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Manchester-Fothergill Procedure

The Manchester-Fothergill procedure is a transvaginal uterus-preserving apical repair that amputates the cervix and plicates ligamentous support to the retained cervical stump. Described variants use the cardinal ligaments, uterosacral ligaments, or both; SAM tested combined plication. A 2026 U-POP meta-analysis associated cardinal-including variants with lower anatomical failure than a comparator group combining uterosacral-only Manchester repair and vaginal USLS (9.16% versus 30.22%); bulge symptoms and retreatment did not differ significantly, and the evidence was mostly retrospective and heterogeneous.[15] Its moderate-quality evidence statement advises considering cardinal or combined cardinal/uterosacral suspension rather than uterosacral-only Manchester to reduce anatomical recurrence; this statement was not formally voted on.[15] The operation is used for symptomatic uterine prolapse, often with cervical elongation, in patients who have completed childbearing.[1][2][15]

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 later modified the technique by adding the step of cardinal-ligament plication onto the anterior cervical stump. Sources give differing dates for the modification (1907, 1915 and 1921 are all cited).[3][4] See also the History of Prolapse Surgery & Urogynecology.

The AUGS / IUGA 2020 terminology report defines the Manchester procedure as shortening or amputation of the cervix while retaining the uterine body, with extraperitoneal uterosacral-ligament plication caudad to the amputation, below the internal cervical os.[2]

The operation has been used little in the United States. Interest has returned, particularly in Europe and Scandinavia, with the trend toward uterus-preserving surgery.[3][5]

Indications​

  • Symptomatic uterine prolapse, particularly with cervical elongation. In SAM, point D at or proximal to −1 cm defined uterine-descent eligibility; 73/215 Manchester participants had point-C stage 1, while overall POP-Q stage was at least 2 in the baseline table.[1][6]
  • Patients who desire uterine preservation and have completed childbearing.[5]
  • Uterine descent with POP-Q point D at or proximal to −1 cm (numerically ≤−1 cm) was the SAM eligibility criterion.[1] NICE NG123 offers Manchester repair as an option for uterine prolapse, with an exception for women who may wish to have children in the future.[16]
  • Prolapse symptoms that have not improved with non-surgical treatment, or a decision to decline it.[16]

Contraindications and selection cautions​

Do not offer uterus-preserving repair with known uterine or cervical malignancy, suspected cervical malignancy, abnormal preoperative endometrial histology, or a genetic syndrome that contraindicates uterine preservation; investigate unexplained bleeding before choosing an operation.[13][19] Evaluate suspected malignancy or unexplained bleeding before choosing this operation; the bullets below also include circumstances requiring individual assessment or limiting trial applicability.[13]

  • Desire for future pregnancy. Limited and concerning obstetric data; reserve for post-childbearing patients.[5]
  • Suspected uterine or cervical malignancy.
  • Uterine descent with POP-Q point D >−1 cm (more distal than the SAM cutoff).[1]
  • Abnormal uterine bleeding requiring further evaluation.

Surgical Technique​

The operation is performed in dorsal lithotomy under regional or general anesthesia.[1][3][4]

  1. 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.
  2. Ligament identification and ureter safety. Identify the cardinal and uterosacral supports bilaterally and account for the ureteral course when placing uterosacral plication sutures.[20] Walsh's instructional repair amputates the cervix before the ligaments are clamped, divided, ligated and attached to the anterior cervical remnant; the SAM modified Manchester trial describes posterior uterosacral and anterior cardinal plication. Its outcomes apply to the trial protocol.[1][4]
  3. Cervical amputation. Cervix amputated at the planned level, removing the elongated portion. Pathology handling follows the clinical context and local protocol; the SAM trial reported abnormal histology in 4 of 164 examined specimens, including one CIN2.[1]
  4. Ligament plication.
    • Plicate the uterosacral ligaments across the midline extraperitoneally at the posterior aspect of the remaining cervical stump, caudad to the internal cervical os.[1][2]
    • 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]
  5. Cervical reconstruction (Sturmdorf sutures). Posterior, then anterior Sturmdorf sutures cover the amputated cervical stump with vaginal mucosa and reconstruct the external os.[4]
  6. Concomitant compartment repair and completion checks. Perform anterior and/or posterior colporrhaphy as needed and close the vaginal incision. The 2018 AUGS consensus recommends cystourethroscopy to inspect the urethra and bladder and confirm bilateral ureteral efflux during prolapse reconstruction, except isolated posterior repair.[17] The AUGS/IUGA terminology report recommends a digital rectal examination after most prolapse repairs and documentation of findings.[2]

