Cervical amputation: indications and consequences

Cervical amputation is an organ-preserving procedure that involves removing the elongated or deformed vaginal portion of the cervix, creating a new external os and restoring anatomy. In modern practice, this procedure is most often part of the so-called Manchester operation, where amputation is combined with fixation of ligaments to support the uterus and, if necessary, plastic surgery of the vaginal walls. The goal is to eliminate prolapse symptoms while preserving the uterus and normal cervical length. [1]

The classic Manchester procedure involves amputation of the cervix and anterior displacement of the cardinal ligaments, while modified versions supplement this with plication of the uterosacral ligaments, which increases apical support. These techniques are considered uterine-preserving surgeries and are contrasted with hysterectomy for similar clinical objectives. The choice of method depends on the anatomy, severity of prolapse, and patient preference. [2]

Contemporary clinical literature emphasizes that, in properly selected cases, uterine-preserving surgeries yield comparable short-term anatomical results with less blood loss and shorter operative times compared to hysterectomy surgeries. This expands the possibilities for individualized treatment and shared decision-making. [3]

National guidelines explicitly list the Manchester procedure as an option for treating uterine prolapse. Patient information leaflets and materials for shared treatment choices describe this procedure as a way to shorten the cervix when it is lengthened and restore pelvic organ support without removing the uterus. This format of care allows for consideration of the patient's reproductive plans and values. [4]

Table 1. Place of cervical amputation in prolapse treatment

Group of methods	Examples	What do they decide?	When appropriate
Uterine-preserving	Manchester, hysteropexy	Uterine support, correction of cervical elongation	If you want to preserve the uterus, with elongation of the cervix
With removal of the uterus	Vaginal hysterectomy with suspension	Elimination of prolapse with organ removal	In case of concomitant pathology of the uterus or preference for removal
Conservative	Pessary, pelvic floor rehabilitation	Control symptoms without surgery	For mild symptoms or contraindications to surgery

Summarized from clinical guidelines and reviews. [5]

Indications, limitations and patient selection

The primary indication for cervical amputation as part of the Manchester procedure is true cervical elongation due to prolapse with adequate uterine support. In such cases, reducing cervical length, combined with strengthening the ligamentous apparatus, eliminates the provoking factor and reduces the sensation of a "foreign body," discomfort, and urinary dysfunction. Correct identification of the anatomical problem is the key to success. [6]

Absolute contraindications include suspected malignant or precancerous changes in the cervix, severe prolapse of the vaginal apex requiring other apical fixation, and uncontrolled genitourinary tract infection. The presence of extensive uterine pathology requiring removal also biases the choice in favor of hysterectomy. These factors are assessed in advance. [7]

Patient selection relies on the POP-Q system with an analysis of points C and D to differentiate between true cervical elongation and apical descent. Proper prolapse classification allows for predicting benefit, reducing the risk of recurrence, and appropriately selecting the type of apical support to be combined with cervical amputation. [8]

In all scenarios, an informed discussion about the pros and cons of uterine preservation versus hysterectomy is necessary. Systematic reviews show that uterine preservation can reduce blood loss and surgical time without compromising short-term anatomical outcomes, but the choice is always individualized and takes into account associated factors. [9]

Table 2. Indications and contraindications

Indications	Contraindications
Prolapse with true elongation of the cervix, desire to preserve the uterus	Suspected cervical neoplasia, severe apical prolapse without adequate support, active infection
There is no need to remove the uterus for other reasons	Large fibroids, adenomyosis, and other indications for hysterectomy
Consent to a joint plan with possible plastic surgery of the vaginal walls	Failure to provide adequate apical fixation

Summarized from national guidelines and reviews. [10]

Diagnostics and preoperative preparation

The examination standard includes a detailed collection of complaints and an obstetric and gynecological history, an objective assessment of prolapse using the POP-Q, and basic oncological surveillance: current cytology and, if indicated, testing for human papillomavirus and a thorough examination of the cervix. This allows us to exclude conditions in which cervical amputation is not indicated. [11]

According to recommendations, a range of conservative measures, including pessaries and pelvic floor rehabilitation, as well as alternative surgical strategies with uterine preservation or removal, are discussed before surgical treatment. This approach improves the quality of shared decision-making and compliance with expectations. [12]

Instrumental diagnostics are selective. Visualization is used when concomitant uterine or ovarian pathology is suspected. Urodynamic testing is considered in cases of severe lower urinary tract symptoms or when concurrent incontinence correction is planned. This is reflected in clinical guidelines. [13]

