Short and long-term outcomes of the Manchester Procedure for Pelvic Organ Prolapse and the impact of major Levator Ani Muscle defects PhD thesis by Sissel Hegdahl Oversand, MD 2018 Department of Gynaecology, Oslo University Hospital, Ullevål and University of Oslo, Faculty of Medicine, Norway © Sissel Hegdahl Oversand, 2018 Series of dissertations submitted to the Faculty of Medicine, University of Oslo ISBN 978-82-8377-335-4 All rights reserved. No part of this publication may be reproduced or transmitted, in any form or by any means, without permission. Cover: Hanne Baadsgaard Utigard. Print production: Reprosentralen, University of Oslo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`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≥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