Chapter 9 Cervical Conization. Operative Techniques

 Chapter 9 Cervical Conization

GENERAL PRINCIPLES

Description

■ Cervical conization refers to surgical excision of a cone-shaped segment of

the cervix and surrounding endocervical canal including the

squamocolumnar junction.

■ The procedure can be performed using cold knife biopsy (cervical

conization) or loop electrosurgical excision (LEEP).

■ It can be regarded as a diagnostic and therapeutic procedure.

■ Cervical conization and LEEP both allow histologic evaluation of the

excised tissue, while ablative procedures (cryotherapy or laser) preclude

histologic evaluation.

Indications

General Indications

■ Excisional therapy with cervical conization or LEEP is the gold standard for

treatment of grade 2 and 3 cervical intraepithelial neoplasia (CIN 2-3).

■ The advent of highly sensitive and specific screening methods for cervical

cancer screening has created a paradigm shift in the diagnosis and

management of CIN.

■ Cervical conization is generally undertaken in nonpregnant patients of

reproductive age with a diagnosis of CIN 2-3, or “young women”2 with

persistent CIN 2 or CIN 3 for 1 year, for treatment purposes and in order to

rule out invasive disease.

■ A conservative approach in the screening for cervical carcinoma in situ has

been advocated in recent years, which has minimized the use of invasive

diagnostic procedures including cervical conization, particularly in “young

women.”

Diagnostic Indications

■ Lack of complete visualization of transformation zone3 on colposcopy

indicative of an unsatisfactory colposcopic examination of the cervix.

■ Lack of consistency between cytologic findings on cervical screening

cytology and histologic findings on cervical biopsy.■ CIN 1 on biopsy preceded by high-grade squamous intraepithelial

neoplasia (HSIL) or atypical squamous cells cannot exclude HSIL (ASCH); (alterative options: co-testing at 12 and 24 months or review of

cytology, histology, and colposcopy).

■ Cytology suggests a higher-grade lesion than that found by colposcopicdirected biopsy.

■ Persistent positive cytology for dysplasia or persistent high-risk HPV with

normal colposcopy:

■ CIN 1 that persists for at least 2 years if continued follow-up is not

desired.

■ Confirmation of microinvasive squamous cell cervical carcinoma detected

on biopsy or suspected on cytology or colposcopy.

■ When cytology, biopsy or endocervical curettage suggests the presence

of endocervical glandular lesion.

■ Presence of dysplastic cells within endocervical curettage.

Therapeutic

■ Treatment of microinvasive cervical carcinoma4 where fertility is desired.

■ Treatment with conization is sufficient if margins are negative.

■ Positive margins are highly predictive of recurrent disease and further

treatment (repeat conization or hysterectomy) may be indicated.

■ Treatment of CIN 2 or CIN 3. Observation is less favored in the following

circumstances:

■ Women who do not desire future fertility

■ Inadequate colposcopy

■ Women with recurrent CIN 2 or CIN 3

■ “Young women” with persistent CIN 2 or CIN 3 for 1 year

■ CIN 2 or CIN 3 present within endocervical curettage

■ Worsening colposcopic findings or persistent high-grade cytology for 1

year

■ HSIL—“see and treat” option.

Indications in Special Populations

■ Women aged 21 to 24 with

■ persistent HSIL for 24 months and no CIN 2 or CIN 3 identified.

■ persistent CIN 2 or CIN 3 for 24 months after close observation with

cytology and colposcopy every 6 months.

■ immediate treatment of CIN 2 or CIN 3.

■ Pregnant women

■ when strong suspicion for invasive cervical carcinoma based on clinicalfindings, cytology, or biopsy is present.

■ CIN 2 and CIN 3 are generally managed expectantly with colposcopic

examinations every 12 weeks. Repeat biopsy is indicated with the

appearance of the lesion worsens or cytology results suggest invasive

cancer.

■ endocervical curettage is contraindicated in pregnancy.

IMAGING AND OTHER DIAGNOSTICS

■ Prior to cervical conization, a colposcopic evaluation of the cervix is

performed to evaluate the extent of disease.

