EKSİZYONEL PROSEDÜRLER

EXCISIONAL PROCEDURES

Prof. Dr. ÇETİN ÇELİK

SELÇUK ÜNİVERSİTESİ TIP FAK. KADIN HAST VE DOĞUM AD. JİNEKOLOJİK ONKOLOJİ BD.

KONYA

EXCISIONAL PROCEDURES

Conization X Hysterectomy

Excision serves two purposes:

Diagnosis of cancerous or precancerous lesions

Remove the abnormality completely X therapy

EXCISIONAL PROCEDURES

Indications of conization:

Diagnosis of high risk of invasive disease and CIN III

Glandular disease

Diagnostic uncertainty

Discordance among with cytology X biopsy X colposcopy

Inadequate colposcopic examination

Nonvisible lesion margin

Non-visible squamocolumnar junction

HYSTERECTOMY

Hysterectomy is not a first-line treatment for CIN

Hysterectomy is reserved for women with

Adenokarsinoma insitu

CIN 2,3 with a positive conization margin

Completed childbearing

Benefit from a definitive procedure

Recurrent or persistent CIN 2,3

Repeat diagnostic excisional procedure

Hysterectomy

Scarring or shortening of the cervix from prior treatments

Not willing or able to comply with long-term follow-up

Invasive disease is suspected

CIN together with benign gynecological disease such as myoma, prolapsus

CONIZATION

Con biopsy

Cone - shaped excision of cervix

Transformation zone

Portion of endocervix

Performed with scalpel (cold knife conization)

Laser

Electrosurgery

Loop Electrosurgical Excision Procedure (LEEP)

Large Loop excision of transformation zone

(LLETZ)

HoffmanMS, Mann WJ, Goff B. UpToDate. 2014

CONIZATION

Conization does not always remove the entire TZ or lesion

Pregnancy

TZ is large or lengthen in the endocervical canal

Lesion extends onto the vaginal fornix or very deep into the

cervical stroma

OPERATIVE TECHNIQUE

The goal to remove the entire TZ

Too small an excision can result in inadequate removal of the lesion

Too large can lead to immediate and delayed complications

The size and shape of the conization

Careful preoperative colposcopy and good surgical judgment

Should be tailored to the individual situation

OPERATIVE TECHNIQUE

Type of TZ very important for conization

TZ Type I

Completely in the ectocervix

Completely visible

TZ Type II

TZ lengthen the endocervical canal

Upper margin of TZ visible with colposcopy

TZ Type III

TZ lengthen the endocervical canal

Upper margin of TZ nonvisible with colposcopy

OPERATIVE TECHNIQUE

Type I TZ

Peripheral cone length 5 mm

Central 8 mm

Tip II-III TZ

Central cone length 7-10mm

Two step excision

High risk of recurrence and cervical failure

OPERATIVE TECHNIQUE

Colposcopic examination may be performed

Demarcate the outer limits of the TZ

3-5 % acetic acid solution

Lugol's iodine

Determined size and configuration of the cone

Deeper cones (2 cm or more) in

postmenopausal women

OPERATIVE TECHNIQUE

COLD KNIFE CONIZATION

Performed with a scalpel

Almost always under general or regional anesthesia

The patient is placed in the dorsal lithotomy position

Drain the bladder

May increase the risk of a postoperative urinary tract infection

A digital examination is not done

Vagina is gently prepared to avoid trauma to the cervix

Appropriate retractors are used

COLD KNIFE CONIZATION

A vasoconstrictor solution may be injected into the cervix

If there are no medical contraindications (eg, hypertension)

Reduces intraoperative blood loss and improves operative

exposure

20 to 30 mL of vasopressin (0.5 U/mL) or

1:200,000 epinephrine solution injected circumferentially deep

into the dense cervical stroma

COLD KNIFE CONIZATION

The anterior lip of the cervix is grasped with

a single tooth tenaculum well outside the

transformation zone

A tenaculum placed on the posterior cervical

lip is also helpful

Abnormally shaped cervix (eg, "fish mouth"

cervix)

