Cervical Conization
Mariam AlHilli
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.1
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 (ASC-H); (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 colposcopic-directed 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 clinical findings, 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 (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).
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