The preoperative consultation includes a discussion of the technique, expected sensations, recovery time, the likelihood of additional procedures, and potential complications. The patient is given a written reminder and a recommended postoperative care plan. This approach reduces anxiety and increases compliance. [14]

Table 3. Preoperative checklist

Step	What to confirm
Classification of prolapse	POP-Q, differentiation of cervical elongation and apical descent
Exclusion of neoplasia	Current cytology, if indicated, in-depth assessment of the cervix
Operation plan	The need for apical fixation, the volume of associated plastics
Alternatives	Pessary, hysteropexy, hysterectomy
Informing	A reminder about risks, care, and recovery timeframes

Summarized from national recommendations. [15]

How is cervical amputation performed and what is added to the surgery?

Technically, cervical amputation is a layer-by-layer removal of the elongated portion, with the formation of a new external os and restoration of the mucous membranes. To prevent stenosis and promote proper healing, Sturmdorff sutures are used, allowing the stump to be lined with epithelium and maintaining cervical canal patency. This technique has been described and is widely used in modifications of the procedure. [16]

In the classic Manchester procedure, amputation is combined with anterior displacement of the cardinal ligaments to strengthen the cervix. A modified version involves plication of the uterosacral ligaments, strengthening apical support and reducing the risk of recurrence. Often, plastic surgery of the anterior or posterior vaginal wall is performed simultaneously if these defects are present. [17]

The choice of a specific apical fixation configuration depends on the anatomy and experience of the team. Recent publications demonstrate interest in connective tissue-preserving options and combined fixations that achieve stable results with minimal trauma. Individualization of technique is the standard in modern prolapse surgery. [18]

Anesthesia can be spinal or general. In most cases, the surgery is performed vaginally; the duration of the procedure and blood loss are typically less than with a hysterectomy for comparable purposes. This is one argument in favor of uterine preservation in properly selected patients. [19]

Table 4. Elements of the operation and their tasks

Element	Task
Amputation of the neck	Shorten the cervix and form a new external os
Sturmdorff-type seams	Epithelialization of the stump, prevention of stenosis
Ligament plication	Apical support for recurrence prevention
Vaginal wall plastic surgery	Correction of associated defects

Systematization based on descriptions of techniques and series of observations. [20]

Efficiency: Comparison with alternatives and long-term results

Observational series and comparative studies demonstrate that cervical amputation as part of the Manchester procedure provides high anatomical success in patients with true cervical elongation. Retrospective cohorts and prospective observations have noted low recurrence rates with proper selection and proper apical fixation. [21]

According to systematic reviews, uterine-preserving surgeries are comparable to hysterectomy in terms of early anatomical outcomes and are also associated with less blood loss and shorter surgical duration. This confirms their place as a rational alternative when preserving the uterus is desired and there are no other indications for its removal. [22]

A randomized trial showed that after 2 years, the overall success rate was higher with the Manchester procedure than with sacrospinal hysteropexy, thus failing to confirm the non-inferiority hypothesis for alternative fixation. This underscores the value of cervical shortening in cases of true cervical elongation as part of the pathogenesis of prolapse. [23]

New comparative publications note comparable subjective results and a low rate of re-interventions in the short term. In the medium and long term, the differences become more subtle, requiring consideration of individual anatomy and preferences when choosing a strategy. [24]

Table 5. Comparison of approaches for prolapse

Criterion	Manchester with neck amputation	Vaginal hysterectomy with suspension	Sacrospinal hysteropexy	Laparoscopic sacrohysteropexy
Short-term anatomical success	High	High	High	High
Blood loss and duration	Below	Higher	Similar	Similar
Two-year composite of success	Higher than with sacrospinal fixation	-	Lower than Manchester	-
Medium-term risk of relapse	Low with proper selection	Short	Short	Short

Summarized from meta-analyses, randomized and comparative studies. [25]

Fertility and pregnancy after cervical amputation

Preserving the uterus allows for pregnancy, but individual obstetric risks are discussed after cervical shortening. Historical reviews note the potential risk of preterm birth with significant shortening and, conversely, the risk of stenosis with excessive reconstruction of the external os. In modern series, pregnancy after surgery is possible but requires monitoring. [26]