■ Colposcopic-guided or direct cervical biopsies of an abnormal ectocervical

lesion must be performed.

■ An endocervical curettage is an essential component of the evaluation of

cervical dysplasia prior to conization, particularly for cervical

adenocarcinoma and where atypical glandular cells are detected on

cytology.

■ The size and shape of cone specimen are determined by patient

circumstances and preoperative colposcopic findings.

PREOPERATIVE PLANNING

■ Cervical conization is performed under general or regional anesthesia in the

operating room for patient comfort and for control of excess bleeding that

may accompany the procedure. It is preferred when the lesion is deep

within the endocervical canal and where there are no restrictions in the

amount of cervical tissue removed.

■ LEEP is usually well tolerated with local anesthesia in the office. It is ideal

for young, nulliparous women, and those with an obvious ectocervical

lesion. It removes less tissue than cervical conization.

■ The choice of cervical conization versus LEEP is dependent on several

factors including surgeon preference, patient preference, desire for

complete excision with minimal thermal effect, and the size and severity of

the lesion (refer to Pearls and Pitfalls section).

■ Informed consent is needed prior to the procedure.

■ Review patient allergies, particularly iodine allergy. If iodine allergy is

present, the use of 3% to 5% acetic acid solution is suggested.

■ Additional considerations:

■ Anticoagulant usage: Aspirin should be stopped 1 week prior to the

procedure and resumed after the procedure. Warfarin should be stopped

5 days prior to the procedure and resumed on the night of surgery.

Consult with hematologist for recommendations regarding

anticoagulation management in patients with prosthetic heart valves,high-risk thrombophilia, recent venous thromboembolism (within 3

months), and if bridging with low–molecular-weight heparin is required.

■ If a concomitant infection of the genital tract is suspected, delay the

procedure until the infection resolves and treats appropriately with

antibiotics.

■ A pregnancy test is required in all women of reproductive age where

pregnancy may be possible.

SURGICAL MANAGEMENT

■ The shape and size of the cone are tailored to the individual situation (Fig.

9.1).

■ A narrow cone is suitable for a lesion deep in the endocervical cancer

with a normal ectocervix.

■ A narrow cone is usually needed in postmenopausal women where the

squamocolumnar junction moves cephalad into the endocervical canal.

Figure 9.1. A shallow cone with a wide base is performed for lesions located in the

ectocervix. A deep cone with a narrow base is performed for lesions in the endocervical

canal.

■ If the lesion is large or confined to the ectocervix, a wide cone is

performed to obtain clear transformation zone margins.

■ The amount of tissue removed generally depends on

■ The location of the squamocolumnar junction: the higher/deeper the

squamocolumnar junction, the narrower the cone should be.

■ Endocervical gland involvement.

■ In general, the endocervical portion of the cone/LEEP should be 20 mm

wide (10 mm on each side of the cervical canal) and no more than 20 mm

deep.Positioning

■ Position the patient in the dorsal lithotomy position using candy cane or

Allen’s stirrups.Procedures and Techniques: Cervical Conization (Video 9.1)

Visualization

■ Place a weighted speculum posteriorly and three Deaver retractors to expose

the cervix wzunzip -(Tech Fig. 9.1).

■ Ensure the entire cervix is well visualized and the vaginal walls are well retracted

to prevent injury.

Tech Figure 9.1. Visualization of the cervix with placement of a weighted speculum

posteriorly and three Deaver retractors.

Primary hemostasis

■ Grasp the cervix laterally at 3 and 9 o’clock with single-tooth tenacula.

■ Place stay sutures (hemostatic sutures) at the 3 and 9 o’clock positions of the

cervicovaginal junction using 1-0 delayed absorbable suture and remove the

tenacula. These sutures are used for traction and hemostasis (Tech Fig. 9.2A).

■ Remove the laterally placed Deaver retractors and tag each stay suture with a

Kocher clamp. Use stay sutures to stabilize the specimen and to partially occlude

the descending branch of the uterine artery (Tech Fig. 9.2B).

