Cervical Conization or LEEP - Indications and Complications

This is part of the Gynsurgery guidelines used in an educational setting for residents in Ob-Gyn.

LEEP

1. Moderate or severe cervical intraepithelial neoplasia (CIN 2, CIN 3)

Cold Knife Conization

1. Carcinoma in situ (CIS) or any suspected microinvasion on biopsy
2. Moderate or severe cervical intraepithelial neoplasia (CIN 2, CIN 3) and not a LEEP candidate
3. Adenocarcinoma of cervix in-situ
4. Previous LEEP or Cone and recurrent CIN 2 or CIN 3
5. Positive endocervical currettage (ECC) for CIN2 or CIN 3
6. Discrepancy between Pap smear and colposcopic directed biopsy (e.g. HGSIL PAP but biopsy shows only inflammation)
7. Extent of lesion into cervical canal not fully visualized

Complications

1. Pain during procedure (office LEEP, laser)
2. Recurrence of dysplasia
3. Leaving residual dysplasia
4. Bleeding (LEEP 2-10%, Cone 5-15%)
   1. Intraoperative
   2. Postoperative
5. Infection (LEEP 0-2%, Cone .2-6.8%)
6. Bladder injury
7. Bowel injury
8. Cervical stenosis (2-8%)
9. Premature labor/cervical incompetence (4.0 - 10.0 fold increase)
10. Post operative persistent pain

Complication Prevention

1. Pain during procedure (office LEEP, laser)
   1. Use paracervical block (approximately 6 ccs) with 1% xylocaine
   2. Avoid touching vaginal side walls with LEEP probe
2. Recurrence of dysplasia
   1. Check HIV status of individual prior to procedure
3. Leaving residual dysplasia (1 - 4%)
   1. Repeat colposcopy in operating room suite or use Lugol's solution to redefine the ectocervical extent of the lesion
   2. carry the cephalad extent of the excision into the endocervix past the extent of the visble lesion or up to the internal os if extent not visualized
   3. Perform endocervical curettage following excision of the tranformation zone
4. Bleeding (LEEP 2-10%, Cone 5-15%)
   1. Intraoperative
      1. Inject about 10 cc's of vasopressor solution (e.g., xylocaine 1% with epinephrine or pitressin 10 units in 50 cc's) intracervically
   2. Postoperative
      1. Apply Monsel's solution to cervical bed
5. Postoperative cervical infection (LEEP 0-2%, Cone .2-6.8%)
   1. Administer prophylactic antibiotics
6. Bladder injury/Bowel injury
   1. Keep incision in the axis of the endocervical canal
   2. Place traction on cervix with lateral sutures or tenacula
7. Cervical stenosis (2-8%)
   1. Avoid excessive cautery of the cervical excision bed
   2. Use Monsel's solution for hemostasis instead of suture if possible
8. Premature labor/ cervical incompetence
   1. Excise specimen tissue parallel to the ectocervical surface and endocervical canal so as not to remove excessive cervical support tissue (strive for inverted T-shaped specimen rather than cone-shaped specimen
9. Post operative persistent pain