Cervical Conization (Cold Knife)

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Chapter 234 Cervical Conization (Cold Knife)

DESCRIPTION

Cervical conization is a diagnostic or therapeutic procedure that removes a cone-shaped specimen from the uterine cervix. Cold knife cone biopsy used to be the preferred treatment for removing abnormal cells, but now most cone biopsies are performed using wire loop and electrosurgical energy (loop electrosurgical excision procedure [LEEP]/large loop excision of the transformation zone [LLETZ] cone). Cold knife cone biopsy is generally used for special situations, such as when the size or shape of the specimen must be customized to a greater degree than allowed by loop procedures.

INDICATIONS

Histologically verified advanced epithelial atypia (for diagnosis or therapy) or inability to adequately evaluate the cervix through colposcopy.

CONTRAINDICATIONS

Coagulopathy, advanced pregnancy, known or suspected allergy to the agents used.

REQUIRED EQUIPMENT

• Skin (vaginal) preparation materials (iodine-based antibacterial solution [e.g., Betadine] or other suitable cleansing agents)
• Sterile gloves
• 0 or 2-0 synthetic absorbable suture on a medium needle
• Needle holder, long thumb forceps, suture scissors
• Retractors (two Deaver or right-angle retractors and/or weighted speculum)
• Scalpel (#11 blade)
• Uterine sound (blunt probe) or small cervical dilator
• Sponge stick (may be useful to atraumatically grasp and manipulate the cervix)
• Electrosurgical generator, hand piece, and return electrode (“ground pad”)
• Monsel’s solution or paste (ferric subsulfate)
• Histology fixative (10% formalin) in containers
• 5% acetic acid or Lugol solution (super-saturated potassium iodide) if colposcopy is to be performed
• Vaginal Pack (optional)

TECHNIQUE

Cold knife conizations are generally performed under regional or general anesthesia. After providing appropriate informed consent, the anesthetized patient is placed in the dorsal lithotomy position, the vagina and cervix are disinfected, and the cervix is visualized using retractors. If necessary, a colposcopic examination, facilitated by acetic acid or Lugol solution, may be performed to further characterize any abnormalities present.

The procedure begins with the placement of hemostatic sutures (simple loop or figure-of-eight) at the 3- and 9-o’clock positions on the cervix near the cervicovaginal reflections bilaterally. These are generally tied and held to stabilize the cervix until the end of the procedure. (The role of these sutures in actually reducing blood loss has been debated and they may be omitted.) Dilute vasopressin (one pressor unit per 20 mL saline) may be injected into the cervical parenchyma to further reduce blood loss. If desired, a blunt uterine probe or small cervical dilator is placed into the endocervical canal to guide the dissection.

A cone-shaped plug of cervical tissue is excised by sweeping the scalpel blade around the ectocervix with the blade angled inward to intersect the endocervical canal. The width and depth of the conization is determined by the anatomy of the cervix, the location of the transformation zone, and the lesion being treated; it must include the transformation zone and any specific lesion.

Hemostasis may be obtained through electrosurgical energy or the application of styptics such as Monsel solution. Some advocate general cautery of the cut surface of the cervix, although the resultant slough of damaged tissue may delay final healing. If desired, the ectocervical edges may be sewn with a running suture to provide hemostasis at the edge and to roll the edges inward. As an alternative, Sturmdorf stitches may be placed to partially reconstruct the external cervical os, although some argue that this may increase the risk of cervical stenosis. At the close of the procedure, the held tails of the hemostatic sutures may be either clipped (leaving the suture in place) or tied across the cervix to apply pressure or to hold a hemostatic pledget (oxidized regenerated cellulose [Surgicel, or similar]) in place. Pelvic rest (no tampons, douching, or sexual intercourse) is generally advised for 2 to 3 weeks following the procedure, and the patient is instructed to return for heavy bleeding or bleeding that lasts more than 2 weeks.

COMPLICATIONS

Bleeding (acute and delayed, 5% to 10%, <1% transfusion rate), infection, uterine perforation, injury to the bladder or bowel, cervical stenosis, cervical incompetence. Conization appears to approximately double the risk that a woman will subsequently have a preterm delivery, a low-birthweight infant, or premature rupture of the membranes.

FOLLOW-UP

The cervix is generally inspected at about 6 weeks after the procedure. Treatment success for cervical intraepithelial neoplasia is generally 95%.

CPT CODE(S)

57520 Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair; cold knife or laser

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REFERENCES

Level I

Cullimore JE, Luesley DM, Rollason TP, et al. A prospective study of conization of the cervix in the management of cervical intraepithelial glandular neoplasia (CIGN)—A preliminary report. Br J Obstet Gynaecol. 1992;99:314.

Duggan BD, Felix JC, Muderspach LI, et al. Cold-knife conization versus conization by the loop electrosurgical excision procedure: a randomized, prospective study. Am J Obstet Gynecol. 1999;180:276.

Mathevet P, Dargent D, Roy M, et al. A randomized prospective study comparing three techniques of conization: cold knife, laser, and LEEP. Gynecol Oncol. 1994;54:175.

Level II

El-Bastawissi AY, Becker TM, Daling JR. Effect of cervical carcinoma in situ and its management on pregnancy outcome. Obstet Gynecol. 1999;93:207.

Jackobsson M, Gissler M, Sainio S, et al. Preterm delivery after surgical treatment for cervical intraepithelial neoplasia. Obstet Gynecol. 2007;109:309.

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. 2006;367:489.

Kyrgiou M, Tsoumpou I, Vrekoussis T, et al. The up-to-date evidence on colposcopy practice and treatment of cervical intraepithelial neoplasia: the Cochrane colposcopy and cervical cytopathology collaborative group (C5 group) approach. Cancer Treat Rev. 2006;32:516.

Sadler L, Saftlas A, Wang W, et al. Treatment for cervical intraepithelial neoplasia and risk of preterm delivery. JAMA. 2004;291:2100.

Level III

American College of Obstetricians and Gynecologists. Diagnosis and treatment of cervical carcinomas. ACOG Practice Bulletin 35. Obstet Gynecol. 2002;99:855.

American College of Obstetricians and Gynecologists. Management of abnormal cervical cytology and histology. ACOG Practice Bulletin 66. Obstet Gynecol. 2005;106:645.

Montz FJ. Impact of therapy for cervical intraepithelial neoplasia on fertility. Am J Obstet Gynecol. 1996;175:1129.

Morris M, Mitchell MF, Silva EG, et al. Cervical conization as definitive therapy for early invasive squamous carcinoma of the cervix. Gynecol Oncol. 1993;51:193.

Sokol H. A modification of the Sturmdorf suture. Am J Obstet Gynecol. 1964;89:823.

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