Treatment outcomes of Manchester procedure versus vaginal hysterectomy for mid‐compartment prolapse: A systematic review and meta‐analysis

Abstract

Introduction

To compare the effectiveness and safety of Manchester procedure versus vaginal hysterectomy in the treatment of mid‐compartment prolapse in women.

Material and Methods

We searched PubMed, Web of Science, Google Scholar, and the Cochrane Library for randomized controlled trials (RCTs), prospective, or retrospective studies comparing the Manchester procedure and vaginal hysterectomy up to July 2024. Primary outcomes included anatomical recurrence, subjective recurrence, overall complication rate, and reoperation. Secondary outcomes included estimated blood loss, operative time, and relevant subgroup analyses. This study has been registered in PROSPERO with the registration number CRD42024575874.

Results

A total of 11 783 cases from 1 RCT, 1 prospective study, and 9 retrospective studies were included. For the primary outcomes, the Manchester procedure demonstrated significantly lower subjective recurrence rates (risk ratio [RR] = 0.85; 95% confidence interval [CI]: 0.73–0.98; I ² = 0%; p = 0.03) and reoperation rates (RR = 0.62; 95% CI: 0.43–0.89; I ² = 64%; p = 0.009) compared with vaginal hysterectomy, with no significant difference in anatomical recurrence rates (RR = 0.84; 95% CI: 0.58–1.21; I ² = 54%; p = 0.34) and overall complication rates (RR = 0.89; 95% CI: 0.79–1.00; I ² = 0%; p = 0.06) between the two groups. Secondary outcomes indicated that the Manchester procedure had a significantly shorter operative time and less estimated blood loss (p < 0.05). Subgroup analysis indicated that the Manchester procedure was associated with lower short‐term (1–3 years) subjective recurrence rates (RR = 0.87; 95% CI: 0.78–0.98; I ² = 0%; p = 0.02) and reoperation rates (RR = 0.71; 95% CI: 0.55–0.92; I ² = 0%; p = 0.008). No significant differences were found between the two groups in terms of short‐term anatomical recurrence rates or in mid‐ to long‐term (>3 years) subjective recurrence rates, anatomical recurrence rates, and reoperation rates (p > 0.05).

Conclusions

Overall, the rates of anatomical recurrence and overall complications for Manchester procedure and vaginal hysterectomy are similar. Manchester procedure appears to have a lower subjective recurrence and reoperation rate in the short term, but this advantage was not observed in mid‐ to long‐term follow‐up. Further high‐quality prospective studies are needed to confirm these findings.

The study compares the effectiveness and safety of the Manchester procedure (MP) and vaginal hysterectomy (VH) for treating mid‐compartment prolapse. MP demonstrated lower short‐term subjective recurrence and reoperation rates than VH, with comparable anatomical outcomes and complication rates. These findings highlight MP as a viable alternative for prolapse management, particularly for short‐term outcomes.

Abbreviations

MD

mean difference

MP

Manchester procedure

POP

pelvic organ prolapse

POP‐Q

pelvic organ prolapse quantification

RCT

randomized controlled trial

VH

vaginal hysterectomy

Key message.

The Manchester procedure demonstrates lower short‐term subjective recurrence and reoperation rates compared with vaginal hysterectomy for mid‐compartment prolapse, with comparable anatomical outcomes and complications. These findings may provide new insights into surgical decision‐making for prolapse treatment.

1. INTRODUCTION

Pelvic organ prolapse (POP) is a common global health issue. It is estimated that the prevalence of symptomatic POP ranges from 3% to 6%, while gynecological examinations reveal a prevalence as high as 41% to 50%, with uterine prolapse being one of the most common types. ¹ With increasing life expectancy, its incidence is projected to rise. ² POP has a significant impact on quality of life and imposes economic burdens on both individuals and society. ³