■ Inject a dilute solution of vasopressin (0.5 mL/100 mL NS [10 units/100 mL])

deep into the four quadrants of the cervix (2, 4, 6, and 8 o’clock positions of the

cervix) (5 to 10 cc/quadrant) using an 18-gauge spinal needle. Draw back before

injecting to ensure intravascular injection has not occurred. Observe for blanching

of the cervical stroma prior to proceeding (Tech Fig. 9.3).

Tech Figure 9.2. A and B: Placement of left stay suture lateral to the cervix. Stay

sutures are tagged with Kocher clamps and are used to provide traction on the cervix

and hemostasis.

Tech Figure 9.3. Deep injection of cervix with a dilute solution of vasopressin for

hemostasis in four quadrants. Blanching of the stroma must be seen.

Preparation

■ Bathe the cervix with Lugol’s solution to demarcate areas of dysplasia. If the

patient has an iodine allergy, use 3% to 5% acetic acid solution instead.

Colposcopy may be used as appropriate (Tech Fig. 9.4).

■ Use a uterine sound to determine the direction of the endocervical canal and

cervical length (Tech Fig. 9.5).

Tech Figure 9.4. The cervix is bathed with Lugol’s solution to demarcate areas of

dysplasia and identify the transformation zone.

Tech Figure 9.5. The cervix is sounded to identify the length and direction of the cervix.

Excision of cone

■ Use a #11 blade to score the cervix making a circumferential clockwise incision

starting at 3 o’clock and incorporating the entire transformation zone. Angle the

tip of the blade toward the endocervical canal (Tech Fig. 9.6A,B).

■ Place a 3-0 silk suture in the cone stroma at 12 o’clock and tie it. Place two

additional silk sutures at 4 and 8 o’clock and leave them untied. Tag all three

sutures with a Kelly curve clamp and use it to rotate and manipulate the cone.

Avoid instruments touching the ectocervix during conization (Tech Fig. 9.7A,B).

■ Place traction on the cone using the tagged sutures, and complete the cone

resection by re-orienting the blade to remove a wedge of cervical tissue (Tech

Fig. 9.8).

■ Remove the untied silk sutures and use the tied suture placed at 12 o’clock to

orient the specimen (Tech Fig. 9.9).

■ Check the adequacy of the cone with a sound and submit the specimen to

pathology. Avoid manipulating or touching the ectocervix during the process.

Tech Figure 9.6. The cervix is scored with a #11 blade starting at 3 o’clock and going

clockwise (A) ending at 3 o’clock (B).

Tech Figure 9.7. A: Silk suture is placed at 12 o’clock in the stroma of the cervix

avoiding touching or manipulating the ectocervix. This suture is tied. B: Two additional

silk sutures are placed at 4 and 8 o’clock and are left untied. All three sutures are

tagged and used for retraction for the cone.

Tech Figure 9.8. The cone is completed by making a deeper incision within the cervical

stroma and orienting the blade toward the endocervical canal to remove a wedge of

tissue.

Tech Figure 9.9. The specimen is oriented—the silk sutures at 4 and 8 o’clock are

removed and the suture at 12 o’clock is left in place.

Endocervical curettage

■ Use an endocervical curette to perform a thorough endocervical curettage. Take

caution not to enter the lower uterine segment during the process (Tech Fig. 9.10).

This is performed to exclude residual squamous or glandular disease of the

endocervical canal.

■ An endometrial curettage can be performed to exclude disease of the

endometrium.

Tech Figure 9.10. Appearance of cervix postconization.

Hemostasis

■ Control bleeding using a combination of electrosurgical coagulation (30 W—ball

electrode coagulation) and Monsel’s (ferric subsulfate) solution (Tech Fig. 9.11).

■ The cone bed can be sutured with either running absorbable suture or figure-ofeight stiches if excessive bleeding is encountered.

■ If hemorrhage is encountered:

■ Inject vasopressin into the cone bed.

■ Place a purse-string suture through the cone bed and tie it. However, this may

increase the risk of cervical stenosis.

