Int Urogynecol J

DOI 10.1007/s00192-014-2610-8

IUJ VIDEO

The ManchesterFothergill and the Elevate Posterior technique

for the correction of a cervical elongation and large enterocele
in a patient with bladder exstrophy and multiple surgeries
M. Luisa Snchez Ferrer & Eduardo Bataller Snchez &
Laura Hernndez Hernndez & Francisco Machado Linde &
Ana Isabel Hernndez Pealver & Anbal Nieto Daz

Received: 14 August 2014 / Accepted: 2 December 2014

# The International Urogynecological Association 2015

Abstract
Introduction and hypothesis A 60-year-old woman presented
with congenital bladder exstrophy, urinary incontinence since
birth, and pelvic organ prolapse since the menopause at the
age of 46 years.
Methods The patient (gravida 2, para 2 by cesarean sections
and tubal ligation) described an extensive past surgical history
that included epispadias and neourethral procedures, antireflux surgery using the LichGrgoir technique, bilateral
ureterosigmoidostomy achieving continence, uterine fixation
after the Dolris operation, and neovaginal reconstruction.
The physical examination revealed a fourth-degree enterocele
with cervical elongation (POP-Q: Aa-2, Ba-2, C+3, D+4,
gh:5, pb:2.5, Tvl:6, Ap+3, Bp +6). Gynecological ultrasound
and uro-CT were performed to ensure that the
ureterosigmoidostomy had been successful, and CT-based
3D bone reconstructions were obtained to calculate the distance between the pubic rami and the ischial spines. Based on
a literature review of the management options for these patients and the specific characteristics of our patient, a decision
was made to perform trachelectomy (the Manchester technique with Fothergill stitches) and a polypropylene mesh
Electronic supplementary material The online version of this article
(doi:10.1007/s00192-014-2610-8) contains supplementary material. This
video is also available to watch on http://videos.springer.com/. Please
search for the video by the article title
M. L. S. Ferrer (*) : L. H. Hernndez : F. M. Linde :
A. I. H. Pealver : A. N. Daz
Department of Gynecology and Obstetrics, Hospital Clnico
Universitario Virgen de la Arrixaca, Murcia, Spain
e-mail: marisasanchez@um.es
E. B. Snchez
Department of Gynecology and Obstetrics, Hospital Clinic,
Barcelona, Spain

placement with sacrospinous ligament anchor (Elevate Posterior PC, AMS).

Results Six months after the surgery, we observed good anatomical and functional results with significant improvement in
the patients quality-of-life scale score.
Conclusion We believed that the vaginal approach was minimally invasive with a low risk of morbidity in our patient,
who had a very altered anatomy, but produced a satisfactory
functional result.
Keywords Bladderexstrophy . Pelvicorganprolapse . Surgical
technique . Elevate Posterior . ManchesterFothergill
operation

Aim of the video/introduction

Bladder exstrophy is a rare congenital disorder, affecting 1 in
125,000 to 250,000 female infants. The condition is caused by
persistence of the cloacal membrane, which impedes the
merger of the midline structures. This results in an open
bladder, closure defect of the anterior abdominal wall, absent
urethral sphincter, pubic diastasis, external genitalia anomalies, and abnormal pelvic diaphragm muscle. The pelvic ring
is open because of the pubic diastasis and uterine support is
poor because of the defective cardinal and uterosacral ligaments. Furthermore, the vagina is short, anteriorly displaced
and positioned on an abnormal horizontal axis, making the
uterus more vulnerable to prolapse when the abdominal pressure is increased. The incidence of pelvic organ prolapse
(POP) has been reported to be 18 % [1], 52 % [2], and 30 %

Int Urogynecol J

[3], and is most common in young patients (average age,

20 years), with a high rate of recurrence. There is no consensus on the best surgical technique for the management of POP
in these patients. The aim of the video is to display the surgical
technique used to solve this case.

Patient and methods

A 60-year-old patient presented with congenital bladder
exstrophy. She described an extensive past surgical history
with 9 operations (see previous introduction and video),
achieving a satisfactory functional result (fully continent, able
to maintain sexual relationships, and preserved fertility). She
presented with complaints of genital bulging since menopause
at the age of 46. The physical examination revealed fourthdegree enterocele with cervical elongation (POP-Q: Aa-2, Ba2, C+3, D+4, gh:5, pb:2.5, Tvl:6, Ap+3, Bp +6), and the
gynecological ultrasound showed cervical elongation. A uroCT disclosed correct drainage of both ureters into the sigmoid
loop. CT-based 3D bone reconstructions were used to determine the distance between the pubic rami (anteroposterior
view 10.89 cm; cephalocaudal view 13.40 cm) and the distance between the ischial spines (posterior view 11.97 cm).
The patient was treated using the Manchester technique with
Fothergill stitches and polypropylene mesh placement with a
sacrospinous ligament anchor (Elevate Posterior PC, AMS).

Results
Six months after the surgery, we observed good anatomical
and functional results with significant improvement in the
patients quality-of-life scale score.

