EKSİZYONEL PROSEDÜRLER EXCISIONAL PROCEDURES Prof. Dr. ÇETİN ÇELİK SELÇUK ÜNİVERSİTESİ TIP FAK. KADIN HAST VE DOĞUM AD. JİNEKOLOJİK ONKOLOJİ BD. KONYA
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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