Surgical intervention remains a key treatment for moderate to severe POP, with a lifetime risk for POP surgery estimated at 12.6% to 19%. ⁴ , ⁵ While synthetic mesh was previously favored, the US Food and Drug Administration's warnings in 2008 and 2011 about complications led to a shift back to non‐mesh techniques like vaginal hysterectomy (VH), which remains widely used for mid‐compartment prolapse. ⁶ , ⁷ , ⁸ However, the removal of the uterus in VH can weaken pelvic floor support and potentially contribute to prolapse recurrence. ⁹ Additionally, VH has been associated with longer operative times and higher complication rates compared with MP. ¹⁰ There has been a growing patient preference for uterine‐sparing procedures that correct prolapse while preserving the uterus. ¹¹ , ¹² In response, uterine‐sparing surgeries, such as the Manchester procedure (MP), have gained renewed interest for their ability to preserve the uterus and maintain pelvic support. Notably, MP has been the preferred surgical approach for addressing mid‐ and anterior compartment prolapse in several Scandinavian countries for many years. ¹³ , ¹⁴

Recent studies, ¹⁵ , ¹⁶ , ¹⁷ , ¹⁸ including a 2023 high‐quality randomized controlled trial (RCT), have shown favorable outcomes for MP, but debate remains about whether this historical technique, introduced in 1888, is outdated. ¹⁹ , ²⁰ During the course of this study, we conducted a literature search and found that reviews on this topic are extremely scarce, with only the study by Tolstrup et al. published in 2017 identified. ¹⁰ Unfortunately, due to the lack of comparative studies between MP and VH at that time, as well as the heterogeneity of the available data, only a systematic review could be completed, without the ability to perform a meta‐analysis. However, in recent years, several comparative studies on MP and VH have been published, reflecting the growing interest and focus of urogynecologists in this field. ²¹ , ²² , ²³ , ²⁴ , ²⁵ , ²⁶ , ²⁷ , ²⁸ , ²⁹ , ³⁰ , ³¹

Our systematic review and meta‐analysis aim to evaluate the efficacy and safety of MP versus VH, providing evidence‐based insights for clinical decision‐making.

2. MATERIAL AND METHODS

This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta‐Analysis (PRISMA) statement guidelines. ³² A detailed review protocol was developed in advance to ensure a structured and comprehensive approach, and it was registered and approved in the PROSPERO with the registration number CRD42024575874. As this meta‐analysis used data from previously published studies in open‐access databases and did not involve new data, ethical approval, and informed consent were not required.

2.1. Search strategy and eligibility

We systematically searched the PubMed, Web of Science, Google Scholar, and Cochrane Library databases for studies published from the inception of each database until July 2024. The search process followed the pre‐defined Population, Intervention, Comparator, Outcomes, and Study design (PICOS) criteria set by the review team. Our target was to identify studies comparing the efficacy and safety of MP and VH in the surgical treatment of POP in adult women. The inclusion criteria were as follows: (1) The included patients had to be adult women with POP requiring surgery; (2) The primary surgical interventions had to be MP and VH, potentially including concurrent anterior or posterior vaginal wall repair, or uterosacral ligament plication or suspension; (3) The included studies had to report at least one of the following primary outcomes: anatomical recurrence, subjective recurrence, complication rates, or reoperation rates; (4) Eligible studies included RCTs, prospective studies, or retrospective cohort studies, with no restrictions on language. Exclusion criteria were (1) Reviews, case reports, commentaries, abstracts, book chapters, and animal experimental studies; (2) Studies that did not include comparative results between MP and VH or reported insufficient data; (3) Studies for which the full text was not available. We searched using a combination of the following keywords and text terms: “pelvic organ prolapse,” “urogenital prolapse,” “uterine prolapse,” “pelvic floor prolapse,” “Manchester operation,” “Manchester‐Fothergill procedure,” “Manchester procedure,” “cervical amputation,” and “hysterectomy.” A complete search strategy example for PubMed can be found in the Supplementary Material.

2.2. Study selection and data extraction

Two authors (Q.W. and X.J.) conducted the literature search and review independently based on the inclusion and exclusion criteria outlined above. First, they screened potentially eligible studies by reading the titles, abstracts, keywords, and conclusions. Full texts of the potentially eligible studies were then comprehensively reviewed to determine whether they met the inclusion criteria. In cases of disagreement regarding eligibility, other reviewers (S.M. and C.L.) were consulted, and a consensus was reached. The references of the included studies were also manually screened to avoid missing any potentially eligible studies. We contacted the authors of the relevant studies by email to request important missing information and also searched for studies currently awaiting publication. The literature search for this review was completed in August 2024.