Specimen may need to be removed in pieces

The tenaculum is moved from one location to

another

Placement of absorbable sutures at the three

and nine o'clock positions just below the

cervicovaginal junction

COLD KNIFE CONIZATION

A long-handled scalpel with a #11 blade is

used to make a circumferential incision

just lateral to TZ

Starting posteriorly, the scalpel blade is

inserted to the desired depth and direction

Using a very slight sawing motion the

desired circular incision is completed

COLD KNIFE CONIZATION

An Allis clamp is used to gently grasp and

manipulate the partially released

specimen

Mayo scissors are used to complete and

deepen the incision as necessary

The residual endocervical canal is then

curetted

Dilation and curettage is indicated, the

conization is done first

COLD KNIFE CONIZATION

COLD KNIFE CONIZATION

LEEP TECHNIQUE

Utilizes a very thin wire in the shape of a loop and

electrosurgical generators

The loops are available in a variety of sizes

Allowing individualization and avoidance of excessive

excision

A plastic or insulated speculum should be used

Can be performed in an office setting

Use of a local anesthetic, topical anesthetic spray

LEEP TECHNIQUE

The electrosurgical generator is set at 40 to 50 watts

on blend

Cuting 40 W (35-55)

Coaqulation 50 W (40-60)

The higher the blend, the more the coagulating current

and the greater the thermal damage

The loop should be allowed to glide through the cervix

from one side to the other, allowing the cutting current

to divide the tissue

If the surgeon attempts to pull quickly through the

cervix, the loop will drag, bend, or adhere to the

tissue, resulting in a shallower excision

Loop moves too slowly, however, excess thermal

damage to the specimen will ocur

LEEP TECHNIQUE

Lesion extends into the

endocervical canal beyond the

reach of the loop (ie, 5 mm),

additional tissue may be excised

from this area with a smaller-

diameter rectangular loop

An endocervical curettage is

performed following completion of

excision

BLEEDİNG CONTROL

Optimal management of the cone bed is not well established

Firmly place in the cervix a tampon or rolled gauze soaked in ferric

subsulfate solution (Monsel’s solution)

The pack can removed in 12 to 24 hours.

Open cone bed technique can be performed

Spot hemostasis with electrocautery

Lateral cervical sutures

A long, narrow piece of oxidized cellulose (eg, Surgicel)

Vasopressin

COMPLICATIONS

Early

Intraoperative bleeding

Uterine perforation

Bladder laseration

Rectum laseration

COMPLICATIONS

Late

Postoperative bleeding 5-15%

Infection 0.2-6.8%

prophylactic antibiotics should be used in high-risk

patients (eg, history of gonorrhea, pelvic inflammatory

disease)

Cervical stenosis 0-27%

Reproductive effects

Infertility ?

COMPLICATIONS

Cervical stenosis (0-27%)

Cold knife (8 %)

LEEP (4.3 to 7.7%

Laser (7.1%)

Risk factors for cervical stenosis

Size of removed tissue (İncision depth of ≥1 to 2 cm)

Postmenopausal status

Results of cervical stenosis

Difficulty of examination TZ and cervical canal

Difficulty of endometrial biopsy

Affected conception

Affected menstruel bleeding

Cause of hematometra-pyometra

REPRODUCTIVE EFFECTS

OF CONIZATION

Because of destruction of cervical gland and stroma

Removed of glands

Effects of cervical mucus

Risk of ascendan infection ↑

Risk of EMR ↑

Prematurity ↑

Maternal-neonatal sepsis

Cervical stromal destruction

Prematurity

Effects of vaginal flora

Lactobasillus ↓

Cervical scar

COMPLICATIONS Risk of second trimester loss

Risk of PROM ↑

Increased premature delivery and perinatal mortality

Especially cold knife conization

Risk factors for prematurity

Lenth of excision ≥10 mm

Over 12mm, increased risk 6% every 1mm

Recurrent conization

The time between conization and pregnancy

Prophilaktic cerclage don’t prevent pramaturity

Tal Rafaeli-Yehudai . J Matern Fetal Neonatal Med, 2014

Crane JM et al. Obstet Gynecol 2006

Samson SL et al. Obstet Gynecol 2005

RECOMMENDATIONS AFTER

CONIZATION

Mild vaginal bleeding among with 2-3 week

Can resume normal daily activities

Avoiding sexual intercourse

Not placing anything in the vagina (eg, douches, tampons)

