High-power--density carbon dioxide laser therapy for early cervical neoplasia

Efficacy of pulsed high-intensity laser therapy on pain, functional capacity, and gait in children with haemophilic arthropathy

AIM

The aim of this study was to evaluate the effects of pulsed high-intensity laser therapy (HILT) on pain, functional capacity, and gait in children with haemophilia.

METHODS

Thirty children with haemophilia type A with ages ranging from 9 to 13 years were selected for this study. They were assigned randomly, into two equal treatment groups. The laser group received the traditional physical therapy programme plus active laser (total energy of 1500 J through three phases/3 sessions/week), whereas the placebo group received the same physical therapy programme plus placebo laser over three consecutive months. Baseline and post-treatment assessments used the visual analogue scale (VAS) to evaluate pain, a 6-min walk test (6MWT) to evaluate functional capacity, and the GAITRite^® system to evaluate gait parameters.

RESULTS

Children in the laser group showed significant improvement in pain, functional capacity, and gait parameters compared to those in the placebo group (p < 0.05). Post-treatment functional capacity for the laser and placebo groups were 316.6 ± 35.27 and 288 ± 43.3 m, respectively.

CONCLUSIONS

HILT is an effective modality in reducing pain, increasing functional capacity, and improving gait performance in children with haemophilic arthropathy. Implications for Rehabilitation Haemophilic arthropathy due to recurrent joint bleeding leads to physical, psychological, and socioeconomic problems in children with haemophilia and reduces their quality of life. Early physiotherapeutic interventions help to prevent and treat the sequelae of recurrent haemarthrosis. High-intensity laser therapy has been introduced as non-invasive and an effective physiotherapy modality for rapid pain control, with consequent improvement in children's quality of life. High-intensity laser therapy should be used as an adjunct to exercise programme in the rehabilitation of children with haemophilic arthropathy.

Laser miniconization procedure

OBJECTIVE

To describe the outpatient procedure of minimal conization with free-hand guided high power density carbon dioxide laser for simultaneous diagnosis and treatment of CIN producing a one-piece tissue specimen for histological examination.

MATERIAL AND METHODS

3100 non-pregnant patients with mild, moderate or severe dysplasia in pap smear, having colposcopically proved ectocervical lesions but without evidence of invasive carcinoma, or 85 pregnant patients with severe dysplasia in pap smear having extensive colposcopic signs of at least carcinoma in situ were admitted for this treatment. This outpatient procedure including cervical curettage is performed under local anesthesia to excise a one-piece 5 mm (during pregnancy 7 mm) deep minicone.

RESULTS

The degree of patient discomfort, bleeding complications, postoperative pain, infection or vaginal discharge were all minimal. The procedure was fast, causing minimal thermal damage of resection lines of the minicone specimen. Histopathological examination of the non-pregnant minicones revealed microinvasive or invasive carcinoma in 1.2%, the primary cure rate was 96.1%. During pregnancy, 13.3% malignancy was found. No unexpected sudden onset of invasive carcinoma was recorded during the 15-year follow-up and the cumulative risk of recurrence for all forms of CIN was 3.02%

CONCLUSIONS

The outpatient miniconization procedure, performed with a free-hand guided 60-W high power density CO2 laser is a reliable method for simultaneous diagnosis and treatment of CIN. Because of the paucity of complications, this procedure may also be appropriate during pregnancy.

A comparison of cold knife, CO2 laser, and electrosurgical loop conization in the treatment of cervical intraepithelial neoplasia

Thirty patients with histologically confirmed high-grade squamous intraepithelial lesions (SIL) were treated by either cold knife, laser, or electrosurgical loop conization, all of which were performed under general anesthesia. The three methods were compared with respect to the immediate surgical complications, ease of performance, delayed complications, and quality of histologic specimens. The electrosurgical loop conization had decreased blood loss and reduced operative time and proved to be tissue sparing. There were no significant differences in the three groups in the persistence rates of cervical intraepithelial neoplasia (CN) after treatment. Histologic analysis revealed comparable coagulation artifact in the laser and electrosurgical loop groups that the cold knife group did not have. The endocervical component of the electrocautery showed extensive denudation and coagulation artifact that made recognition of CIN extremely difficult. We conclude that the electrocautery should be used only as an excisional method of the transformation zone for lesions well defined on the ectocervix, since it is unreliable if the lesion extends into the endocervix.

