A Systematic Review (and Meta-Analysis) and Global Expert Consensus Statements (U-POP): The Manchester Procedure

Abstract

Abstract Introduction and Hypothesis The Manchester procedure (MP) is the oldest uterus-sparing technique for uterine prolapse and has traditionally been used to treat cervical elongation (CE). However, its optimal application remains unclear. This review aimed to evaluate the best management of CE during primary uterovaginal prolapse repair, and to assess whether MP technique variations influence outcomes. Methods Following PRISMA guidelines, studies were retrieved from MEDLINE, Embase, and Pubmed through November 3, 2025. Evidence quality was assessed using GRADE criteria. Eligible studies included women undergoing surgery for primary uterovaginal prolapse. Outcomes included anatomic recurrence, patient-reported symptoms of vaginal bulge, and retreatment at ≥ 12 months. Random-effects meta-analyses were performed when ≥ 2 studies reported the same intervention and outcome. Evidence-based clinical statements were developed and evaluated through a consensus conference. Results Of 456 screened abstracts, 12 studies met inclusion criteria (one RCT, one prospective cohort, ten retrospective cohorts). Overall study quality was low (grade C). Only one study clearly defined and measured CE, preventing determination of the most effective surgical approach for women with CE. MP techniques incorporating cardinal-ligament suspension showed lower anatomic failure rates than those without (9.16% vs 30.22; p = 0.024). Patient-reported bulge symptoms were similar (17.59% vs 17.32%; p = 0.969), as were retreatment rates (3.91% vs 9.45%; p = 0.136). Conclusions Current evidence does not identify an optimal surgical strategy for CE due to inconsistent definitions and limited reporting of CE measurement. MP techniques incorporating cardinal-ligament suspension may reduce anatomic recurrence, although data remain limited and heterogeneous. Standardized CE definitions and improved reporting are needed to strengthen the evidence base.