Not taking a bath or swimming for a few weeks

FALLOW-UP AFTER CONIZATION

Patient is seen in the office at six weeks

Assessment of cervical cytology and colposcopy are

performed three to four months postoperatively

Specimens should not be obtained before three months

Advised to wait at least three months before attempting to

become pregnant

FALLOW-UP AFTER CONIZATION

HPV/cervical cytology cotesting at 12 and 24 months

If both cotests are negative, cotesting should be

repeated in three years

If cotesting is again negative, the patient may resume

routine screening

If there is abnormal cytology or a positive HPV test

Colposcopy with endocervical sampling should be

performed

Routine screening is at least 20 years even if screening

continues beyond age 65 years

Konner SN. Am. Col. Obst Gyn 2013

COMPARISON OF METHODS

The three conization methods similar outcomes nd hemorrhage

Thermal artifact was greater with laser compared to LEEP

Laser allows greater flexibility in managing the ectocervical

component of the disease

Ability to combine the vaporization and conization techniques

LEEP is readily performed as an office procedure

Cold knife or laser conization usually removes a larger volume of

tissue than LEEP

A cold knife cone avoids thermal damage to the margins of the

specimen

LEEP and CKC biopsy appear equally effective in the treatment of

ACIS

Munro A, Gynecol Oncol. 2015

Jiang Y. PLOS ONE | DOI:10.1371/journal.pone.0170587 January 26, 2017

EFFICIENCY OF CONIZATION

Most important factor is margin

positivity (13-23%)

Positive margin efficiency 70%

Negative margin efficiecy 95%

Cone length <15 mm higher rate

of positive endocervical margin

Cold conization 4.8%

LEEP 24%

Residual tumor

3-8.5% (5.4%)

Localization of lesion

Endocervical lesion have

lower succes than

ectocervical

Size of lesion

>1 cm2

High grade lesion especially

HSIL-CINIII-ACIS

Postmenopausal women

Operative difficulties

Miss diagnosis

EFFICIENCY OF CONIZATION

Margin positivity with CIN I

Ectocervical or only one site endocervical

Fallow-up 4 – 6 month with cytology-colposcopy-endocervical sample

Margin positivity with CIN II-III

Ectocervical

Fallow-up 4 – 6 month with cytology-colposcopy-endocervical sample

Endocervical

Reexcision ?

EFFICIENCY OF CONIZATION

Reconization of margin positive CIN III

5-10% invasive Ca

Most of stage Ia2

Ayhan A. Int J Gynecol Obstet 2009

INSUFFICIENCY OF CONIZATION

Risk factors of recurrence (4-

27%)

Positive margins

Persistans 9.3-33 %

Positive margins was 4 times

higer than of negative margins

Negative margins had a

persistence rate of 1.8%

HSIL, carcinoma insitu

Volume of lesion (greater

than two-thirds of the

surface of the cervix)

Persistan HPV (HPV 16)

Endocervical gland

involvement

İmmünosuppression

Moleculer markers

Postmenopausal women

Maurizio Serati . Eurp J Obstet &

Gynecol Reprode Biol 2012

Yaxia Chen Int. J. Gynecol Obstet 2009

OUTCOME

Treatment CIN can reduce the risk of invasive cancer 95 %

Recurrent or persistent CIN is 5 to 17 % despite therapy

Most failures occur within two years

But recurrences may occur up to 20 years later

The risk of invasive cervical cancer greater than general

population of women

56 X 5.6 per 100,000 woman-years in the general populatio

CONCLUSION

Excision of the entire TZ with a cone-shaped biopsy is

Diagnostic

Therapeutic

Standard procedures for performing a cone biopsy include

Scalpel

Laser

Electrosurgical loop excision

Conization should be individualized, depending on the specific

lesion

The most significant perioperative complication is bleeding

Generally managed with local measures

Hysterectomy is not a first-line treatment for preinvsive disease

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