some authors are concerned with the possibility of uterine cancer. Tipton and Atkin [9] examined 82 premenopausal women 6 to 12 years after they underwent the Manchester operation and found that uterine carcinoma had developed in 2. Hopkins and colleagues [10] also reported on 2 patients in whom adenocarcinoma of the endometrium developed in the retained uterus after they underwent the Manchester operation. These 2 patients were lost to follow-up, and the authors suspected that hysterectomies had been performed. Yet there is no proven relationship between endometrial carcinoma and the Manchester operation. Of course, it is important to inform the patient that her uterus has not been removed and that regular pelvic examinations, Pap smears, and endometrial biopsies are necessary. In the present study, none of the patients developed uterine carcinoma during a median follow-up of 5 years. Thomas et al. [7] reported that the Manchester operation is quick, efficacious, and associated with less blood loss than vaginal hysterectomy. In another study comparing the Manchester operation with vaginal hysterectomy, lower postoperative and surgical complication rates were reported for the Manchester operation [11]. The present study
232 also found that the operative complication rates were within acceptable ranges; and, since the cure rate of uterine prolapse was 96.1% within a mean follow-up of 5 years, the Manchester operation may be a good alternative to vaginal hysterectomy in the absence of uterine disease. The incidence of cervical stenosis following cervical conization is approximately 1%, but reaches 24% in cases of cold knife conization [12]. In this study of women undergoing the Manchester operation rather than conization, 23 incurred cervical stenosis, for a high rate of 11.27%. Because no data from other studies were available to the authors regarding patients who underwent the Manchester operation, a comparison with their results was not possible. The possible reason for the decreasing popularity of the Manchester operation worldwide may be the high rate of cervical stenosis. Conger and Keettel [13] and Thomas et al. [7], respectively, reported the rates of recurrent prolapse to be approximately 4.3% and 6.0%. In the study by Tipton and Atkin [9], the reoperation rate among 82 women treated with the Manchester operation for uterine prolapse was 21% 6 to 12 years after initial surgery. Comparisons of the Manchester operation with vaginal hysterectomy have often overlooked the fact that there are more vault prolapses following vaginal hysterectomy, whereas cystoceles recur more often after Manchester operations [1,7]. In the present study, the recurrence rates were 3.9% for uterine prolapse and 1.47% for cystocele or rectocele, which is in accordance with results from previous studies. If the patient does not desire to remain fertile, bilateral tubal ligation may be performed concomitantly with the Manchester operation via posterior colpotomy. In the present study, 40.2% of patients underwent bilateral tubal ligation along with the Manchester operation, and there were no significant differences between the Manchester operation with and without tubal ligation with regard to blood loss, length of hospital stay, operating time, satisfaction scores, and early- or late-onset complications. Only 1 patient became pregnant following the procedure and the baby was born without any complications. In this study, because the Manchester operation was performed in women who had no desire to become pregnant, a conclusion regarding pregnancy complications after the Manchester operation was not possible. However, women who do not want to bear any more children should be able to recognize that, on balance, they are better off having their uterus removed. It has been shown repeatedly that possessing a uterus does not
A. Ayhan et al. enhance sexual responsiveness or provide a better support for the other pelvic organs. In the preantibiotic era, at a time when vaginal hysterectomy was in its infancy, the Manchester operation was designed, to avoid intraperitoneal exposure. The high score of acceptance/satisfaction (8.52 F 2.13) shows that the tolerability of the Manchester operation is good and suggests that the procedure is a good option for women who want to retain their uterus. Since 94.1% of the patients whose records were reviewed underwent the Manchester operation before 2000, the frequency of the procedure declined between 1985 and 2004 at the Department of Obstetrics and Gynecology of Hacettepe University. This decline resulted in fewer surgeons and residents learning to perform it. Worldwide, most studies on the Manchester operation were conducted in the early 20th century and there are few studies about its long-term efficacy. The declining number of Manchester operations performed will mean fewer studies about the procedure. Older patients, patients whose severe conditions render anesthesia dangerous, younger patients who want to bear children, and patients who refuse to undergo hysterectomy are suitable candidates for the Manchester operation. This retrospective study suggest that the procedure may be recommended for patients desiring uterine conservation, especially that better anesthesia and new surgical materials may increase its tolerability and success rate. Observational, randomized, controlled, prospective, long-term studies are needed to confirm the results of the present study.