The use of CO 2 laser for reproductive surgery

The use of the CO 2 dioxide laser in infertility surgery has expanded during the past several years. The results are equal to those of conventional microsurgery, and the CO 2 laser has been associated with bloodless surgery and easy accessibility to deep locations in the pelvic cavity. Tissue healing is good, with a marked reduction in fibrosis, especially with the use of pulsed mode. Recently, the introduction of the waveguide enhanced the use of the CO 2 laser during laparoscopy for treatment of pelvic pathology. The results suggest that laser laparoscopy shortens the recovery period and duration of hospitalization of patients.

The use of carbon dioxide laser in female urology

The carbon dioxide (CO 2) laser can be used to treat a variety of soft tissue disorders encountered by the urogynecologist. Urethral caruncles, red fleshy masses located at the urethral meatus, can be excised and vaporized using the CO 2 laser. Distal urethral diverticula, a common urologic disorder in women, can be marsupialized using the CO 2 laser. The epithelial lining of the diverticulum can be vaporized, thereby decreasing the risk of recurrence. Distal urethral stenosis may lead to symptoms associated with urethral syndrome and can be caused by a fibroelastic band of tissue. The CO 2 laser can be used to destroy this abnormal tissue band, increasing the caliber of the urethral meatus and improving symptoms. This review details the diagnostic workup of these disorders and describes the surgical management using the CO 2 laser.

A ten-year experience treating cervical intraepithelial neoplasia with the CO2 laser

Between 1977 and 1987, the CO2 laser was used to treat 4024 women who were diagnosed by cytology studies, colposcopy, and biopsy examination to have cervical intraepithelial neoplasia. On the basis of specific indications, these women were treated by vaporization, excisional conization, or combination conization procedure. The evolution of methodology for each laser technique was based on specific pathophysiology and long-term observation of results. A total of 3070 patients underwent vaporization, 2881 of whom had no evidence of disease after one laser exposure (93.8%). Of the 954 patients who had laser excisional procedures, 925 (97%) had no evidence of disease. The most common complications observed were intraoperative and postoperative bleeding; however, sutures were required in only 1.34% of the latter. The risks of cervical stenosis (1.1%), incompetent cervix (0%), and pelvic infection (0.05%) were very low. This 10-year study demonstrated that the CO2 laser was a highly effective method for treating cervical epithelial neoplasia and had the added benefit of preserving reproductive function and anatomic integrity.

Carbon dioxide laser treatment of cervical stenosis

Fifteen women diagnosed with cervical stenosis were treated by vaporization of scar tissue using the carbon dioxide laser. Ninety-three percent of the cases demonstrated binding constriction of the cervical os to a 2-mm diameter or less and 40% of the cases had either a pinpoint opening or total endocervical obliteration. The technique for laser treatment and the success of the method depend on precise variations of mode, power, beam diameter, and "buttoning" the endocervical mucosal remnant. Twelve of the 15 patients were relieved of stenosis and 9 achieved pregnancy within 2 years of the operative procedure. Critical analysis of possible causative factors in this study revealed that virtually every case of stenosis had been iatrogenic.

