Cervical Cryocautery

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Chapter 239 Cervical Cryocautery

DESCRIPTION

Cervical cryocautery is the use of cold to produce “frost bite” as an ablative therapy for cervical abnormalities.

INDICATIONS

Histologically verified advanced epithelial atypia. Because this is an ablative technology, a histology must be established prior to instituting this therapy.

CONTRAINDICATIONS

Undiagnosed cervical lesions, pregnancy.

REQUIRED EQUIPMENT

• Skin (or vaginal) preparation materials (iodine-based antibacterial solution [e.g., Betadine] or other suitable cleansing agents)
• Cryosurgery unit (e.g., nitrous oxide-powered, carbon dioxide or similar)
• Cryoprobes: flat and conical, assorted sizes
• Water-soluble lubricant (e.g. K-Y Jelly)
• Timer (optional, although recommended)
• Vaginal speculum
• Colposcope (if colposcopy has not been previously performed or the boundaries of the lesion are not visible)
• 3% to 5% acetic acid (white vinegar) or Lugol (5%) solution (if desired)
• Gauze pads and/or cotton balls
• Vaginal sidewall retractor (optional)
• Ibuprofen (800 mg) or other similar nonsteroidal anti-inflammatory agent taken approximately 1 hour prior to therapy (if desired)

TECHNIQUE

After informed consent has been obtained, the patient is placed in the dorsal lithotomy position as for a speculum examination. The cervix should be brought into view and any cultures or cytologic smears should be obtained as needed. If the extent of the lesion has not been documented or is not immediately visible, acetic acid or Lugol solution should be applied to the cervix to delineate the area of abnormality.

A cryoprobe tip should be chosen to allow the freezing effect to extend approximately 5 mm beyond the extent of the lesion. Whenever possible, the probe should be flat or slightly conical to minimize the risk of extensive endocervical damage and the risk of inward migration of the squamocolumnar junction. After the tip is secured to the device (following manufacturer’s directions), turning on and checking the tank pressure to ensure an adequate supply readies the device.

A water-soluble gel or lubricant is applied to the tip of the cryoprobe. (Lidocaine jelly may be substituted if desired.) The tip of the probe should be placed against the cervix, covering the lesion and avoiding contact with the vaginal sidewalls. The unit is activated, and after approximately 5 seconds the tip will adhere to the cervix. Once the tip is adhered to the cervix, the device is maneuvered outward and farther away from the vaginal sidewalls to avoid adherence to other tissues. This outward movement will bring along the cervix, minimizing lateral freezing as well.

Freezing should continue for 3 minutes, resulting in an ice ball that extends 5 mm beyond the cervical lesion. The freezing mechanism is then deactivated to allow for a 5-minute thaw. The probe should not be actively loosened from the cervix but allowed to defrost and detach by itself. After thawing for 5 minutes, the lesion is refrozen for another 3 minutes. A single 5-minute freeze may also be used, but with either method, the ice ball must extend to a distance of more than 5 mm for the procedure to be effective.

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COMPLICATIONS

Cervical stenosis (unlikely unless the procedure is performed repetitively or a probe tip that extends high into the endocervix is used).

FOLLOW-UP

A follow-up sequence of Pap tests should be discussed with the patient. The first Pap test should be delayed at least 3 months to allow for complete healing.

CPT CODE(S)

57511 Cauterization of cervix; cryocautery, initial or repeat (surgical procedure only)
56501 Destruction of lesion(s), vulva; simple, any method
56515 Extensive, any method
57061 Destruction of lesion(s), vagina; simple, any method
57065 Extensive, any method

REFERENCES

Level I

Kwikkel HJ, Helmerhorst TJ, Bezemer PD, et al. Laser or cryotherapy for cervical intraepithelial neoplasia: a randomized study to compare efficacy and side effects. Gynecol Oncol. 1985;22:23.

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;54:175.

Mitchell MF, Tortolero-Luna G, Cook E, et al. A randomized clinical trial of cryotherapy, laser vaporization, and loop electrosurgical excision for treatment of squamous intraepithelial lesions of the cervix. Obstet Gynecol. 1998;92:737.

Level II

Andersen ES, Thorup K, Larsen G. Results of cryosurgery for cervical intraepithelial neoplasia. Gynecol Oncol. 1988;30:21.

Benedet JL, Miller DM, Nickerson KG, Anderson GH. The results of cryosurgical treatment of cervical intraepithelial neoplasia at one, five, and ten years. Am J Obstet Gynecol. 1987;157:268.

Loobuyck HA, Duncan ID. Destruction of CIN 1 and 2 with the Semm cold coagulator: 13 years’ experience with a see-and-treat policy. Br J Obstet Gynaecol. 1993;100:465.

Ostergard DR. Cryosurgical treatment of cervical intraepithelial neoplasia. Obstet Gynecol. 1980;56:231.

Wright VC, Davies EM. The conservative management of cervical intraepithelial neoplasia: the use of cryosurgery and the carbon dioxide laser. Br J Obstet Gynaecol. 1981;88:663.

Level III

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

American College of Obstetricians and Gynecologists. Evaluation and management of abnormal cervical cytology and histology in the adolescent. ACOG Committee Opinion 330. Obstet Gynecol. 2006;107:963.

Cox JT. Management of cervical intraepithelial neoplasia. Lancet. 1999;353:857.

Ferenczy A. Management of patients with high grade squamous intraepithelial lesions. Cancer. 1995;76:1928.

Figge DC, Creasman WT. Cryotherapy in the treatment of cervical intraepithelial neoplasia. Obstet Gynecol. 1983;62:353.

Gage AA. Cryosurgery in the treatment of cancer. Surg Gynecol Obstet. 1992;174:73.

Kirwan PH, Smith IR, Naftalin NJ. A study of cryosurgery and the CO2 laser in treatment of carcinoma in situ (CIN III) of the uterine cervix. Gynecol Oncol. 1985;22:195.

Ostergard DR. Cryosurgical treatment of cervical intraepithelial neoplasia. Obstet Gynecol. 1980;56:231.

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