■ Pack a piece of oxidized cellulose (Surgicel) or thrombin-soaked Gelfoam into

the cervical cone bed.

■ Last resort: internal iliac artery embolization or hysterectomy.

Tech Figure 9.11. An endocervical curettage is performed using a small curette.Procedures and Techniques: LEEP

Visualization

■ Insert a nonconductive nylon or plastic-coated speculum into the vagina and align

the cervix.

■ Affix an electrical grounding pad on the patient to ensure safety.

■ Ensure the entire cervix is well visualized and the vaginal walls are well retracted

to prevent injury.

Preparation

■ Rinse the cervix and upper vagina with normal saline solution.

■ Prepare a solution of vasopressin and lidocaine (20 to 30 mL (0.5 U/mL)

vasopressin into 30-mL vial of 1% lidocaine). This serves to provide both local

anesthesia and hemostasis.

■ Apply 5% acetic acid solution using cotton swabs and inspect the cervix and

transformation zone with colposcopy. Apply Lugol’s solution to determine the

margins of resection.

■ Perform colposcopy to evaluate the cervix and determine the location of the

transformation zone and the distribution of the lesion.

■ Ensure electrosurgical generator is connected and set at 30–40 W (40 cut/40

coag) and a smoke evacuator is connected.

■ Select the appropriate shape and size of the loop to be used based on the size

and location of the lesion as well as patient characteristics.

Hemostasis and local anesthesia

■ Inject 10 cc of 1% vasopressin and 0.5 mL vasopressin at 12, 3, 6, and 9 o’clock

deep into the stroma of the cervix and an additional 10 cc superficially at 2, 4, 8,

and 10 o’clock.

Excision of cone

■ Using cut current and the appropriate tip/loop, resect a cone of cervical tissue.

Place the loop 2 mm from the tissue and advance it perpendicularly into the

cervix about 2 to 3 mm lateral to the lesion on each side prior to electrosurgical

cutting. Aim for approximately 5 to 7 mm depth of tissue. Excessive thermal

damage may ensue if resection is too slow. Perform the procedure under

colposcopic control.

■ Consider performing a second pass (using a square tip loop) in older or

postmenopausal patients or when the lesion is large or deep.

■ Orient the specimen by cutting through the stroma at 12 o’clock with scissors andsubmit to pathology.

Endocervical curettage

■ Perform an endocervical curettage using both a sharp endocervical curette and a

cytobrush.

Hemostasis

■ Fulgurate the external edges of the cervix and cone bed with a rollerball tip at 40

W coagulation current.

■ Apply Monsel’s solution to the cone bed/cervix to maintain hemostasis.

■ Consider applying estrogen (Premarin) cream to the cervix.PEARLS AND PITFALLS

Cervical conization is recommended over LEEP when margin status is critical for

determining residual disease (microinvasive squamous cell carcinoma or

adenocarcinoma in situ).

Excessive cauterization of post cone bed (particularly crater rim) is associated with

higher risk of postconization/LEEP cervical stenosis.

Cervical conization removes more tissue than LEEP and is considered for more

severe disease, and that which may extend to the endocervical canal. It generally

allows better control of depth of tissue resection.

Stay sutures are placed lateral to the cervix at the cervicovaginal junction. They are

used to manipulate and stabilize the cone specimen. Placement of sutures

unnecessarily in the cone bed is not advised due to the risk of inversion of the

cervical canal and burying of residual disease.

Use of intraoperative colposcopy allows precise evaluation of the amount of tissue

needed to be removed and reduces the incidence of positive margins.

Avoid touching the ectocervix in order to minimize the effect of artifact on histologic

interpretation.

Fertility is not affected by LEEP or cervical conization.

The risk of preterm delivery is increased if the depth of LEEP or cone is greater than

10 mm. The risk of preterm delivery must be balanced against the risk of untreated

CIN 2-3.

Patient is advised that vaginal discharge for up to 3 weeks after the procedure is

normal and not unexpected. Similarly minor spotting for 2 weeks postoperatively may

occur.