Carbon dioxide laser vaporization of cervical subclinical papillomaviral infection and intraepithelial neoplasia: short-term effectiveness

134 patients with biopsy-proved cervical subclinical papillomaviral infection (SPI) (the so-called 'flat condylomas'), or with associated intraepithelial neoplasia (also called 'atypical condyloma' or 'CIN with features of condyloma'), or with isolated, apparently 'non-warty' intraepithelial neoplasia were treated by means of the carbon dioxide laser between July, 1982, and January, 1985, following a planned approach and on an outpatient clinic basis, without the use of anesthesia or analgesia. The complication rate was extremely low. The overall cure rate was 91.0%. This confirms that laser surgery, combined with colposcopic expertise, can offer acceptable treatment effectiveness, comparable to other techniques of local destruction. Moreover, rapid tissue healing allows early identification of persistent disease. Converging cytological, histopathological, immunochemical and serological evidence has established human papillomavirus - belonging as a subgroup to the papovavirus family - as an important etiologic factor in female genital tract carcinogenesis. The marked increase in prevalence of these mainly sexually transmitted cervical SPI lesions creates a growing problem of their management and/or follow-up.

A comparison between laser excisional conization and laser vaporization for the treatment of cervical intraepithelial neoplasia

One hundred twenty patients with cervical intraepithelial neoplasia who were treated by laser excisional conization were compared with a group of 100 women who had similar diagnoses and were treated by laser vaporization. Every operation in the series was performed in the outpatient surgical unit or in the office. In two thirds of the cases the procedures were carried out with the patients under local anesthesia. The parameters studied included time required to perform the procedure, immediate and delayed bleeding, postlaser stenosis, healing time, patient discomfort, persistence or recurrence of disease, and risk of invasion. The results of this study revealed few disadvantages to performing a laser excisional procedure. Immediate and delayed complications were less frequent with laser excisional conization. The time required to perform an excisional conization was on the average only 4 minutes longer than that for a vaporization. Most significantly, the laser excisional cone provides a large and excellent specimen for the pathologist to review.

Results of CO2 laser cylinder vaporization of cervical intraepithelial disease in 1234 patients. An analysis of failures

This report analyses 1234 patients with CIN and non-condylomatous wart virus infection (NCWVI) managed by CO2 laser ablation in the Regional Department of Gynaecological Oncology, Queen Elizabeth Hospital, Gateshead from 1979 to 1983. Thirty-five patients (3%) were lost to follow-up. Of the 1157 patients currently under review and with at least 1 year of follow-up, 44 (3.8%) were laser treatment failures. This group is analysed and the results compared with other series.

Laser or cryotherapy for cervical intraepithelial neoplasia: a randomized study to compare efficacy and side effects

A randomized study was performed to compare efficacy and side effects of laser and cryotherapy: 51 patients were treated with laser vaporization and 50 patients with cryotherapy. Success rates for laser and cryotherapy were not significantly different. Success rates were significantly related to lesion size. Grade of CIN, positive endocervical curettage, parity, and age at treatment were not found to be related. Vaginal discharge, both in duration and amount, was significantly less in patients treated with laser vaporization, compared with cryotherapy, but pain and bleeding occurred more often in patients treated with laser vaporization. A brief review of possible sources of bias in comparative studies on laser and cryotherapy is given, indicating the preference for a randomized study. It is concluded that widespread introduction of laser facilities in smaller centers is not justified, because the success rates are not better than those of cryotherapy, and because the advantages of less discharge are outweighed by the high cost.

CO2 laser therapy for cervical intraepithelial neoplasia

One hundred and fifty-six patients with cervical intraepithelial neoplasia (CIN) were treated with CO2 laser and followed for 2 1/2 to 6 years. There were 19 recurrences, of which 14 occurred in patients treated with a power density of less than 1000 W/cm2 to a depth of 6 mm. All of the recurrences were subjected to a second laser treatment. Overall failure rate was 4.5%. The incidence of acute bleeding during, and late bleeding 6 to 14 days following treatment, were 8 and 4%, respectively. Late bleeding occurred in patients who were treated with 800 to 1000 W/cm2 power density and to a 3 to 10 mm depth of destruction. Complications were directly and failures were inversely proportional to the power density and depth of destruction. Following therapy, the transformation zone was adequately seen in the majority of the patients.