Data extraction was also performed by two authors (Q.W. and X.J.) independently according to the PICOS criteria, using a specially designed form to collect the following information and characteristics from the studies: title, author names, year of publication, study type, sample size, patient information (age, body mass index [BMI]), operative time, estimated intraoperative blood loss, follow‐up duration, anatomical recurrence rates, subjective recurrence rates, reoperation rates, overall complications, and details of the complications.

2.3. Assessment of risk of bias

We assessed the methodological quality of RCTs using guidelines proposed by the Cochrane Collaboration, ³³ categorizing final literature quality into very low, low, moderate, or high based on risk of bias. Non‐RCT studies were evaluated using the Newcastle–Ottawa Scale, ³⁴ with final quality graded as low, moderate, and good based on scores in the domains of comparability and outcome or exposure. Two reviewers independently conducted these quality assessments, and any disagreements were resolved through consultation with a third reviewer.

2.4. Definition of outcomes

The primary outcomes included anatomical recurrence rate, subjective recurrence rate, reoperation rate, and overall complication rate. According to prevailing academic opinion, anatomical recurrence is defined based on a validated Pelvic Organ Prolapse Quantification (POP‐Q) system as follows: (1) Examination indicates POP‐Q stage ≥II in any compartment, or any POP‐Q point is at or below 1 cm above the hymen; (2) Examination indicates that the lowest point in any compartment reaches the hymen. Subjective recurrence is defined as the patient's perception of bulge symptoms or the need for re‐intervention. Reoperation is defined as the need for a subsequent POP surgery during the follow‐up period due to recurrence in any compartment. Overall complications encompass intraoperative, postoperative, and follow‐up period complications, including but not limited to intraoperative hemorrhage, organ injury, urinary tract infections, urinary retention, ureteral obstruction, postoperative bleeding, and abscess formation.

2.5. Statistical analyses

The study results were analyzed using the Mantel–Haenszel fixed effects model. When the I ² statistic exceeded 50%, a random effects model was employed instead. Dichotomous outcomes from the original studies were aggregated to derive risk ratios (RR) along with their 95% confidence intervals (CI). For continuous variables, data were combined using means and standard deviations. The I ² statistic was utilized as an indicator to evaluate the proportion of total variability attributable to heterogeneity across studies. Typically, I ² values of 25%, 50%, and 75% are interpreted as low, moderate, and high heterogeneity, respectively. In cases where high heterogeneity was detected, sensitivity analysis was performed to identify its source. Publication bias was assessed using funnel plots only when more than 10 studies were included. All analyses were carried out using REVIEW MANAGER 5.3.

3. RESULTS

A total of 167 records were identified through electronic database searches. After removing duplicates, the review team screened the remaining 76 articles by reading the abstracts and excluded 56 of them. Twenty articles were considered for full‐text evaluation, of which 4 were excluded for not reporting primary outcomes, 2 for not comparing MP and VH, 1 for full‐text unavailability, and 2 as a duplicate based on the same study. Ultimately, 11 studies involving 11 783 patients were included in this analysis, comprising 1 RCT, 1 prospective study, and 9 retrospective cohort studies. The detailed study selection process is shown in Figure 1, and the characteristics of the included studies are listed in Table 1. The risk of bias in these studies was assessed according to the Cochrane Handbook and the Newcastle–Ottawa Scale. The results showed that 9 studies were of high quality, 1 was of medium quality, and 1 was of low quality, with detailed assessments provided in Tables S1 and S2. There were no significant differences between the two groups in terms of age (mean difference [MD] = −0.64; 95% CI: −1.83 to 0.55; I ² = 71%; p = 0.29) or BMI (MD = 0.01; 95% CI: −0.20 to 0.22; I ² = 0%; p = 0.91) (Figures S1 and S2). The operative time in the MP group was significantly shorter than that in the VH group (MD = −27.31; 95% CI: −36.41 to −18.22; I ² = 85%; p < 0.001). Given the I ² > 75%, indicating substantial heterogeneity, we attempted to exclude studies one by one to identify the source of heterogeneity. The results confirmed that after excluding the study by Ünlübilgin, the I ² in the pooled analysis dropped significantly (MD = −30.64; 95% CI: −37.37 to −23.90; I ² = 55%; p < 0.001). Detailed results are shown in Figures S3 and S4. The pooled analysis also showed that the intraoperative estimated blood loss was significantly less in the MP group than in the VH group (MD = −104.38; 95% CI: −132.20 to −76.55; I ² = 34%; p < 0.001) (Figure S5).

