The Manchester repair: an instructional video.

OBJECTIVE: The Manchester repair, developed in the UK by Donald, described in 1908, and later modified by Fothergill, is a well-studied and proven surgical treatment for uterovaginal prolapse when uterine preservation is desired. This operation is currently not widely performed in parts of the world (USA) but is becoming increasing popular in Europe. The objective of this video is to demonstrate our surgical technique and recommendations for successful completion of the procedure. METHODS: This patient is a 39-year-old woman with two previous vaginal deliveries who presented with a 1-year history of vaginal protrusion. She had no urinary or bowel symptoms. On examination, she had a grade 2 cystocele and uterine descent. She desired surgical management of her uterovaginal prolapse but wished to retain her uterus. The procedure involves mobilizing the vagina and bladder off the cervix and uterosacral cardinal ligament complex anteriorly and laterally. The cervix is then amputated. The ligaments are clamped, cut, and ligated and attached to the anterior cervical remnant with an overlapping suture. This pulls the cervix backward into the pelvis and results in anteversion of the uterus. A posterior and then anterior Sturmdorf suture is used to reconstruct the cervix by covering the amputated cervix with vaginal mucosa. CONCLUSION: The Manchester repair is an operation worth considering in patients where preservation of the uterus is desired. It uses native tissue and has a low complication rate and good long-term results.

Technique of extraperitoneal uterosacral ligament suspension for apical suspension.

AIM OF THE VIDEO/INTRODUCTION: Vaginal vault prolapse can occur alone or in combination with anterior or posterior compartment prolapse. Apical prolapse has shown a strong correlation with anterior wall prolapse and a moderate correlation with posterior wall prolapse. The McCall culdoplasty uses the extraperitoneal vaginal approach to support the vault at the time of hysterectomy. Sacrospinous fixation and ileococcygeus suspension with or without mesh have also been used for the treatment of vaginal vault prolapse. The uterosacral ligaments can also be used to re-suspend the vaginal vault using the extraperitoneal or transperitoneal approach. With the extraperitoneal approach, the peritoneal sac, which can be difficult to access at times, especially when there are dense pelvic adhesions, does not need to be opened. The extraperitoneal approach also carries a lower risk of ureteric injury, as the ureters and the bladder can be retracted from the field using a Breisky-Navratil retractor. METHODS: This video, which documents the surgical treatment of a woman with a complete vaginal eversion and grade 3 pelvic organ prolapse (POP), was recorded in a live workshop during the 2015 Urogynaecology and Reconstructive Pelvic Surgery Conference, held in Chennai, India, in January 2015. It is aimed at educating interested surgeons in the technique of extraperitoneal uterosacral suspension. CONCLUSIONS: This video demonstrates the extraperitoneal approach to uterosacral ligament suspension for apical support in women with vaginal vault prolapse.

Progranulin regulates neurogenesis in the developing vertebrate retina.

We evaluated the expression and function of the microglia-specific growth factor, Progranulin-a (Pgrn-a) during developmental neurogenesis in the embryonic retina of zebrafish. At 24 hpf pgrn-a is expressed throughout the forebrain, but by 48 hpf pgrn-a is exclusively expressed by microglia and/or microglial precursors within the brain and retina. Knockdown of Pgrn-a does not alter the onset of neurogenic programs or increase cell death, however, in its absence, neurogenesis is significantly delayed-retinal progenitors fail to exit the cell cycle at the appropriate developmental time and postmitotic cells do not acquire markers of terminal differentiation, and microglial precursors do not colonize the retina. Given the link between Progranulin and cell cycle regulation in peripheral tissues and transformed cells, we analyzed cell cycle kinetics among retinal progenitors following Pgrn-a knockdown. Depleting Pgrn-a results in a significant lengthening of the cell cycle. These data suggest that Pgrn-a plays a dual role during nervous system development by governing the rate at which progenitors progress through the cell cycle and attracting microglial progenitors into the embryonic brain and retina. Collectively, these data show that Pgrn-a governs neurogenesis by regulating cell cycle kinetics and the transition from proliferation to cell cycle exit and differentiation. © 2017 The Authors. Developmental Neurobiology Published by Wiley Periodicals, Inc. Develop Neurobiol 77: 1114-1129, 2017.