Outcomes — vs Sacrospinous Hysteropexy​

The Enklaar 2023 multicenter RCT (n = 434 randomized; 393 analyzed) compared these uterus-sparing operations as a first prolapse surgery for uterine descent with POP-Q point D at or proximal to −1 cm; women needing concomitant anti-incontinence surgery were excluded.[1] The primary composite outcome required no prolapse beyond the hymen in any compartment, no bothersome bulge symptoms and no prolapse retreatment at 2 years.[1]

EndpointManchesterSacrospinous HysteropexyNotes
Composite success at 2 yr87.3%77.0%Risk difference −10.3% (95% CI −17.8 to −2.8); sacrospinous hysteropexy did not meet the 9% noninferiority margin, and the authors concluded it is inferior to Manchester
PGI-I (much or very much improved)82.1%80.0%No significant difference in patient-reported outcomes at 2 yr
Anterior prolapse beyond hymen at 2 yr5/195 (2.6%)20/196 (10.2%)The trial authors proposed dorsal vaginal deflection after sacrospinous fixation as a possible explanation.[1]
Posterior POP-Q stage ≥2 at 2 yr54/195 (27.7%)22/196 (11.2%)Posterior prolapse beyond the hymen: 3/195 (1.5%) vs 4/196 (2.0%), P = .71. The 0 vs 9 operated-compartment reoperations refer to all compartments, not specifically posterior recurrence.[1]

A British Society of Urogynaecology database cohort (n = 718 Manchester versus 2,384 sacrospinous hysteropexy) reported better PGI-I scores with the Manchester procedure, along with lower symptomatic prolapse within 1 year (OR 0.36) and lower apical recurrence (OR 0.09) at short-term follow-up. The PGI-I difference was not seen in the randomized trial.[1][7] A planned 24-month SAM analysis found that the between-group PISQ-IR score-change difference (0.09, 95% CI 0.01–0.17) fell within its prespecified ±0.31 equivalence margin among sexually active participants (101 Manchester, 99 sacrospinous hysteropexy). It separately reported de novo dyspareunia rates of 5% versus 13%, without a statistically significant between-group difference.[18]

Outcomes — vs Vaginal Hysterectomy​

A 2017 review of nine comparative studies reported the descriptive ranges below.[8] A 2025 meta-analysis of 11 studies (11,783 women; one randomized trial) found lower subjective recurrence (RR 0.85, 95% CI 0.73–0.98) and reoperation (RR 0.62, 95% CI 0.43–0.89) with Manchester overall, but no significant difference in anatomical recurrence or overall complications.[14] The subjective-recurrence and reoperation differences were not observed in the subgroup followed for >3 yr; most included studies were retrospective.[14]

EndpointManchesterVaginal Hysterectomy
Middle-compartment recurrenceVery rare4–7%[8]
Reoperation rate3.3–9.5%9–13.1%[8]
Operative timeShorterLonger
Blood lossLowerHigher
Bladder injury / infectionLess frequentMore frequent

Medium- to Long-Term Outcomes​

A retrospective cohort of 254 women had a modified Manchester procedure. Follow-up ranged from 1 to 8.8 yr (median 4.18 yr), and 173 women (68%) completed telephone or clinic follow-up. The percentages below refer to those 173 women:[9]

  • Subjective recurrence: 9.25% (16 women)[9]
  • Surgical failure: 1.7% (3 women)[9]
  • De novo SUI: 5.2% (9 women)[9]
  • PGI-I satisfaction: 94.8%[9]
  • The most serious complications were Clavien-Dindo grade III.

