Cervical amputation with uterosacral ligament plication
In case of concomitant anterior colporrhaphy, this procedure is performed first. The colporrhaphy is started with hydrodissection with 20–30 cc of normal saline followed by a vaginal midline incision from the urethrovesical junction until the fold of the bladder at the cervix. The cervix is circumcised. The bladder is then dissected from the cervix over 2–3 cm. The peritoneal cavity is not opened. The dissection of the bladder from the vagina is performed sharply with either scissors or knife. The bladder is subsequently plicated with a number, usually five or six, interrupted sutures Vicryl 2-0. In order to prevent an anterior enterocele, the most proximal plicating suture incorporates the cervix cranial to the level of subsequent cervical amputation. After removal of excessive vaginal epithelium, the vagina is closed with a continuous non-locking Vicryl 2-0 stitch. In case the procedure is not combined with an anterior colporrhaphy, the cervix is simply circumcised, and the bladder is dissected from the cervix over 2 to 3 cm.
The next step is to identify the uterosacral ligaments by palpating them at the lateral posterior side of the cervix. The uterosacral ligaments are marked with an Allis clamp on both sides. The cervix is now amputated over 1 to 2.5 cm depending on the amount of cervical elongation. The vaginal epithelium of the cervix is dissected from the cervix over 0.5 cm in order to get a better application of the epithelium to the amputated cervix after suturing. Haemostasis of the cervix and vaginal wall is achieved by cauterization.
Plication of the uterosacral ligaments is now performed by a deep Sturmdorf Vicryl 1 suture. This suture was originally used to re-epithelialise the cervix after a conisation. We modified it in such a way that the uterosacral ligaments are incorporated (Fig. 1). It starts with a deep bite at the left, still clamped, uterosacral ligament, running to or close to the cervical ostium. The vaginal epithelium of the posterior vaginal wall is grasped in the same stitch in the midline in one or two bites, and on the patient’s right side, the same deep stitch runs from the cervical ostium through the clamped uterosacral ligament on the right side. Before tying this suture, the anterior side of the cervix is re-epithelialised with either a very superficial Sturmdorf suture or simple interruptured Vicryl 2-0 sutures. In contrast with the original Manchester procedure, the ligaments are not cut and transposed but they are transposed merely by plication with the Sturmdorf stitch.
Knot tying of the deep posterior Sturmdorf suture on the posterior side of the cervix now elevates the cervix, because it shortens the uterosacral ligaments and prevents the development of a posterior enterocele. After this procedure, it is checked that the cervical canal is still open and easily accessible. Posterior colporrhaphy is then performed with use of midline fascial plication if deemed necessary.
Vaginal hysterectomy with high uterosacral ligament plication
In case of additional anterior colporrhaphy, this procedure is performed before or after the vaginal hysterectomy at the discretion of the surgeon. The cervix is grasped with a tenaculum forceps and circumcised. The bladder is dissected, and the anterior peritoneum is opened. Posteriorly, a similar procedure is performed, and the pouch of Douglas is opened. Now, the uterosacral ligaments are palpated and grasped with a forceps and cut and ligated with a Vicryl 2-0 suture which is left long. The uterus is removed in several steps with clamps and ligatures of Vicryl 1. After removal of the uterus, the adnexa are inspected. The patient is placed in deep Trendelenburg position. A wetted gauze with a securing suture is introduced in the peritoneal cavity, and a high purse string suture monocryl 0 is started on the left side with a deep bite through the uterosacral ligaments usually about 2 to 3 cm proximally from the previous attachment to the cervix and close to the level of the ischial spine. Identification of the uterosacral ligaments is facilitated by firm traction on the sutures through the ligament which had been left long. Care is taken to avoid the ureters. The purse string is now proceeding clockwise to the middle of the posterior vaginal wall which is taken in full thickness. Thus, this monocryl suture runs through the peritoneum into the vaginal cavity and back into the peritoneal cavity. The purse string is continued with a similar deep bite on the uterosacral ligament on the right side and, anteriorly, only superficial peritoneum of the vesicouterine fold is incorporated. With the closure of this purse string suture, the posterior vaginal wall is elevated to the level of the deep bites in the uterosacral ligaments. Adaptation of the vaginal epithelium is performed with Vicryl 2-0 interrupted sutures.
Posterior colporrhaphy is performed if deemed necessary with use of midline fascial plication. Our group has a very restrictive policy for concomitant anti-incontinence surgery, and these combined operations were not present in this case series. In both operations, a vaginal pack (for 12–24 h) and a catheter (for 24–48 h) are inserted after the procedure. The procedures are performed under antibiotic prophylaxis coverage with metronidazole, and cefazolin cystoscopy was not performed.
The study groups consist of consecutive women who underwent either vaginal hysterectomy with high uterosacral ligament plication or cervical amputation with uterosacral plication in the years 2002–2007 in three large teaching hospitals in The Netherlands (Radboud University Nijmegen Medical Centre, Erasmus University Medical Centre, and Reinier de Graaf Group Delft). The choice for the type of surgery was made in mutual agreement between physician and patient. All women underwent preoperative cytology of the cervix and ultrasound screening of the uterus and adnexa to exclude abnormalities. All women underwent a full gynaecological examination including the pelvic organ prolapse quantification (POP-Q) score  and were invited for a postoperative visit 1-year after the operation in which the POP-Q score was repeated. For the compartmental POP-Q stages, the points Ba (anterior), C (middle), and Bp (posterior) were used in the study. The overall staging was assigned by the leading compartment.
Patient characteristics and perioperative complications were collected from the medical files. Procedures were performed or supervised by senior (uro)gynaecologists. The choice for either procedure was left to the surgeon’s discretion. All data are part of a registration project, which was formally deemed exempt from CME/IRB approval.
The patient self-reported questionnaire is a composite of internationally well-known questionnaires that have been validated for the Dutch language. It contains disease-specific questions from the validated Dutch translation of the incontinence impact questionnaire (IIQ) , urogenital distress inventory (UDI) , and the defaecatory distress inventory (DDI) . Patients rate the amount of bother of various symptom on a 5-point Likert scale, from 0 (no complaints at all) to 4 (very serious complaints). Scores on various domains are composed  on the basis of their Likert scale values on a scale ranging from 0 (best quality of life) and 100 (worst quality of life).
Data are presented as number of women (percentage), mean (standard deviation), or median (range) as appropriate. To compare the difference between groups, the independent samples Student’s t test was used in case of normally distributed numerical values, Mann–Whitney in case of not normally distributed numerical values, and chi-square in case of two by two tables. The level of significance was set at alpha of 0.05. All data were entered and analysed in a Statistical Package for the Social Sciences 15.0 database for Windows (SPSS, Inc., Chicago, IL, USA).