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Simulation

Cervical Excision Procedures: Loop Electrosurgical Excision Procedure and Cold Knife Cone

Module

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Introduction

  • Excision is widely used as treatment for high-grade squamous intraepithelial lesions (HSIL) of the uterine cervix (cervical intraepithelial neoplasia [CIN2 and CIN3]).* It is preferred over ablation:
    • With large lesions (> 75% of cervix area)
    • With large lesions (> 75% of cervix area)
    • With lesions extending into the endocervical canal
  • If the transformation zone is not fully visualized
  • LEEP is usually an office procedure performed under local anesthesia.
  • CKC is performed in the operating room usually with general or regional anesthesia.
  • Excision provides tissue for histologic examination. It:
    • Reduces risk of missing occult invasive cancer
    • Allows assessment of surgical margins
    • Success rates high with both LEEP and CKC
    • Risk of recurrence lower with CKC
    • Perinatal risks in subsequent pregnancy is higher with CKC

*LAST terminology is used in this module


Author

  • Alan G. Waxman, MD, MPH, Department of Obstetrics & Gynecology, University of New Mexico

References

  • Kyrgiou M, Koliopoulos G, Martin-Hirsch P et al. Obstetric outcomes after conservative treatment for intraepithelial or early invasive cervical lesions: Systematic review and meta-analysis. Lancet Feb 2006; 367, 489-498. 
  • Conner SN, Frey HA, Cahill AG, et al. Loop electrosurgical excision procedure and risk of preterm birth: a systematic review and meta-analysis. Obstet Gynecol;123:752-61.
  • Melnikow J, McGahan C, Sawaya, et al. Cervical intraepithelial neoplasia outcomes after treatment: Long-term follow-up from the British Columbia cohort study. JNCI 2009;101(10):721-728. 
  • Arbyn M, Kyrgiou M, Simoens C et al. Perinatal mortality and other severe adverse pregnancy outcomes associated with treatment of cervical intraepithelial neoplasia: meta-analysis. BMJ 2008;337:1-11. 
  • Ghaem-Maghami S, Sagi S, Majeed G, et al Incomplete excision of cervical intraepithelial neoplasia and risk of treatment failure: a meta-analysis. Lancet Oncol. 2007;8:985-93. 
  • Mathevet P, Dargent D, Roy M, Beau G. A randomized prospective study comparing three techniques of conization: cold knife, laser, and LEEP.  Gynecol Oncol. 1994 Aug;54(2):175-9.
  • Massad LS, Einstein MH, Huh WK, et al . 2012 Updated consensus guidelines for the management of abnormal cervical cancer screening tests and cancer precursors. J Low Genit Tract Dis 2013;17(5S):S1-17.
  • Darragh et. al. J. Low Genit Tract Dis 2012;16:205-42.

Developed in association with ASCCP, the society for lower genital tract disorders.

Version 1.0, posted April 2015