A separate retrospective comparison with vaginal hysterectomy plus low uterosacral suspension found subjective recurrence in 51% of both groups at approximately 13 years; only 160/398 eligible women (40%) responded. Reintervention occurred in 19/53 (36%) after modified Manchester versus 29/107 (27%) after hysterectomy (P = .26), leaving long-term comparative effectiveness uncertain.[21]

Complications​

Cervical stenosis — characteristic procedure-specific complication​

PopulationRate
JAMA RCT (Enklaar 2023)0.9% (2/212 participants)[1]
Most series0.7–3.3%[1][5]
Younger women (older series)Up to 11%, but treatment required in only 0.5%[1]

In SAM, one patient with cervical stenosis presented with postmenopausal bleeding; a second had dysmenorrhea with hematometra.[1]

Other complications[5][9][10]​

ComplicationRate / note
Suspected fatal pulmonary embolismOne Manchester participant died five weeks after surgery (1/213, 0.5%); investigators judged the event plausibly surgery-related but unlikely specific to the study intervention.[1]
Urinary retentionSAM RCT: 25/204 (12.3%) after treatment; Chen 2025 cohort: 19/254 (7.5%) during the perioperative period.[1][9]
Postoperative fever during the perioperative period (Chen 2025 modified Manchester cohort)13/254 (5.1%)[9]
Urinary tract infectionSAM RCT: 24/209 (11.5%) within 6 weeks; Chen 2025 cohort: 3/254 (1.2%) during the perioperative period.[1][9]
Bladder injuryOne bladder perforation among 24 women with follow-up data in a single-center series; none among 254 in Chen 2025[9][10]
Hemorrhage / hematomaSAM reported intraoperative blood loss >500 mL in 1/213 (0.5%) and postoperative hematoma in 2/212 (0.9%).[5][1] Stoter et al. pooled intraoperative hemorrhage at 0.92% (95% CI 0.40–2.12) in cardinal-including variants; no pooled hematoma rate was reported.[15]
Posterior compartment findings at 2 yrPOP-Q stage ≥2 was more frequent after Manchester (54/195 versus 22/196), while posterior prolapse beyond the hymen was similar (3/195 versus 4/196); posterior reoperations were uncommon.[1]
Incidental abnormal cervical histology among examined amputated specimens4/164 (2.4%; Enklaar 2023, including 1 CIN2)[1]

Cost-Effectiveness​

An economic evaluation alongside the JAMA trial estimated lower societal costs for Manchester than sacrospinous hysteropexy (mean difference €1,458 lower, 95% CI −2,746 to −171), with no statistically 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.
  • Available post-procedure pregnancy reports are few and too limited for reliable risk estimates.[5]

Special Indication — Cervical Elongation Without Uterine Descensus​

The Manchester procedure has also been used for isolated cervical elongation without true uterine body descent. A retrospective 36-patient series reported significant improvements in POP-Q, P-QoL and PISQ-12, with one anterior-compartment reoperation and no serious complications.[6]

Advantages and Disadvantages​

AdvantageDisadvantage
Superior 2-yr composite success vs sacrospinous hysteropexy[1]More posterior POP-Q stage ≥2 findings at 2 yr; posterior prolapse beyond the hymen was similar.[1]
Preserves the uterine bodyCervical stenosis 0.7–3.3%[1][5]
Does not require sacrospinous ligament fixation[1]Not appropriate for women desiring future pregnancy[5]
Lower anterior compartment recurrence than sacrospinous hysteropexy[1]Point D is >−1 cm (more distal)[1]
Shorter operative time and lower EBL than vaginal hysterectomy[8]Retained uterus/cervix requires usual symptom-based evaluation and age-appropriate screening
Dutch societal-cost estimate favored Manchester; not a transferable price comparison[11]Many surgeons lack training and familiarity[3][12]
Native tissue — no mesh—
Examination of the amputated cervix may detect incidental lesions; it does not replace age-appropriate cervical screening.[1][13]—