FIGURE 1.

Flowchart for electronic database search.

TABLE 1.

Main characteristics of the studies incorporated in the systematic review.

Year	Reference	Study design	Sample size			Follow‐up	Primary outcomes
			Total	MP	VH
2009	Boer 21	Retrospective	156	81	75	1 year	Anatomical recurrence rates, complication rates
2022	Brunes 22	Retrospective	3450	1807	1643	1 year	Subjective recurrence rates, overall complication rates, reoperation rates
2022	Enklaar 23	Retrospective	160	53	107	13 years	Subjective recurrence rates, reoperation rates
2019	Husby 24	Retrospective	6831	2786	4045	43 months a	Reoperation rates
2014	Iliev 25	Retrospective matched cohort	66	33	33	1 year	Anatomical recurrence rates, complication rates, reoperation rates
2021	Kotani 26	Retrospective	96	66	30	17 months a	Anatomical recurrence rates, complication rates, reoperation rates
2008	Miedel 27	Prospective	104	70	34	48 months a	Anatomical recurrence rates, subjective recurrence rates, reoperation rates
2019	Park 28	Retrospective matched cohort	40	20	20	1 year	Anatomical recurrence rates, complication rates
2011	Thys 29	Retrospective matched cohort	196	98	98	6 years	Anatomical recurrence rates, complication rates, reoperation rates
2017	Tolstrup 30	Retrospective matched cohort	590	295	295	4 years	Anatomical recurrence rates, complication rates, reoperation rates
2012	Ünlübilgin 31	RCT	94	49	45	61 months a	Complication rates, reoperation rates

Abbreviations: MP, Manchester procedure; VH, vaginal hysterectomy; RCT, randomized controlled trial.

^a The follow‐up time here refers to the median or mean follow‐up duration of the cohort.

3.1. Anatomical recurrence rate

Seven studies reported on anatomical recurrence during the follow‐up period. ²¹ , ²⁵ , ²⁶ , ²⁷ , ²⁸ , ²⁹ , ³⁰ Among the 1191 patients included 235 experienced anatomical recurrences with rates of 17.9% (114/636) in the MP group and 21.8% (121/555) in the VH group. The pooled analysis, as shown in Figure 2, did not reveal a significant difference in anatomical recurrence rates between the two groups (RR = 0.84; 95% CI: 0.58–1.21; I ² = 54%; p = 0.34).

FIGURE 2.

Primary outcomes, including anatomical recurrence rate, subjective recurrence rate, overall complication rate and reoperation.

3.2. Subjective recurrence rate

Only four studies reported on subjective recurrence outcomes, ²² , ²³ , ²⁵ , ²⁶ yet they included a total of 3776 patients, of whom 594 (15.7%) experienced subjective recurrence. The subjective recurrence rates were 14.1% (276/1963) in the MP group and 17.5% (318/1813) in the VH group. The pooled analysis showed that MP was associated with a lower subjective recurrence rate during the follow‐up period compared with VH (RR = 0.85; 95% CI: 0.73–0.98; I ² = 0%; p = 0.03) (Figure 2).

3.3. Complication rate

A total of eight studies compared the complication rates between MP and VH. ²¹ , ²² , ²⁵ , ²⁶ , ²⁸ , ²⁹ , ³⁰ , ³¹ Many studies reported intraoperative complications, such as bladder perforation, ureteral injury, bowel injury, and significant hemorrhage (>500 mL). They also examined postoperative complications occurring during the hospital stay or follow‐up period, including urinary tract infections, urinary retention, and postoperative bleeding. Among these, urinary retention and urinary tract infections were the most commonly reported complications. Pooled analysis showed no significant difference in the overall complication rate of patients between the two groups (RR = 0.89; 95% CI: 0.79–1.00; I ² = 0%; p = 0.06) (Figure 2).