Cervical conization is associated with higher rate of extreme prematurity and low birth

weight than LEEP. Thus, LEEP is preferred in young nulliparous patients.

POSTOPERATIVE CARE

■ Patients are discharged home on the same day.

■ Patients are advised to refrain from intercourse, tampon sue, swimming,

tub soaking (nothing per vagina) for 28 days.

■ Review bleeding precautions. Patients are asked to contact their surgical

team in the case of excessive bleeding which consists of soaking a large

(maxi) pad in an hour for two consecutive hours.

■ Worrisome symptoms to prompt medical attention include:

■ Excessive bleeding (soaking a large pad in a hour × 2 hours)

■ Fever >38.0°C

■ Uterine cramping or pelvic pain■ Persistent foul smelling discharge.

■ Patient is seen in the office in 4 weeks and evaluated for bleeding and

cervical stenosis. Evaluation of cervical integrity is done through visual

assessment.

■ Use of estrogen cream is generally not recommended and has not been

shown to reduce the rate of postconization stenosis.

OUTCOMES

■ Cervical conization:

■ Increased risk of preterm birth and low birth weight

■ Higher rate of hemorrhage than LEEP

■ Cure rate >95%

■ LEEP

■ Increased risk of preterm birth and low birth weight

■ Increased risk of cervical stenosis

■ Risk of unsuspected invasive cancer and high-grade glandular dysplasia

1% to 2%

■ Cure rate >95%

■ Positive conization margins:

■ Presence of dysplasia or carcinoma at margins of excisional procedure or

endocervical sample is associated with a significantly higher risk of

recurrent disease (up to 30%) than uninvolved margins.

■ For CIN 2-3, reassessment with cytology and endocervical curettage 4

to 6 months after the procedure is recommended, and re-excision is

optional.

■ For microinvasive cervical carcinoma or adenocarcinoma in situ, where

future fertility is desired, repeat excision/conization to achieve

negative margins is recommended.

■ A hysterectomy may be considered in patients with positive margins

who have completed childbearing.

COMPLICATIONS

■ Short term:

■ Bleeding

■ Early: within 48 hours of the procedure.

■ Delayed: 10 to 21 days after procedure (5% to 10%)—may be due to

erosion of vessel during healing or suture dissolving.

■ Infection: 0.2% to 6.8%

■ Cervicitis—may present with persistent vaginal discharge or bleeding

■ Ascending endometritis—may present with vaginal discharge,bleeding, uterine cramping, abdominal tenderness, or fever

■ Damage to adjacent organs

■ Inadvertent opening of pouch of Douglas

■ A Deaver retractor is placed within the pouch of Douglas to inspect

for damage to adjacent organs (bowel or rectum). The vaginal

mucosa is then repaired with interrupted 2-0 delayed absorbable

suture.

■ If the pouch of Douglas (or bladder) is entered with a knife blade, a

laparoscopic evaluation (or cystoscopy) is warranted.

■ Uterine perforation

■ If perforation occurs with the use of a blunt object (uterine sound)

and the patient is hemodynamically stable, observation is reasonable.

■ If perforation occurs with a sharp object, or perforation of the lateral

uterine walls is suspected, laparoscopic evaluation is recommended.

■ Long term:

■ Cervical stenosis (0% to 27%): higher risk with increased depth of

incision ≥1 to 2 cm (vs. <1 cm) and postmenopausal status.

■ Cervical incompetence—not likely to be clinically significant.

■ Preterm labor: increased risk in women who have undergone more

than one conization procedure.

■ Premature delivery

■ Preterm premature rupture of membranes (PPROM)

■ Greater depth of excision is associated with higher rate of preterm

delivery and PPROM

■ Increased risk with depth of excision >12 to 15 mm; minimal risk

with depth of excision <10 mm or up to 15 mm

■ Miscarriage—second trimester loss

■ Recurrent or persistent CIN—5% to 17%. Higher risk with larger lesions,

endocervical gland involvement, positive margins, persistent positive

high-risk HPV.

KEY READINGS

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