References [1] Pearce EW. The Manchester procedure. Mo Med 2004;101: 46 – 50. [2] Samuelsson EC, Arne Victor FT, Tibblin G, Svardsudd KF. Signs of genital prolapse in a Swedish population of women 20 to 59 years of age and possible related factors. Am J Obstet Gynecol 1999;180:299 – 305. [3] MacLennan AH, Taylor AW, Wilson DH, Wilson D. The prevalence of pelvic floor disorders and their relationship to gender, age, parity and mode of delivery. BJOG 2000; 107:1460 – 70. [4] Porges RF, Smilen SW. Long-term analysis of the surgical management of pelvic support defects. Am J Obstet Gynecol 1994;171:1518 – 26. [5] Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 1997;89:501 – 6. [6] Thakar R, Stanton S. Management of genital prolapse. BMJ 2002;324:1258 – 62. [7] Thomas AG, Brodman ML, Dottino PR, Bodian C, Friedman Jr F, Bogursky E. Manchester procedure vs. vaginal hysterectomy for uterine prolapse: a comparison. J Reprod Med 1995;40:299 – 304.
The Manchester operation [8] Diwan A, Rardin CR, Kohli N. Uterine preservation during surgery for uterovaginal prolapse: a review. Int Urogynecol J Pelvic Floor Dysfunct 2004;15:286 – 92. [9] Tipton RH, Atkin PF. Uterine disease after the Manchester repair operation. J Obstet Gynaecol Br Commonw 1970; 77:852 – 3. [10] Hopkins MP, Devine JB, DeLancey JO. Uterine problems discovered after presumed hysterectomy: the Manchester operation revisited. Obstet Gynecol 1997;89:846 – 8. [11] Kalogirou D, Antoniou G, Karakitsos P, Kalogirou O. Comparison of surgical and postoperative complications
233 of vaginal hysterectomy and Manchester procedure. Eur J Gynaecol Oncol 1996;17:278 – 80. [12] Larsson G, Gullberg B, Grundsell H. A comparison of complications of laser and cold knife conization. Obstet Gynecol 1983;62:213 – 7. [13] Conger GT, Keettel WC. The Manchester—Fothergill operation, its place in gynecology: a review of 960 cases at University Hospitals, Iowa City, Iowa. Am J Obstet Gynecol 1958;76:634 – 40.
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CLINICAL ARTICLE
The Manchester operation for uterine prolapse A. Ayhan, S. Esin, S. Guven *, C. Salman, O. Ozyuncu Hacettepe University, School of Medicine, Department of Obstetrics and Gynecology, Ankara, Turkey Received 28 August 2005; received in revised form 27 November 2005; accepted 6 December 2005
KEYWORDS Manchester operation; Complications; Uterine prolapse
Abstract Objective: To evaluate the clinical characteristics, complications, and satisfaction scores of patients who underwent the Manchester operation. Methods: This retrospective observational study evaluated data from 204 women who underwent the Manchester operation at the Department of Obstetrics and Gynecology of Hacettepe University School of Medicine, Ankara, Turkey, from January 1985 to April 2004. Results: Mean age was 34.68 F 4.24 years and parity 2.47 F 0.96; 85.8% of the patients were premenopausal; 176 patients (86.28%) had grade 3 and 28 (13.72%) had grade 2 uterine prolapse; 95.1% of the patients had associated cystoceles and 51.3% had associated rectoceles; and 81.4% had urinary incontinence. Regarding early postoperative complications, 27 patients (13.23%) had febrile morbidity; retroperitoneal hematoma occurred in 1 patient (0.49%); urinary retention occurred in 45 patients (22.05%), and cervical stenosis occurred in 23 patients (11.27%). At 1 year, 1 patient had undergone abdominal hysterectomy because of unsuccessful cervical dilatation; and a mean of 3.6 years following the operation, 8 patients (3.9%) had undergone the tension-free vaginal tape procedure plus a vaginal hysterectomy for recurrent stress urinary incontinence and uterine prolapse. The mean satisfaction/acceptance score for the operation was 8.52 F 2.13 (range, 2— 10). Conclusion: A high degree of acceptance/satisfaction and a low morbidity rate show the Manchester operation to be a good option for the treatment of uterine prolapse in women who wish to keep their uterus. D 2005 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction
* Corresponding author. Mahmut Esat Bozkurt Caddesi No: 69/2 ONCEBECI, Ankara, Turkey. Tel.: +90 312 419 49 16; fax: +90 312 432 24 15. E-mail address: [email protected] (S. Guven).