Key Principles​

  • Manchester-Fothergill preserves the uterine body and amputates the cervix; described variants plicate cardinal ligaments, uterosacral ligaments, or both. SAM tested the combined technique.[1][2][15]
  • Reserve for women who have completed childbearing. Pregnancy data are limited and concerning.[5]
  • SAM eligibility. The trial enrolled uterine descent with point D at or proximal to −1 cm (numerically ≤−1 cm).[1]
  • Composite success at 2 yr was higher than with sacrospinous hysteropexy (87.3% versus 77.0%; Enklaar 2023), and a BSUG database cohort reported lower short-term recurrence.[1][7]
  • The Dutch trial-based economic estimate favored lower societal cost for Manchester with no significant QALY difference.[11]
  • Trade-off. In SAM, Manchester repair had fewer anterior defects beyond the hymen and more posterior POP-Q stage ≥2 findings; posterior defects beyond the hymen were similar (3/195 versus 4/196), and posterior reoperations were uncommon.[1]
  • Cervical stenosis occurred in 2/212 Manchester-procedure participants in the SAM trial.[1]
  • Many surgeons lack training in the technique, a gap in contemporary urogynecologic surgical education despite the evidence base.[3][12]

Videos​

Fothergill Surgery: Uterine Conservation for Prolapse in Young Women
Urogynecology for Beginners (2023)

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. 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.

13. Chang OH, Carter Ramirez A, Edwards A, et al. "The role of uterine preservation at the time of pelvic organ prolapse surgery." Urogynecology (Phila). 2025;31(5):482-495. doi:10.1097/SPV.0000000000001667

14. Wang Q, Manodoro S, Jiang X, Lin C. "Treatment outcomes of Manchester procedure versus vaginal hysterectomy for mid-compartment prolapse: A systematic review and meta-analysis." Acta Obstet Gynecol Scand. 2025;104(5):792-803. doi:10.1111/aogs.15053

15. Stoter LM, Bing MH, Wood M, Kang K, Matthews CA, van Eijndhoven HWF. "A systematic review (and meta-analysis) and global expert consensus statements (U-POP): The Manchester procedure." Int Urogynecol J. 2026. doi:10.1007/s00192-026-06895-y

16. National Institute for Health and Care Excellence. Urinary incontinence and pelvic organ prolapse in women: management. NICE guideline NG123. 2019, recommendation 1.8.1. Recommendations.

17. Cohen SA, Carberry CL, Smilen SW. "American Urogynecologic Society Consensus Statement: Cystoscopy at the Time of Prolapse Repair." Female Pelvic Med Reconstr Surg. 2018;24(4):258-259. doi:10.1097/SPV.0000000000000529

18. Stoter LM, Peters K, Enklaar RA, et al. "Sexual function after the Manchester procedure versus sacrospinous hysteropexy in women treated for uterine prolapse: a planned analysis of a randomized clinical trial." Am J Obstet Gynecol. 2026;234(4):1112-1120. doi:10.1016/j.ajog.2025.12.035

19. Gupta A, Grimes CL, Badlani G, et al. "A Global Consensus Conference on Surgical Management of Primary Uterovaginal Prolapse and Lower Urinary Tract Dysfunction: Combining Evidence with Expert Opinion." Int Urogynecol J. 2026. doi:10.1007/s00192-026-06758-6

20. Manodoro S, Frigerio M, Milani R, Spelzini F. "Tips and tricks for uterosacral ligament suspension: how to avoid ureteral injury." Int Urogynecol J. 2018;29(1):161-163. doi:10.1007/s00192-017-3497-y

21. Enklaar RA, Knapen FMFM, Schulten SFM, et al. "The modified Manchester Fothergill procedure compared with vaginal hysterectomy with low uterosacral ligament suspension in patients with pelvic organ prolapse: long-term outcome." Int Urogynecol J. 2023;34(1):155-164. doi:10.1007/s00192-022-05240-3