The treatment of cervical intraepithelial neoplasia by laser vaporization

Of 711 women with cervical intraepithelial neoplasia (CIN) treated by laser vaporization 675 (95%) remain colposcopically and cytologically free from disease after a median follow-up of 20 months. Thirty-six patients needed other forms of treatment to eradicate suspected residual disease. One patient presented with invasive carcinoma of the cervix 34 months after treatment with the carbon dioxide laser. It is concluded that in selected cases laser vaporization is an effective method of treating pre-invasive disease of the cervix.

Carbon dioxide laser for combination excisional-vaporization conization

Extensive cervical intraepithelial neoplasia may simultaneously involve large areas of the ectocervix, even extending to the vaginal fornices, as well as the endocervical canal. In such instances conventional sharp knife conization would result in virtual removal of the cervix if the surgeon wished to completely circumscribe the entire lesion. By combining a narrow carbon dioxide laser excisional conization with ectocervical vaporization, cervical intraepithelial neoplasia may be eradicated by a virtually bloodless surgical procedure and fertility may be preserved. Sixty-one combination conizations with 6 months to 4 years of follow-up are reported. In 95% of the cases biopsy demonstrated cervical intraepithelial neoplasia in three or more ectocervical quadrants, and 16% had extension of disease into the vagina. The technique of combination conization uses 20 to 30 W of power and 1/2 to 1 mm spots for excision and 10 to 15 W and 1 to 1.5 mm spots for vaporization. The average time to complete the entire procedure was 21 minutes. In three of 61 cases endocervical margins were positive; there were no instances of persistence of neoplasia at either the ectocervical or the vaginal margins. Four complications were observed, all related to delayed bleeding; however, only two patients required the placement of a suture. The volume of tissue removed by a large excisional conization is more than two times greater than that of a laser combination conization.

CO2 laser surgery of the cervix, vagina, and vulva

The gynecologic laser surgeon must be an expert colposcopist and skilled in the use of the surgical microscope. Surgical protocols for CO2 laser surgery of the cervix, vagina, and vulva are outlined and techniques discussed. Indications for its use, including treatment of cervical intraepithelial neoplasia, condylomata acuminata, and genital herpes are described and illustrated.

Healing of cervical epithelium after laser ablation of cervical intraepithelial neoplasia

Healing of cervical epithelium was studied in 30 patients after destruction of cervical intraepithelial neoplasia using a carbon dioxide laser. Repeated examinations, using photography and colposcopically directed punch biopsies, were made from the eighth to the 32nd day after treatment. The biopsy specimens were submitted to examination by light and transmission electron microscopy. There was complete epithelial cover of the laser induced craters in all patients by 28 days. The base of the crater and endocervical edge became covered by columnar epithelial cells originating in endocervical crypts, while the vaginal edge re- epithelialised by an ingrowth of the surrounding squamous epithelium. Squamous metaplasia of the new columnar epithelium was a common observation as early as eight days after treatment. There was no evidence for a stromal contribution to epithelial cover.

Carbon dioxide laser surgery for cervical intraepithelial neoplasia

During 1977-1983, 787 consecutive referred cases of CIN were treated by vaporization of a dome-shaped defect, by excision of a cylindrical specimen, or a combination of procedures where 48% were CIN III. Vaporization was used for 72% of CIN I, 76% of CIN II, and 64% of CIN III cases. Less than 15% of vaporization and all excision cases were done in hospital under anesthesia; 11% had delayed bleeding requiring attention (admission was required in 2%); 100% of CIN I, 96% of CIN II, and 96% of CIN III cases were cured. Persistent disease was diagnosed at the first (96%) or second (4%) visit. Subsequent treatment included laser and less than 1% hysterectomy. Overall cure for laser surgery was 99.5%. Sixty-eight patients subsequently became pregnant; outcomes were normally distributed. Treatment success is related to adequate volume of tissue removed.