With or without cystocele and/or rectocele, uterine prolapse, i.e., the descent of the uterus and cervix down the vaginal canal toward the introitus, causes great discomfort. Vaginal hysterectomy is the preferred procedure for the treatment of
0020-7292/$ - see front matter D 2005 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2005.12.002
The Manchester operation uterine prolapse, unless the patient is of reproductive age and wishes to remain fertile. In this case, the surgical procedures of choice are uteropexy or the Manchester—Fothergill operation. In the late 19th and early 20th century, 2 surgeons from Manchester, England, developed a successful technique for the correction of uterine prolapse [1]. Archibald Donald combined anterior and/or posterior colporrhaphy with amputation of the cervix into a single operation; later, W.E. Fothergill modified the technique, giving the anterior colporrhaphy incision a triangular shape with its base near the cervix and plicating the parametrium anterior to the cervix [1]. The operation has been known as the Manchester Donald— Fothergill operation but will be referred to as the Manchester operation. The aim of this study was to assess the early and late complications of the Manchester operation as well as the satisfaction scores of women who underwent it.
2. Methods The 204 available records of 232 eligible women who underwent the Manchester operation at the Department of Obstetrics and Gynecology of Hacettepe University School of Medicine, Ankara, Turkey, from January 1985 to April 2004 were reviewed. The institutional ethics board approved the study. The degree of prolapse had not been reported at the time of surgery for most patients, either by the pelvic organ prolapse quantitation (POP-Q) classification proposed by the International Continence Society—which standardizes terminology for female pelvic organ prolapse and pelvic floor dysfunction— or by any of the more commonly accepted standards. Therefore, the level of descent was graded on a scale of 0 to 4, with grade 0 referring to no prolapse; grade 1, prolapse half-way to the hymen; grade 2, at the hymen; grade 3, half-way out of the hymen; and grade 4, total prolapse (i.e., procidentia). Patients with procidentia were excluded from this retrospective study. No patients had a history of pelvic surgery. Endometrial biopsies were performed in all patients preoperatively and no sample revealed hyperplasia or neoplasia. Preoperative cervical Pap smear results were normal for all patients. All Manchester operations were performed with a few modifications by the same pelvic surgeon team. The components of the standard Manchester operation are diagnostic curettage; detachment, suturing, and reattachment of both cardinal and uterosacral ligaments to the anterior aspect of the
229 uterine isthmus; amputation of the cervix; and covering of the cervical stump with vaginal mucosa, as per the Sturmdorf technique. Tubal ligation was performed concomitantly via posterior colpotomy in 82 patients (40.2%) who no longer desired to become pregnant. No patients underwent culdoplasty. Of the 166 patients with urinary stress incontinence, 160 (96.3%) underwent the standard Kelly—Kennedy plication procedure and 6 (3.7%) the tension-free vaginal tape (TVT) procedure along with the standard plication. A vaginal pack was placed into the vagina and removed on the second postoperative day. The urethral catheter was removed on the second postoperative day as well. If the patient had urinary retention, she was recatheterized, and if the residual urine volume was greater than 100 mL, the catheter was left in place for 3 days. During this period, the patient was taught to perform bladder exercises. If her condition persisted, 25 mg/day of bethanechol chloride (Myocholin; Glenwood, Essen, Germany) was prescribed. Febrile morbidity was defined as a temperature higher than 38.3 8C on a single occasion or 38.0 8C or higher on 2 occasions more than 24 h after surgery. Cervical stenosis was suspected in patients with pelvic pain, hypomenorrhea or amenorrhea, and negative results for blood pregnancy tests. It was confirmed if a Hegar dilator 3 mm or less in diameter could not be passed through the cervix, and by transvaginal sonography. Following confirmation of the diagnosis of cervical stenosis, patients underwent cervical dilatation with Hegar dilators. Six weeks and 6 months after surgery, all patients underwent pelvic examinations by the same surgeon team to determine whether the uterine prolapse and the cystocele or rectocele had improved. All patients were asked by questionnaire about their satisfaction with and acceptance of the Manchester operation at a median of 60 months (range, 4—228 months) after the procedure. They were asked to scale their degree of satisfaction from 0 (lowest) to 10 (highest). The statistical software SPSS for Windows, version 10.0 (SPSS, Chicago, Illinois) was used to perform the statistical analyses. The v 2, t, and Mann—Whitney U tests were used, and P b.05 was considered significant.