Discussion
Although these patients undergo nine utero-vaginal procedures on average [1], sexual function and fertility are normal
[4]. Cesarean section is usually the preferred form of delivery
to avoid complications, particularly in patients with good
functional reconstruction, but vaginal deliveries have been
described. Urinary incontinence is present in 22 %. MilesThomas et al. [5] reported outcomes in 52 patients with
ureterosigmoidostomy: urinary incontinence (48 %), bowel
incontinence (26 %), and combined incontinence (63 %).
The incidence of vaginoplasty was 35.8 % [3] and pelvic
osteotomy (near the pubic rami) 37.3 % (average age,
6 months).
1. Possible POP preventive actions to manage these patients
have been studied (none can be assessed from the

literature as the studies usually contain small numbers of

subjects and often short-term follow-up):
a) Osteotomy: nearing the pubic rami and reconfiguring
the pelvic ring improves outcomes for closure of the
abdominal wall and bladder and can lower the risk of
pelvic organ prolapse (POP), but according to Benson
et al. [4], it has not been successful because pubic
diastasis reappears over time. Imaging studies based
on 3D perineal ultrasound and MRI have been used to
describe the pelvic floor in these patients (Table 1).
b) Hysteropexy:
i. With fixation to the anterior abdominal wall,
hysteropexy has been found to be useful in the prevention of POP [2], but not for therapeutic reasons [8].
ii. Rotundum psoas hitch procedure. In some patients,
this type of hysteropexy seems to re-establish the
vaginal axis in a more physiological position, as
does fixation of the round ligaments to the psoas
muscle.
iii. Sacrohysteropexy with placement of synthetic abdominal mesh has also been suggested, but longterm results are not available. This procedure is
used both prophylactically and as a treatment option for POP.
2. POP treatment in bladder exstrophy patients. Considerations and techniques:
a) Hysteropexy: in cases of genital prolapse, fertility is
preserved and, therefore, patients should not undergo
hysterectomy until their parenthood goals have been
achieved. Although hysterectomy is controversial
even after fertility desires are fulfilled, we, along with
many experts [2, 9] believe that it should not be
performed without providing adequate support to
the vaginal wall. They claim that hysterectomy does
not solve the problem, as the uterus is the only solid
pelvic organ that provides support to the pelvic floor
muscles. Moreover, any vaginal vault prolapse would
be difficult to manage. Many preserve the uterus
because of anatomical differences, which may predispose exstrophy patients to developing pelvic floor
defects. Hysterectomy may worsen pre-existing pelvic floor instability, whereas uterus preservation may
counteract any abdominal and pelvic floor weakness,
thus lowering POP susceptibility.
i. Sacrohysteropexy: it has been reported with use of
laparotomy, laparoscopy, and robotics [4]. Several
types of mesh have been used: polyvinyl alcohol
sponge, Teflon, Mersilene, Gore-Tex, polypropylene, etc. The major successful series reported

Int Urogynecol J
Table 1

Pelvic floor studies using 3D ultrasound and MRI [6, 7]

Bladder exstrophy

Bladder exstrophy
with osteotomy

Control group

Hiatus area (cm2)

Average levator angle ()
Levator ani muscle area (cm2)
Anterior portion of the levator ani muscles (cm)

5.97.6
104.1104.3
9.5 (larger than the control group)
1.2 (shorter than the control group)

4.94.1
86.687.3

4.23.2
71.345.5

Posterior portion of the levator ani muscles (cm)

Degree of divergence of the levator ani
Transverse diameter of the levator hiatus
Length of the levator hiatus

2.5 (larger than the control group)

38 (considerably more externally rotated)
2 times larger than thee control
1.3 times larger than the control group

involved use of Gore-Tex [2], with 16 patients, with

a success rate of 75 %. The advantages of the GoreTex are that there is a less intense inflammatory
response and it is easier to remove in the case of
erosion than Mersilene. Polypropylene has been
superior in other clinical situations. Both materials
have been shown to be safe in posterior pregnancy.
ii. Vaginal sacrospinous hysteropexy with and without
mesh: one publication [1] describes two cases of
fixation with Prolift. A vaginal approach including
the sacrospinous ligament with mesh is generally less effective than an abdominal approach
with mesh [2], although the short-term functional results in both are acceptable, the anatomical results were less optimal in the vaginal approach. The defenders of the vaginal
approach argue that they prefer it because it
is a minimally invasive procedure with a low
risk of morbidity, such as adhesion formation
and organic lesions due to altered anatomy in
patients with many previous surgeries.
b) Hysterectomy and colposacropexy: a risk described
in hysteropexy is the posterior cervical elongation,
and this problem has also been found in nonexstrophy patients [10]. These authors reported that
POP (stage 2) recurrence after 1-year follow-up is
17 % more likely to appear in patients with sacral
hysteropexy compared with patients who underwent
hysterectomy when performing colposacropexy.
Hysterectomy subsequent to fixation with mesh can
be complex, and no published results are available
[1]. Kwong et al. [9] describe a patient with a bladder
exstrophy and POP initially repaired by sacral
hysteropexy and posterior cervical elongation treated
with trachelectomy. Others claim similar
urogynecological outcomes for both techniques
(with/without hysterectomy).

Conclusions
We carried out a literature review taking into account the
specific characteristics of our patient, who had undergone
multiple operations previously (uterus fixation to the anterior
abdominal wall; fourth-degree enterocele and cervical elongation without descent of the fundus uteri), but who had no
anterior compartment defect. We then calculated the distance
between the ischial spines (to ensure that the mesh chosen
could be inserted, anchored smoothly, and reach the ischial
spines), and decided on the Manchester procedure or cervical
amputation with Fothergill stitches, colpopexy with polypropylene mesh placement (which has a lower erosion rate), and
sacrospinous ligament anchor (Elevate Posterior PC; AMS).
We believed that the vaginal approach was minimally invasive
with a low risk of morbidity for our patient, who had altered
anatomy, but produced a satisfactory functional result. Six
months later, the anatomical and functional results were good,
with significant improvement in the patients quality-of-life
scale score.

Conflicts of interest Dr Bataller is a consultant for the AMS (American

Medical System).

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Int Urogynecol J
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Consent
Written informed consent was obtained from the patient for publication of
this video article and any accompanying images