Research shows that LEEP is associated with an increased risk of overall preterm delivery, preterm delivery after premature rupture of membranes, and low-birth-weight infants in subsequent pregnancies at greater than 20 weeks gestation (123). Loop excision should not be used before an intraepithelial lesion is identified with histopathology. Although “see and treat” may be appropriate in certain settings and among populations for whom follow-up is not possible, the potential excision of the entire transformation zone along with varying amounts of the cervical canal, may compromise birth outcomes (114,116). This is particularly true for young women, who may have large, immature transformation zones with
Table 19.6 Therapeutic Efficiency of Cervical Conization: Comparison between Laser and Knife Techniques
Percentage of patients who are “cured” by conization aPatients had negative cone margins.
extensive acetowhite areas. Complications following loop electrosurgical excision are minimal and compare favorably with those following laser ablation and conization. Intraoperative hemorrhage, postoperative hemorrhage, and cervical stenosis can occur but at low rates, as noted in Table 19.6. The SCJ is visible in more than 90% of patients after this procedure. Effectiveness of LEEP and comparison of LEEP to other excision procedures are shown in Tables 19.7 through 19.9.
Conization Conization of the cervix plays an important role in the management of CIN. Before the availability of colposcopy, conization was the standard method of evaluating an abnormal Pap test result. Conization is both a diagnostic and therapeutic procedure and has the advantage over ablative therapies of providing tissue for further evaluation to rule out invasive cancer (117,118,120,124).
Conization is indicated for diagnosis in women with HSIL or AGC-adenocarcinoma in situ and may be considered under the following conditions: 1.
Limits of the lesion cannot be visualized with colposcopy.
2.
The SCJ is not seen at colposcopy.
3.
Endocervical curettage (ECC) histologic findings are positive for CIN 2 or CIN 3.
4.
Substantial lack of correlation between cytology, biopsy, and colposcopy results.
5.
Microinvasion is suspected based on biopsy, colposcopy, or cytology results.
6.
The colposcopist is unable to rule out invasive cancer.
Lesions with positive margins are more likely to recur after conization (117,118,120) (Table 19.10). Endocervical gland involvement is predictive of recurrence (23.6% with gland involvement compared with 11.3% without gland involvement) (125). When compared with conization, LEEP is the simpler technique, and short-term results are similar to those obtained with conization or laser excision (91,126). In a prospective study examining the long-term effects of LEEP, conization, and laser excision, no difference in recurrence of dysplasia or in pregnancy outcomes was found (127) (Tables 19.11 and 19.12).
Table 19.7 Perioperative and Postoperative Bleeding from Cervical Conization: Comparison between Laser and Knife Techniques
Percentage of patients undergoing conization who develop significant vaginal bleeding
Table 19.8 Complications of Electrosurgical Excision
Hysterectomy Hysterectomy is considered a treatment of last resort for recurrent high-grade CIN. In a study of 38 cases of invasive cancer occurring after hysterectomy among 8,998 women (0.4%), the incidence of significant bleeding, infection, and other complications, including death, is higher with hysterectomy than with other means of treating CIN (128). There are some situations in which hysterectomy remains a valid and appropriate (although not mandatory) method of treatment for CIN: 1.
2.