3. Results A total of 232 patients underwent the Manchester operation from January 1985 to April 2004 but data
230
A. Ayhan et al.
were available of only 204. Mean F SD age at the time of surgery was 34.68 F 4.24 years (range, 18— 53 years) and mean F SD parity was 2.47 F 0.96 (range, 0—5). Twenty-nine patients (14.2%) were postmenopausal at the time of surgery. The patients’ demographic and clinical characteristics are shown in Table 1. In 187 (91.6%) of the patients, the main complaint was pelvic pressure and a feeling of dragging. In addition, 166 patients (81.4%) had urinary incontinence and 72 (35.2%) had defecation dysfunction. All had symptomatic genital prolapse, which was the main indication for surgery. Preoperative pelvic examination findings and urogynecological results are also shown in Table 1. Only 1 (1.22%) of the 82 patients who underwent tubal ligation concomitantly with the Manchester operation became pregnant, and she gave birth to a healthy full-term baby via cesarean section. There were no complications during the initial surgery, but the recanalization of the left fallopian tube was observed on cesarean section.
Table 1 Demographic characteristics and operative factors of 204 women who underwent the Manchester operation* Variable Age at time of diagnosis Parity, No. Length of operation, min Intraoperative blood loss, mL Length of hospitalization, d Menopausal status Premenopausal Postmenopausal Systemic disease None Chronic obstructive pulmonary disease Chronic constipation Degree of uterine prolapse Grade 2 Grade 3 Associated cystocele None Grade 1 Grade 2 Grade 3 Incontinence None Stress incontinence Urge incontinence Mixed Associated rectocele None Grade 1 Grade 2 Grade 3
34.68 F 4.24 (18—53) 2.4 F 0.96 (0—5) 85.37 F 42.63 (40—120) 247.35 F 97.20 (50—750) 5.40 F 3.68 (1—42) 176 (85.8) 28 (14.2) 201 (98.5) 1 (0.5) 2 (1.0) 28 (13.7) 176 (86.3) 10 28 151 15
(4.9) (13.7) (74.0) (7.4)
38 91 10 65
(18.6) (44.6) (4.9) (31.9)
99 14 67 24
(48.7) (6.8) (32.8) (11.7)
* Values are given as mean F SD (range), or number (%).