3.4. Reoperation rate

A total of eight studies provided data on reoperation rates due to POP recurrence. ²² , ²³ , ²⁴ , ²⁵ , ²⁶ , ²⁷ , ²⁹ , ³⁰ , ³¹ The overall reoperation rate was 7.9% (915/11565), with the VH group showing a higher reoperation rate compared with the MP group [5.8% (307/5250) vs. 9.6% (608/6315)]. The pooled analysis also indicated that VH group has a significantly higher reoperation rate for POP recurrence (RR = 0.62; 95% CI: 0.43–0.89; I ² = 64%; p = 0.009) (Figure 2).

3.5. Subgroup analysis

Given the well‐recognized importance of follow‐up duration in evaluating POP surgery outcomes, we categorized the included studies into short‐term (1–3 years) and mid‐ to long‐term (>3 years) follow‐up groups. We then performed subgroup analyses for anatomical recurrence rates, subjective recurrence rates, and reoperation rates, with detailed results presented in Figures 3, 4, 5, respectively.

FIGURE 3.

Subgroup analysis of anatomical recurrence rate stratified by follow‐up.

FIGURE 4.

Subgroup analysis of subjective recurrence rate stratified by follow‐up.

FIGURE 5.

Subgroup analysis of reoperation rate stratified by follow‐up.

Regarding anatomical recurrence rates, no significant differences were observed between the two groups across different follow‐up periods. However, subgroup analyses of subjective recurrence rates and reoperation rates indicated that within the 1–3 year follow‐up period, the MP group had significantly lower subjective recurrence rates (RR = 0.81; 95% CI: 0.69–0.96; I ² = 0%; p = 0.02) and reoperation rates (RR = 0.71; 95% CI: 0.55–0.92; I ² = 0%; p = 0.008) compared with the VH group. No significant differences were found between the two groups for subjective recurrence and reoperation rates in the mid‐ to long‐term follow‐up.

We also conducted a detailed analysis of specific complications recorded in the included studies and performed subgroup analyses. As shown in Figure 6, the results demonstrated that the MP group was associated with a lower risk of urinary tract infections (RR = 0.58; 95% CI: 0.36–0.92; I ² = 0%; p = 0.02). No significant differences were observed between the two groups for other specific complications.

FIGURE 6.

Subgroup analysis of detailed complication rate.

4. DISCUSSION

The current systematic review and meta‐analysis found that compared with VH, the MP has a shorter operative time and reduced intraoperative blood loss. In summary, MP is associated with lower subjective recurrence rates and reoperation rates compared with VH, particularly during short‐term follow‐up (1–3 years). However, there are no significant differences between the two groups in terms of overall complication rates, anatomical recurrence rates, or long‐term subjective recurrence rates, and reoperation rates. MP seems to offer additional benefits when uterine preservation is not contraindicated, for these patients, as MP provides a less invasive surgical option with comparable effectiveness to VH. This approach aligns with the preference of many women who, given similar expected outcomes, prefer to retain their uterus. ¹¹ , ¹²

The meta‐analysis results demonstrate that the anatomical recurrence rates for MP and VH are comparable. Subgroup analyses based on follow‐up duration further confirmed that there are no significant differences in anatomical recurrence rates between the two surgical methods in both short‐term and mid‐to‐long‐term follow‐up periods. These findings affirm the reliability of MP as a surgical option, consistent with the conclusions of previous reviews by Dietz et al. and Thapa et al. ³⁵ , ³⁶ In the study by Dietz et al., the anatomical cure rate for MP was reported to be between 93% and 100%. Considering the follow‐up period of 12–43 months in their study, this result aligns with the current study's findings of a short‐term anatomical recurrence rate of 5.3% (100/1895).