The treatment of cervical intraepithelial neoplasia using the carbon dioxide laser

A total of 423 patients with cervical intraepithelial neoplasia (CIN) have been treated with a carbon dioxide laser in the out-patient colposcopy clinic. Thirty patients required two or more treatments. Outcome has been assessed in 408 patients followed for more than 1 year. Sixteen patients (4%) have had a recurrence of CIN. Failures were not related to age, parity or size of lesion.

Management and follow-up of cervical intraepithelial neoplasia treated by CO2 laser vaporization method

Forty-four patients with cervical intraepithelial neoplasia (CIN) II and 31 patients with CIN III were followed up for up to 6 months after cervical cone vaporization with carbon dioxide laser. In addition to colposcopy and pap smear, all patients underwent cervical biopsies as part of their follow-up. This protocol permitted a diagnosis of persistent disease in the presence of normal colposcopy and pap smear.

Carcinoma of the cervix--a review

Carcinoma of the cervix is the fourth most common neoplasm in women. The mortality from this tumor has dropped with the advent of Papanicolaou smears and routine periodic screening, particularly in high risk populations. Diagnosis and staging includes a careful physical examination, the use of colposcopy, directed biopsy, intravenous urogram and cystoscopy. Computed tomography and lymph-angiography may be helpful for detection of iliac or paraaortic lymph nodes. Early, noninvasive stages of this disease (CIN) may be treated with cryosurgery or laser vaporization. Carcinoma in situ (CIS) and microinvasive carcinoma is usually treated with simple hysterectomy for cure. More advanced invasion localized to the cervix may be treated with radical hysterectomy or radiation therapy with 90% of patients surviving 5 years. More advanced tumors are treated with external and intracavitary radiation therapy. For patients with paraaortic lymph node involvement or recurrent tumor, 5-year survival is less than 10%. Chemotherapy may provide some palliation to patients with recurrent tumors but does not increase long term survivorship.

Assessment of failures of cryosurgical treatment in cervical intraepithelial neoplasia

The overall recurrence rate in 166 patients treated with cryosurgery is 10.8%. Recurrent cervical intraepithelial neoplasia is much more common in patients with severe dysplasia. Failures are commonly due to one of four factors. First, cryosurgery is to be used only after adequate colposcopic assessment and a negative endocervical curettage. Cryosurgery is a safe, effective treatment in selected patients, but consideration of surgical management should be given in the older patient who has completed childbearing, particularly those with severe dysplasia or carcinoma in situ. A full 7-minute freeze with optimum application of the cryoprobe to the full affected surface is essential. Careful follow-up of these patients is mandatory. The majority of failures occur within the first 12 months and probably represent persistent rather than recurrent diseases.

The management of cervical intraepithelial neoplasia: the use of the carbon dioxide laser

This report concerns the experience of an abnormal Pap smear clinic in treating cervical intraepithelial neoplasia (CIN). The CO2 laser was the primary treatment method in 283 consecutive cases during 1977-1981, which fulfilled the criteria for conservative management. Seven percent of cases were performed in hospital as out-patients; the remainder were performed in the clinic without anesthesia. The location and shape of the defect was individualized in each case to conform to the topography of the cervix. The basic configuration, however, was the same for all cases; a dome-shaped defect with a curved apex and straight sides of at least 6 mm in height. Laser surgery was well tolerated; few post-operative complications arose. The squamocolumnar junction reappeared in each case at the level of the external os, facilitating follow-up. Eleven cases (3.9%) exhibited persistent disease within 3 months of primary treatment. Thereafter no primary laser failures occurred. Follow-up in this series ranged from 18 to 36 months. Failure rates for CIN grades are as follows: CIN I, 1.3%; CIN II, 2.0%; CIN III, 7.3%. No case of persistent disease was of greater severity than was originally diagnosed. Ten of the 11 cases were successfully managed with repeat laser surgery, yielding an overall therapeutic success rate of 99.6%. These data indicate that laser surgery is the most efficacious conservative method for eradicating this disease.