Tubal ligation was performed again with the Pomeroy technique. The operative factors are outlined in Table 1. Bladder perforation occurred during surgery in 2 patients (0.98%). Regarding early postoperative complications, 27 patients (13.23%) experienced febrile morbidity; 1 patient (0.49%) developed a postoperative retroperitoneal hematoma, which was managed conservatively; 45 patients (22.05%) developed urinary retention postoperatively, of whom 20 (9.80%) required 25 mg/day of bethanechol chloride for 1 week. Twenty-three patients (11.27%) developed cervical stenosis, and cervical dilatation under general anesthesia was performed for symptomatic and therapeutic relief. Of these patients, 12 (5.88%) required cervical dilatation once; because of recurrence, 5 (2.45%) required it twice, 3 (1.47%) required it 3 times, and 3 (1.47%) required it 4 times. One year after the Manchester operation, 1 patient (0.49%) underwent abdominal hysterectomy because of recurrent cervical stenosis after cervical dilatation failed 4 times. A mean of 3.6 years following the Manchester operation, only 8 patients (3.9%) experienced recurrent uterine prolapse. All 8 patients, who were older than 40 years, initially presented with grade 3 prolapse and now had grade 2 prolapse. The clinical risks and the risk of another prolapse recurrence following conservative surgery or with medical therapy were discussed with these patients. After giving informed consent, they underwent vaginal hysterectomy plus the TVT procedure for recurrent stress urinary incontinence. Moreover, another 3 patients (1.47%) who had recurrent grade 3 cystocele plus grade 2 rectocele also underwent further anterior and posterior colporrhaphy. In this study, performing tubal ligation concomitantly with the Manchester operation did not yield statistically significant differences in mean operating time, blood loss, length of hospital stay, satisfaction scores, or rates of early or late complications (P N.05) (Table 2). Furthermore, age at diagnosis, parity, and presence of urinary incontinence did not cause statistically significant differences in the mean satisfaction scores of patients (Table 3). Malignant mesothelioma developed in 1 patient 6 years after the operation, and she died 1 year after diagnosis; renal oncocytoma developed in 1 patient, who underwent nephrectomy; but no gynecologic malignancy developed in any of the patients following the operation. The mean satisfaction/acceptance score for the Manchester operation was 8.52 F 2.13 (range, 2—
The Manchester operation Table 2 ligation*
231
Comparison of operative variables for the Manchester operation with or without concomitant tubal
Variable
MO (n = 122)
MO + TL (n = 82)
P value
Mean hospital stay, d Mean operation time, min Mean blood loss, mL Postoperative complications, % Hematoma formation Urinary infection
5.35 F 4.25 71.43 F 17.55 185.18 F 74.44
5.47 F 2.63 95.56 F 102.53 222.10 F 124.97
.82 .29 .22
0.8 12.5
0 11.0
NA .47
Abbreviations: MO, Manchester operation; NA, not applicable; TL, tubal ligation. * Values are given as mean F SD unless otherwise indicated.
10). The median postoperative follow-up was 5 years (range, 4 months to 19 years).
4. Discussion Approximately half of all parous women have loose pelvic floor support and some degree of uterine prolapse, but only 10% to 20% of these women seek medical attention [2,3]. Uterine prolapse increases with parity, age, genetic predisposition, and traumatic delivery [3,4]. The lifetime risk for a parous woman to undergo surgery for pelvic organ prolapse or incontinence is 11% by the age of 80 years [5]. Treatment modalities for uterine prolapse are complex, and they include nonsurgical procedures (such as pelvic floor exercises and placement of pessaries) and surgical procedures (such as vaginal hysterectomy, the Manchester operation, anterior and/or posterior colporrhaphy, and uteropexy). The failure of nonsurgical treatment and the need for a definitive therapy make surgery the appropriate choice for the correction of pelvic support defects [6]. The vaginal route is preferable to the abdominal route for uterine prolapse treatment. For the Table 3 Distribution of satisfaction scores (from 0 to 10) according to clinical characteristic* Characteristic
Satisfaction scores
Age at diagnosis, y V30 7.80 F 2.24 N30 8.59 F 2.10 Parity, No. V2 8.78 F 1.96 N2 8.22 F 2.27 The choice of surgical therapy MO 8.53 F 2.12 MO + TL 8.50 F 2.13 Associated urinary incontinence Yes 8.44 F 2.11 No 8.77 F 2.14
P value .11
.06
.91
.35
Abbreviation: MO, Manchester operation; TL, tubal ligation. * Values are given as mean F SD.