Overall data on uterine-preserving surgeries indicate a low incidence of adverse obstetric outcomes overall. However, some studies note that the option involving cervical amputation may be associated with a higher risk of complications during pregnancy compared to certain types of hysteropexy, which should be considered when planning a family. [27]

Contemporary clinical data and individual case series report favorable pregnancy outcomes after the Manchester procedure in appropriately selected patients; however, the evidence base remains limited and heterogeneous. In practical terms, this means individual assessment of the residual cervical length and discussion of follow-up strategies, including the possibility of prophylactic cerclage for obstetric indications. [28]

When planning a pregnancy after surgery, it is recommended to discuss possible scenarios with your obstetrician/gynecologist in advance, including monitoring cervical length in the second trimester and indications for preventive measures. This approach helps reduce the risk of unexpected complications and improves safety. [29]

Table 6. Pregnancy after cervical amputation: what to discuss

Question	A practical approach
Length of residual neck	Second trimester assessment and monitoring plan
Risk of premature birth	Individual stratification, discussion of prevention
Risk of stenosis	Accounting for the technique of reconstruction of the external os
Delivery plan	Individually, taking into account obstetric factors

Summarized from clinical reviews and case series. [30]

Risks and complications: how to prevent and recognize them in time

Early complications include bleeding, infection, pain, watery discharge, and urinary discomfort. With proper technique and postoperative care, most of these complications resolve spontaneously. Written recovery instructions reduce anxiety and the frequency of unscheduled visits. [31]

Specific risks of cervical amputation include canal stenosis with excessive reconstruction and, conversely, functional impairment with excessive shortening. These risks are prevented by proper technique, the use of epithelializing sutures, and individualized resection depth. Early monitoring allows for early detection of problems. [32]

The risk of prolapse recurrence depends on the initial anatomy and the quality of apical fixation. Long-term series comparing the modified Manchester procedure with hysterectomy procedures have not shown worse long-term outcomes with proper selection, confirming the role of proper fixation in preventing recurrence. [33]

Finally, as with any prolapse surgery, lifestyle modification, weight management, and pelvic floor rehabilitation are important to reduce stress on the ligamentous apparatus in the postoperative period. This is part of a standard comprehensive management strategy. [34]

Table 7. Complications and prevention

Complication	Prevention	When to see a doctor urgently
Bleeding, infection	Gentle technique, asepsis, care instructions	Heavy discharge, fever, increasing pain
Cervical canal stenosis	Sturmdorff sutures, moderate reconstruction	Pain, menstrual flow disturbances
Functional insufficiency of the cervix	Avoid excessive shortening	Early signs of threatened miscarriage during pregnancy
Recurrence of prolapse	Adequate apical fixation, rehabilitation	Progressive prolapse, discomfort

Systematization by descriptions of technology and comparative series. [35]

Rehabilitation, observation and quality of life

After surgery, a gentle regimen is recommended, limiting heavy loads, intimate contact, and implants for a period agreed upon with the surgeon. Guidelines from obstetrics and gynecology societies provide guidelines for returning to daily activities and signs of an unfavorable course. Individual timeframes depend on the extent of the procedure. [36]

Follow-up visits are aimed at assessing cervical healing, the adequacy of the external os reconstruction, and the effectiveness of apical support. If concomitant plastic surgeries are present, the condition of the vaginal walls and pelvic organ function are assessed. Pelvic floor physiotherapy is initiated if necessary. [37]

Quality-of-life studies show high satisfaction after uterine-preserving surgeries with appropriate selection, which is associated with symptom relief and organ preservation. This result is important for patients for whom uterine preservation is a valued consideration. [38]

Long-term monitoring allows for the early detection of late problems, including relapses, and allows for discussion of strategies for dealing with changes in life plans, such as the decision to become pregnant. This approach makes treatment more sustainable and tailored to the patient's needs. [39]

Table 8. Postoperative plan

Stage	Target
Early period	Pain control, infection prevention, hygiene
First control	Evaluation of healing of the cervix and external os
3-6 months	Assessment of support, pelvic floor function, and relapse prevention training
Further	Individual schedule based on your well-being and anatomy

Summarized from guides and reviews. [40]

Key findings

Cervical amputation as part of the Manchester procedure is an effective uterine-preserving tactic for prolapse with true cervical elongation. With proper patient selection and adequate apical fixation, excellent anatomical and subjective results are achieved with less blood loss and shorter procedure time compared to hysterectomy. Fertility and pregnancy potential require individual discussion and monitoring. [41]