Another key outcome to consider is the rate of subjective recurrence and reoperation. Our study found that the rate of subjective recurrence and reoperation for MP was significantly lower compared with VH, especially within the short‐term follow‐up (1–3 years). This conclusion is consistent with previous reports. Dietz et al. reported a reoperation rate of 0%–12% following VH and 0%–4% following MP. ³⁵ Another study reported that at 1‐year follow‐up, the subjective recurrence rate for VH was 15%, higher than the 10% observed for MP, with the reoperation rate also significantly higher in the VH group (9.1% vs. 3.3%). ¹⁰ When the follow‐up period was extended to 53 months, the reoperation rate for VH increased to 13.3%, compared with 9.5% for MP. We believe that the lower subjective recurrence rate observed with MP may be partly attributed to the partial removal of the elongated cervix during the procedure. Surgeries that preserve the uterus often face the challenge of managing an elongated cervix, which can cause a sensation similar to vaginal vault prolapse or anterior/posterior wall prolapse, leading to a perceived bulge postoperatively. Milani et al. reported a 21.2% recurrence rate of apical prolapse following uterosacral ligament suspension, with 81.8% of these cases attributed to significant cervical elongation. ³⁷ Similarly, Rosen et al. found that 14% of patients undergoing laparoscopic uterosacral ligament suspension experienced cervical elongation, potentially necessitating reoperation. ³⁸ In contrast, Wang et al. employed the MP technique to remove a portion of the cervix during vaginal high uterosacral ligament suspension, resulting in a recurrence rate of just 2.5% at 12 months postoperatively. ¹⁷ This finding suggests that partial cervical removal may play a role in reducing subjective recurrence and reoperation rates. Additionally, preserving the uterus maintains the integrity of the pelvic floor support structures, which also contributes to a lower recurrence rate. ³⁹ However, these mechanisms appear to be most effective in the short term. As follow‐up extends, patient age increases, and pelvic support tissues continue to weaken, these protective effects may diminish. This could explain why subgroup analysis shows no significant difference in long‐term recurrence and reoperation rates between MP and VH, with the initial advantage of MP fading over time, likely due to aging and further weakening of pelvic support structures.

The results of this study indicate that MP is associated with shorter operative times and less intraoperative bleeding, consistent with previous review findings. ¹⁰ , ³⁵ , ³⁶ Research by Tolstrup et al. and Dietz et al. also reported that intraoperative transfusion, postoperative bleeding, and infection rates are significantly higher with VH compared with MP. ¹⁰ , ³⁵ This is attributed to the greater complexity of VH, leading to longer surgery duration, more extensive damage to surrounding tissues, larger wounds, and longer recovery times. We believe this conclusion is reasonable; however, current studies show no significant difference in overall complication rates between MP and VH, with subgroup analysis only indicating a higher risk of postoperative urinary tract infections in the VH group. We attribute this discrepancy to the insufficiently precise and detailed reporting of complications in the included studies. For example, the study by Brunes et al. recorded 257 complications in the MP group and 265 in the VH group but did not provide a detailed classification of the complication types, preventing subgroup analysis in this study. ²² We also recognize the potential risks of uterine pathologies post‐MP, such as cervical canal stenosis, but the incidence of this is low, reported in multiple studies to be between 0.7% and 3.3%. ¹⁵ , ¹⁶

As a traditional surgical technique originating in 1888, some critics of MP may regard it as an outdated method, thus not considering it the best choice among uterine‐preserving procedures. In reality, MP has continuously evolved and updated with the times as a successful approach to addressing apical compartment prolapse. Initially, it involved simple cervical amputation and reconstruction, later incorporating bilateral cardinal ligament shortening and plication, and more recently, some researchers have combined it with high uterosacral ligament suspension. ¹⁷ This ongoing innovation has breathed new life into this longstanding technique. A high‐quality multicenter RCT in 2023, involving 434 patients, demonstrated that MP had a significantly higher composite outcome of surgical success compared with the more contemporary sacrospinous hysteropexy (87.3% vs. 77.0%, p = 0.007). ¹⁵ Additionally, 2 years post‐follow‐up, the incidence of prolapse beyond the hymen was significantly lower in the MP group than in the sacrospinous hysteropexy group (4.1% vs. 13.3%, p = 0.001). These findings suggest that despite being over 130 years old, the surgical efficacy of MP remains reliable.

