Laser cylindrical excision to replace conization

Management of precursor lesions of cervical carcinoma: history, host defense, and a survey of modalities

Before the initiation of screening and treatment for cervical cancer precursors, approximately 3% to 4% of women were destined to eventually develop cervical cancer. During the last 50 years the rate of cervical cancer incidence and mortality has decreased by more than 75% primarily because of the widespread availability of cervical cytologic screening and of treatment for documented cervical precancer. Successful screening of the entire population and appropriate treatment of lesions could theoretically reduce this risk to one tenth of the risk of an unscreened population [7,28]. The relatively recent understanding of the etiology of cervical cancer precursor lesions and of the immune response to them has given new direction to management options that incorporate healthy habits and dietary measures as part of traditional ablative or excisional treatment options. As we look to the future we can expect that new markers that more specifically identify individuals at-risk for cervical precancer and cancer will be developed and take precedence in cervical screening. At the same time, treating the cause of these lesions, rather than the result, should provide less traumatic and more successful therapies. To this end, harnessing the immune system through immune response modifiers and HPV vaccines seems to be on the horizon, as do new chemopreventative approaches. Of all human cancers, only cervical cancer, once the second most common cancer among women, stands on the threshold of being virtually eliminated.

Laser excisional conization in an office environment

Use of the laser as an excisional tool in the treatment of cervical disease is an established technique. A study was constructed to determine whether laser excisional conization could be done safely and effectively in an office environment. The subjects of the study were 104 sequential patients who underwent laser excisional cone in an office environment. The average cone size was 16.5 mm by 12.5 mm. The average operating time was 15 minutes. Margins of the cone specimen were adequate for interpretation in 100 patients (96%). Of patients available for complete posttherapy follow-up, 96/98 (98%) achieved initial cure of their lesion. Complications included bleeding requiring revisit in 7.7%, relocation of the SCJ out of colposcopic view in 7%, and cervical stenosis/occlusion in 2 patients. Four pregnancies have occurred and have either been delivered or are progressing satisfactorily. We believe that laser excisional conization may safely and effectively be moved out of the operating room environment.

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.

Laser surgery in gynecologic oncology

In the treatment of premalignant epithelial cancers of the female lower genital tract, the CO2 laser beam is used with precision through a surgical microscope for tissue ablation and excision. Intra-abdominal vaporization of abnormal tissues can be performed endoscopically through fiberoptics. Surgical lasers provide thermal scalpels for hemostatic excision of malignant lesions. Photodynamic therapy is applied in the treatment of isolated malignancies persistent after conservative treatment. Surgical laser systems are important tools in the treatment of gynecologic malignancies.

Obstetrical prognosis for carbon dioxide laser conisation of the uterine cervix

Carbon dioxide laser conisation is a very reliable surgical technique for cervical intraepithelial dysplasia. As cervical morphology and function are better preserved than with other techniques, obstetrical morbidity should be lower in the often young and pauciparous women who undergo this procedure. In our study comparing the course of 71 pregnancies (55 children) in 54 operated women with that of 82 pregnancies (59 children) in these same women before conisation, the rates for complications at the beginning of pregnancy were similar (respectively, 14.1% and 13.4%, early spontaneous abortions; 2.8% and 2.4%, extrauterine pregnancies; and no late spontaneous abortions). The increased risks of premature delivery (13.2% vs. 8.5%), chorioamnionitis (1.9% vs. 0%), premature rupture of membranes (1.9% vs. 0%) and prematurity (11.3% vs. 1.7%) were not statistically significant. Only the percentage of natural term births was significantly reduced (73.6% vs. 90%; P = 0.025), but this difference was no longer apparent after correction for the prevalence of associated obstetrical pathologies and prematurity and/or cesarean factors which was significantly greater for the 53 pregnancies that developed after carbon dioxide laser conisation.

The use of electrosurgical techniques in the management of premalignant diseases of the vulva, vagina, and cervix: an excisional rather than an ablative approach

In recent years electrosurgical excision techniques have been advocated for the evaluation and treatment of premalignant diseases of the vulva, vagina, and cervix. Technologic advances in electrosurgical generators and in fine wire loops have made these techniques feasible in the outpatient setting, and considerable experience has been accumulated in Europe and the United States. This article discusses the advantages and disadvantages of this "new" technology with emphasis on the available scientific literature. In summary, electrosurgical excision offers the benefit of providing tissue for complete histopathologic evaluation without compromising the established convenience, safety, and efficacy of ablative techniques.

Intraepithelial neoplasia of the lower female genital tract: etiology, investigation, and management

Lower genital tract neoplasia appears associated with certain types of the human papilloma virus. Surgical approaches using lasers and electricity are available to treat the clinical diseases and in turn provide good cosmetic and functional anatomy. The surgical method employed depends upon the anatomical and histological distribution of disease regardless of its site. Of the three areas (cervix, vagina and vulva), cervical intraepithelial neoplasia is the least difficult to cure. Vulvar intraepithelial neoplasia is the most difficult since recurrences can occur at any time and in some patients for many years.

Conservative treatment of CIN: a review

This review examines the indications for and the various therapeutic techniques used in the management of CIN. There is an extensive review of the literature. We believe that conization should be the long-term therapy of choice in over 90% of patients with CIN.

Large loop excision of the transformation zone (LLETZ) compared to carbon dioxide laser in the treatment of CIN: a superior mode of treatment

A series of 199 patients with histologically confirmed cervical intraepithelial neoplasia (CIN) grade II or III were allocated by hospital number to receive out-patient treatment by carbon dioxide laser vaporization or large loop excision of the transformation zone (LLETZ). All patients received local anaesthesia. The women in the LLETZ group experienced less post operative haemorrhage, less discomfort, operative time was greatly reduced, and histological material was available for confirmation of the diagnosis. There was no significant difference in recurrence of CIN after treatment between the two groups. At 6 month follow-up, recurrence rates of 8.2% (CIN II) and 7.5% (CIN III) were observed in the laser-group and 5% (CIN II) and 5.3% (CIN III) in the LLETZ group. Further advantages of LLETZ are reduced capital expenditure and no hazard to the eyesight of the surgeon, but laser treatment is preferable in patients with widespread vaginal involvement.

Treatment of cervical intraepithelial neoplasia: experience with the low-voltage diathermy loop

Eighty patients with cervical abnormalities that were proved by colposcopy were treated with the low-voltage diathermy loop by excision biopsy of isolated lesions (n = 14), excision of the transformation zone (n = 52), or by cone biopsy (n = 14). Treatment was performed at the time of initial assessment with the patient under a local anesthetic. Treatment proved acceptable to patients and minimal discomfort was reported. Primary hemorrhage was not a problem, although secondary hemorrhage occurred in 3.7% of patients. Excision was histologically complete in 85% of cases, and excision was clinically complete in the remaining cases. Diathermy coagulation to the base of the lesion ensured hemostasis and destroyed any residual cervical intraepithelial neoplasia. Follow-up cytologic findings were normal in 91% of patients at 3 months, and colposcopy showed no abnormality in 95% of patients at 6 months. The squamocolumnar junction was fully visible in 91% of patients. Thus excisional techniques with the low-voltage diathermy loop appear to be a viable treatment option for cervical intraepithelial neoplasia.