title: The Manchester-Fothergill and the Elevate Posterior technique for the correction of a cervical elongation and large enterocele in a patient with bladder exstrophy and multiple surgeries.
abstract: OBJECTIVE
  A 60-year-old woman presented with congenital bladder exstrophy, urinary incontinence since birth, and pelvic organ prolapse since the menopause at the age of 46 years.
  
  
  METHODS
  The patient (gravida 2, para 2 by cesarean sections and tubal ligation) described an extensive past surgical history that included epispadias and neourethral procedures, anti-reflux surgery using the Lich-Grégoir technique, bilateral ureterosigmoidostomy achieving continence, uterine fixation after the Doléris operation, and neovaginal reconstruction. The physical examination revealed a fourth-degree enterocele with cervical elongation (POP-Q: Aa-2, Ba-2, C + 3, D + 4, gh:5, pb:2.5, Tvl:6, Ap + 3, Bp +6). Gynecological ultrasound and uro-CT were performed to ensure that the ureterosigmoidostomy had been successful, and CT-based 3D bone reconstructions were obtained to calculate the distance between the pubic rami and the ischial spines. Based on a literature review of the management options for these patients and the specific characteristics of our patient, a decision was made to perform trachelectomy (the Manchester technique with Fothergill stitches) and a polypropylene mesh placement with sacrospinous ligament anchor (Elevate Posterior® PC, AMS).
  
  
  RESULTS
  Six months after the surgery, we observed good anatomical and functional results with significant improvement in the patient's quality-of-life scale score.
  
  
  CONCLUSIONS
  We believed that the vaginal approach was minimally invasive with a low risk of morbidity in our patient, who had a very altered anatomy, but produced a satisfactory functional result.
authors.affiliation: Department of Gynecology and Obstetrics, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain, marisasanchez@um.es.
authors.forename: M Luisa Sánchez
authors.initials: ML
authors.lastname: Ferrer
authors.forename: Eduardo Bataller
authors.initials: EB
authors.lastname: Sánchez
authors.forename: Laura Hernández
authors.initials: LH
authors.lastname: Hernández
authors.forename: Francisco Machado
authors.initials: FM
authors.lastname: Linde
authors.forename: Ana Isabel Hernández
authors.initials: AI
authors.lastname: Peñalver
authors.forename: Aníbal Nieto
authors.initials: AN
authors.lastname: Díaz
mesh_terms: D001746:Bladder Exstrophy / Q000150:complications*; D002584:Cervix Uteri / Q000473:pathology / Q000601:surgery*; D005260:Female; D006547:Hernia / Q000150:complications; D059685:Herniorrhaphy; D006801:Humans; D008875:Middle Aged; D056887:Pelvic Organ Prolapse / Q000150:complications*; D013526:Surgical Mesh; D013514:Surgical Procedures, Operative / Q000706:statistics & numerical data; D000069339:Trachelectomy / Q000379:methods*; D014549:Urinary Incontinence / Q000150:complications* / Q000151:congenital