As previously mentioned, when returning to the comparison between MP and VH, a review of the literature reveals that a considerable number of studies support the efficacy and safety of MP to varying degrees. In an era where surgical interventions are increasingly trending toward minimally invasive techniques, if the expected outcomes are similar and there are no contraindications for uterine preservation, we believe MP should be considered an alternative to VH. This aligns with the growing demand among POP patients for uterine‐preserving options. Tolstrup et al. suggest that the persistent preference for VH among surgeons is not entirely based on clinical evidence, but rather because VH has been the standard treatment for mid‐compartment prolapse in many clinics over the years, leading to a lack of experience with other procedures, including MP. ¹⁰ This is merely speculative, but our findings underscore the necessity for rigorous evaluation of this issue.

The primary strengths of this analysis are its rigorous methodology and the novelty of the systematic review's topic. This is the first study to aggregate the results of existing comparative literature and demonstrate that MP is not inferior to VH in terms of efficacy and safety, challenging the established status of VH as the most favored non‐mesh surgical option for treating uterine prolapse.

Our study has several limitations. First, although the majority of the included studies were assessed as high quality, they are retrospective in nature, which brings inherent biases and limitations, inevitably leading to a lower overall evidence level in our study. Second, we were unable to obtain comprehensive baseline data on the distribution and severity of prolapse in different compartments, making direct comparisons between the two groups challenging. Although half of the studies reported no significant differences in the degree of prolapse between the VH and MP groups preoperatively, ²¹ , ²² , ²⁸ , ²⁹ , ³⁰ the absence of detailed baseline characteristics in several studies may still have influenced our conclusions. Some of the studies also failed to document in detail the recurrence of prolapse in individual compartments at postoperative follow‐up, which also contributed to our inability to analyze this in more detail. Third, there was insufficient reporting on concurrent procedures, such as anterior or posterior vaginal wall repairs performed alongside VH or MP. Additionally, VH often requires measures to prevent future vaginal vault prolapses, such as high uterosacral ligament suspension or low uterosacral ligament plication combined with McCall culdoplasty. However, many of the included studies lacked detailed records on these procedures, limiting our ability to conduct further subgroup analysis. Some of the included studies focused only on anatomical outcomes post‐surgery without effectively evaluating patient‐reported outcomes. Moreover, the variation in the types of questionnaires used in the remaining studies made it difficult for us to perform a meta‐analysis on subjective outcomes.

Finally, we recognize the inherent limitations of the MP procedure. Although not explicitly contraindicated, MP may not be suitable for severe, multi‐compartment prolapse, where even hysterectomy may not be the optimal solution. Therefore, we do not suggest that MP is a one‐size‐fits‐all treatment for POP. Instead, we believe that clinicians should carefully evaluate each patient's unique situation and select the most appropriate treatment option based on individual needs.

5. CONCLUSION

This study conducted a systematic review and data analysis to compare the efficacy and safety of MP and VH in treating mid‐compartment prolapse. Our findings indicate that MP offers significant advantages in terms of subjective recurrence rates and reoperation rates in the short term, with anatomical recurrence rates comparable to VH. Additionally, MP is associated with shorter operative times and less intraoperative bleeding compared with VH. These results challenge the current preference for VH as the primary non‐mesh surgical option for uterine prolapse, suggesting that MP could be an effective and safe alternative. However, given the limitations of existing research and the inherent constraints of MP, clinicians should carefully consider individual patient circumstances when selecting the most appropriate surgical approach.

AUTHOR CONTRIBUTIONS

Qi Wang: Project development, data collection, data analysis, manuscript writing and revision. Stefano Manodoro: Project development, data collection, data analysis, manuscript writing, and revision. Xiaoxiang Jiang: Project development, data collection, data analysis, and manuscript writing. Chaoqin Lin: Project administration, data collection, data analysis, manuscript review, and revision.

FUNDING INFORMATION

This study was funded by Joint Funds for the Innovation of Science and Technology, Fujian Province (Grant number: 2023Y9367).

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

Supporting information

Table S1.

Table S2.

Appendix S1.

Figure S1.

Figure S2.

Figure S3.

Figure S4.

Figure S5.

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;104:792‐803. doi: 10.1111/aogs.15053

DATA AVAILABILITY STATEMENT

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.