The abnormal Pap smear--what to do next?

The patient with an abnormal Papanicolaou smear must have proper and adequate diagnostic evaluation to determine the degree of cervical abnormality. Gross clinical evaluation alone is inadequate for definitive diagnosis because cytologic screening identifies patients with preclinical disease. Outpatient diagnostic evaluation must include colposcopy, colposcopic-directed biopsies, endocervical curettage, and pelvic examination. Conization of the cervix is required whenever these techniques are unsatisfactory or are unable to rule out invasive cancer. When outpatient diagnostic procedures including cytologic analysis rule out invasive disease, one may elect cryosurgery, electrocautery, or laser in treating cervical intraepithelial neoplasia. Nevertheless, conization or hysterectomy may be inpatient treatments for selected patients.

Cryosurgery and the CO2 laser

Over the past decade, the management of intraepithelial lesions of the visible portion of the female genital tract has substantially changed with the introduction of cryosurgery and the carbon dioxide laser. Although cryosurgery and the carbon dioxide laser are very effective in eradicating preinvasive disease, the selection of patients by colposcopy and appropriate biopsies is more important than the treatment techniques. Failure to properly evaluate women with genital tract neoplasia can result in disastrous consequences for the patient. The CO2 laser shows considerable promise in managing dysplasia and carcinoma in situ of the vagina and vulva. The laser combines the accuracy of the operating microscope and the precision and control of the photon beam. Posttreatment sequelae are minimal, and scarring is absent.

The conservative management of cervical intraepithelial neoplasia: the use of cryosurgery and the carbon dioxide laser

This study comprises 336 consecutive patients of whom 283 were candidates for conservative therapy involving either cryosurgery or the carbon dioxide laser for the management of cervical intraepithelial neoplasia (CIN). A total of 152 patients were treated first in the series with cryosurgery followed by 131 patients in the laser group. Distribution of disease classification within CIN groups was similar. The overall persistent disease after one treatment was higher in the cryo group (14.5 per cent) as compared to the laser group (3.1 per cent). Of particular significance is the high percentage of failures in the cryo treated group (25.0 per cent) with CIN III disease as compared to the CIN III laser treated group (7.7 per cent). The high persistent disease rate observed in the CIN III lesions treated by cryosurgery suggests that this modality be employed with caution in this disease classification.

Complications associated with carbon dioxide laser surgery in gynecology

Complications associated with the use of the carbon dioxide laser in 624 gynecologic patients are presented. Bleeding and pain were the most common side effects of this new modality. Although bleeding occurred in 63 patients, it was considered minor, i.e., requiring no treatment in 56 women. Pain was rather mild and could be dealt with easily by allowing heat buildup to dissipate. Only one laser accident was observed in the entire series. Interestingly, scar formation, e.g., cervical stenosis, was essentially nonexistent. Similarly, no infections were reported. The carbon dioxide laser compares favorably to conventional treatment methods insofar as complications are concerned; however, if future complications are to be avoided, careful training in CO2 laser technology must precede clinical use of the instrument.

Cryosurgical treatment of cervical intraepithelial neoplasia with follow-up of five to eight years

During 1972 to 1974, 181 women of different ages with cervical intraepithelial neoplasia were treated with cryosurgery. Of these, 170 have now been observed for 5 to 8 years. Treatment failures total 16%, but when the different age groups are considered the results are seen to be much better in young women less than 30 years of age, with only a 12% rate of failure, whereas older women have almost twice as many failures. One patient, 45 years of age, developed an early invasive cancer, but in her case pretreatment diagnosis may have been correct. Our conclusions are that cryosurgery is an easy and effective method of treating cervical intraepithelial neoplasia in young women, provided that the diagnosis prior to therapy is correct. Furthermore, we stress that after treatment the status of the patient must be checked with vaginal smears over a long period and also that at lease one endocervical curettage and directed biopsies of the vaginal cervix should be done as a control.