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

Old uterus-sparing prolapse surgery beat newer techniques on recurrence and cost, but pregnancy data is thin

Journal: Acta Obstetricia et Gynecologica Scandinavica | Published: 2026-04-13 | Type: Systematic Review, Scoping Review | PMID: 41969167 Authors: Sophia Elissaoui, Meryam El Issaoui, Karen Husby, Niels Klarskov (Department of Obstetrics and Gynecology, Herlev and Gentofte University Hospital, Copenhagen, Denmark) Funding/COI: No funding listed; all four authors declare no conflicts of interest.

Summary

This is a combined systematic and scoping review, not a meta-analysis, pulling together 19 studies on the Manchester procedure (MP), a uterus-preserving prolapse repair that amputates the cervix and shortens the cardinal ligaments. Across cohort studies and one randomized trial, MP came out ahead of vaginal hysterectomy (VH) and sacrospinous hysteropexy (SSHP) on recurrence, reoperation, operative time, and cost. The catch: outcomes on pregnancy after MP are based on a handful of studies and just three documented term pregnancies, which is a thin basis for the paper's own recommendation that MP be reserved for women done having children.

Claims

• 19 articles included (11 systematic review, 11 scoping review, 3 overlapping) out of 423 initially identified.
• Large cohort studies and one RCT found lower recurrence and reoperation rates after MP compared with SSHP and VH.
• Operative time was shorter for MP than VH and comparable to SSHP; hospital stays were shorter after MP than VH.
• Societal costs were about 14.5% lower for MP than SSHP, and hospital costs roughly one-third lower for MP than VH.
• Sexual function and dyspareunia outcomes were generally comparable across procedures.
• Danish epidemiological studies found no increased incidence or worse prognosis for endometrial cancer after MP versus cystocele surgery, and a lower risk of cervical cancer after MP.
• Only two studies identified a combined total of three pregnancies after MP that reached term delivery.
• Sample sizes across included cohorts ranged widely, from a 92-patient RCT to nationwide cohorts exceeding 4,000 patients (VH) and 2,700 (MP).

Study Quality

This is a narrative synthesis, not a pooled meta-analysis, no forest plots or pooled effect sizes are reported despite the "systematic review" label, so claims like the 14.5% cost difference or shorter operative times reflect individual studies rather than combined statistical estimates. Quality was assessed with the Cochrane risk of bias tool for the single RCT and the Newcastle-Ottawa Scale for the observational studies, and study design was mostly retrospective cohorts, several from national registries. The systematic review arm required NOS ratings of fair or good, ≥12 months follow-up, and ≥45 participants, which is a reasonable bar, but the underlying study designs remain observational and susceptible to selection bias (e.g., surgeons picking healthier or lower-stage-prolapse patients for MP over VH).

The scoping review arm, covering sexual dysfunction, cancer, and obstetric outcomes, explicitly exists because the authors judged the evidence too sparse for systematic synthesis. The obstetric outcome data is the clearest example: two studies, three term pregnancies, is not enough to support a categorical recommendation about who should or shouldn't get this procedure.

Red Flags

• No meta-analysis despite reviewing quantitative outcomes across heterogeneous studies with different follow-up lengths (17-112 months) and prolapse stage mixes.
• The paper's conclusion that MP "should be reserved for women who have completed childbearing" is a clinical recommendation built on three documented pregnancies across two studies.
• Comparator group sizes are uneven and non-randomized in most studies (e.g., one nationwide cohort had 2,786 MP patients vs. 416 SSHP patients), which can distort comparative statistics.
• Authors are based at the same Danish institution that produced several of the large cohort studies cited favorably in the review (e.g., the cervical and endometrial cancer registry studies), raising the possibility of citation of the group's own prior work without independent replication.

Strengths

• PROSPERO pre-registration (CRD42024551520) for the systematic review arm.
• Dual independent screening and extraction with a third/fourth reviewer for disagreements.
• Explicit, defensible inclusion criteria (sample size and follow-up minimums) separating the systematic from the scoping arm rather than blending weak and strong evidence.
• Transparent about the evidence gaps, the paper flags the pregnancy and cancer data as scoping-level (i.e., insufficient for systematic synthesis) rather than overstating them.

Verdict

A well-organized synthesis of a genuinely understudied area, competently separating strong evidence (recurrence, cost, operative time) from weak evidence (obstetric outcomes, long-term cancer risk) via the systematic/scoping split. But it's a narrative review dressed with systematic-review methodology, no pooled statistics, uneven comparator groups, and a headline clinical recommendation resting on three pregnancies. Useful for understanding what's known and what isn't about the Manchester procedure, not for settling the question of who should get one.