definitive treatment of uterine prolapse, hysterectomy is commonly required; however, in patients who want to retain their uterus, the Manchester operation may be the option of choice [6]. In this study, 85.8% of the women were premenopausal, which suggests that younger patients with uterine prolapse who want to retain their uterus prefer to undergo the Manchester operation. Vaginal hysterectomy seems to be favored over other methods, including the Manchester operation, for the treatment of uterine prolapse [7]. However, a question that needs to be answered is whether it is necessary to remove the uterus when there is no uterine disease. Women may be at increased risk for new-onset urinary incontinence, bladder dysfunction or prolapse, and sexual dysfunction—including problems with achieving orgasm—following hysterectomy [8], and some authors are concerned with the possibility of uterine cancer. Tipton and Atkin [9] examined 82 premenopausal women 6 to 12 years after they underwent the Manchester operation and found that uterine carcinoma had developed in 2. Hopkins and colleagues [10] also reported on 2 patients in whom adenocarcinoma of the endometrium developed in the retained uterus after they underwent the Manchester operation. These 2 patients were lost to follow-up, and the authors suspected that hysterectomies had been performed. Yet there is no proven relationship between endometrial carcinoma and the Manchester operation. Of course, it is important to inform the patient that her uterus has not been removed and that regular pelvic examinations, Pap smears, and endometrial biopsies are necessary. In the present study, none of the patients developed uterine carcinoma during a median follow-up of 5 years. Thomas et al. [7] reported that the Manchester operation is quick, efficacious, and associated with less blood loss than vaginal hysterectomy. In another study comparing the Manchester operation with vaginal hysterectomy, lower postoperative and surgical complication rates were reported for the Manchester operation [11]. The present study
232 also found that the operative complication rates were within acceptable ranges; and, since the cure rate of uterine prolapse was 96.1% within a mean follow-up of 5 years, the Manchester operation may be a good alternative to vaginal hysterectomy in the absence of uterine disease. The incidence of cervical stenosis following cervical conization is approximately 1%, but reaches 24% in cases of cold knife conization [12]. In this study of women undergoing the Manchester operation rather than conization, 23 incurred cervical stenosis, for a high rate of 11.27%. Because no data from other studies were available to the authors regarding patients who underwent the Manchester operation, a comparison with their results was not possible. The possible reason for the decreasing popularity of the Manchester operation worldwide may be the high rate of cervical stenosis. Conger and Keettel [13] and Thomas et al. [7], respectively, reported the rates of recurrent prolapse to be approximately 4.3% and 6.0%. In the study by Tipton and Atkin [9], the reoperation rate among 82 women treated with the Manchester operation for uterine prolapse was 21% 6 to 12 years after initial surgery. Comparisons of the Manchester operation with vaginal hysterectomy have often overlooked the fact that there are more vault prolapses following vaginal hysterectomy, whereas cystoceles recur more often after Manchester operations [1,7]. In the present study, the recurrence rates were 3.9% for uterine prolapse and 1.47% for cystocele or rectocele, which is in accordance with results from previous studies. If the patient does not desire to remain fertile, bilateral tubal ligation may be performed concomitantly with the Manchester operation via posterior colpotomy. In the present study, 40.2% of patients underwent bilateral tubal ligation along with the Manchester operation, and there were no significant differences between the Manchester operation with and without tubal ligation with regard to blood loss, length of hospital stay, operating time, satisfaction scores, and early- or late-onset complications. Only 1 patient became pregnant following the procedure and the baby was born without any complications. In this study, because the Manchester operation was performed in women who had no desire to become pregnant, a conclusion regarding pregnancy complications after the Manchester operation was not possible. However, women who do not want to bear any more children should be able to recognize that, on balance, they are better off having their uterus removed. It has been shown repeatedly that possessing a uterus does not
A. Ayhan et al. enhance sexual responsiveness or provide a better support for the other pelvic organs. In the preantibiotic era, at a time when vaginal hysterectomy was in its infancy, the Manchester operation was designed, to avoid intraperitoneal exposure. The high score of acceptance/satisfaction (8.52 F 2.13) shows that the tolerability of the Manchester operation is good and suggests that the procedure is a good option for women who want to retain their uterus. Since 94.1% of the patients whose records were reviewed underwent the Manchester operation before 2000, the frequency of the procedure declined between 1985 and 2004 at the Department of Obstetrics and Gynecology of Hacettepe University. This decline resulted in fewer surgeons and residents learning to perform it. Worldwide, most studies on the Manchester operation were conducted in the early 20th century and there are few studies about its long-term efficacy. The declining number of Manchester operations performed will mean fewer studies about the procedure. Older patients, patients whose severe conditions render anesthesia dangerous, younger patients who want to bear children, and patients who refuse to undergo hysterectomy are suitable candidates for the Manchester operation. This retrospective study suggest that the procedure may be recommended for patients desiring uterine conservation, especially that better anesthesia and new surgical materials may increase its tolerability and success rate. Observational, randomized, controlled, prospective, long-term studies are needed to confirm the results of the present study.
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