Less is More: Manchester Operation in the setting of Spina Bifida and Neurogenic Bladder

Objectives: To educate patients and providers on the Manchester Operation and to show a less invasive approach to POP in the setting of cervical elongation for a patient who would benefit from a shorter and less invasive surgery.

Methods: Case was from an elective procedure performed at home institution. Patient was seen in clinic for consultation and consented for exam under anesthesia, Manchester operation, as well as the videoing and presenting of this case.

Clinical Relevance: Pelvic Organ Prolapse (POP) is a common disorder that generally becomes symptomatic when the prolapse extends to or beyond the hymen. A subset of POP arises from cervical elongation. Patients with POP due to cervical elongation can be candidates for the Manchester Operation. The Manchester Operation is the excision of the distal cervix with plication of the cardinal ligaments to the anterior aspect of the cervical stump resulting in reduction of pelvic organ prolapse.

The patient is a 31 year old female with bothersome pelvic organ prolapse who presented to clinic for consultation with desire for surgical intervention. She had a history of Spina Bifida with resultant neurogenic bladder managed with clean intermittent catheterization and surgical history of ventriculoperitoneal shunt, augmentation cystoplasty, and bilateral hamstring and Achilles tendon releases. The patient is of small stature with height of 4.5 ft (137cm) at full extension but with significant contraction at the hip and knee joints bilaterally. Her pelvic examination revealed cervical elongation with tip of cervix at 3 cm beyond the hymen (C +3). Her total vaginal length was only 4 cm with no anterior or posterior compartment prolapse. She had a recent normal Pap smear with negative HPV co-testing. The patient’s primary goal of treatment was for her and her care provider to be able to catheterize her bladder without obstruction. Also, imaging showed significantly altered anatomy of the sacrum and pelvic support structures. She was counseled on surgical options including hysterectomy, hysteropexy and the Manchester procedure. She ultimately decided to proceed with a Manchester procedure.

Post-operatively, the patient was very satisfied with ability to self-catheterize without obstruction, which was her primary goal for the outcome of the surgical intervention. The remaining cervical stump was well suspended with small cystocele (Ba -1) and she reports resumption of normal menses without pain or obstruction.

Therefore, the Manchester Operation is a safe and effective surgical option for patients with cervical elongation leading to pelvic organ prolapse who would benefit from a less invasive surgery.