Cervical intraepithelial neoplasia: Procedures for cervical conization
- Mitchel S Hoffman, MD
Mitchel S Hoffman, MD
- USF Morsani College of Medicine
- William J Mann, Jr, MD
William J Mann, Jr, MD
- Section Editor — Gynecologic Surgery
- Clinical Professor
- Department of Obstetrics and Gynecology
- Virginia Commonwealth University School of Medicine
Cervical conization (also known as cone biopsy) refers to the excision of a cone-shaped portion of the cervix surrounding the endocervical canal and including the entire transformation zone. Excisional treatment can be performed using a scalpel, laser, or electrosurgery (ie, loop electrosurgical excision procedure [LEEP], also called large loop excision of the transformation zone [LLETZ]). There is no evidence that one technique is significantly better than another .
Since squamous lesions typically arise at the transformation zone, the procedure usually enables the pathologist to study an intraepithelial or superficially invasive lesion in its entirety. However, conization does not always remove the entire transformation zone or lesion. Excision is less likely to be complete in certain situations, such as pregnancy, or when the transformation zone is large or high in the endocervical canal, or when the lesion extends onto the vaginal fornices or very deep into the cervical stroma.
Ablative procedures, which are usually done with cryosurgery or with the laser, are an alternative to conization. However, no pathologic specimen is obtained since the cervical tissue is destroyed. These procedures are purely therapeutic and not of diagnostic value. They are appropriate for selected patients with previously well characterized lesions histologically and colposcopically, in whom invasive cancer has been excluded. (See "Cervical intraepithelial neoplasia: Ablative therapies".)
The goal of cone biopsy is to remove the entire transformation zone. Too small an excision can result in inadequate removal of the lesion, while an excision that is too large can lead to immediate and delayed complications. The size and shape of the cone biopsy should be tailored to the individual situation and based upon careful preoperative colposcopy and good surgical judgment. Colposcopy in the operating room just before cone biopsy is not always practical, but may be helpful in many situations. Extending colposcopy to include evaluation of the upper vagina is worthwhile, especially in the presence of large, high-grade ectocervical lesions.
If the transformation zone and lesion are in the endocervical canal and the exocervix appears normal, the cone biopsy may be made narrower to preserve the normal ectocervical tissue, but should extend well upward along the endocervical canal (figure 1). By comparison, if the lesion and transformation zone are largely confined to the ectocervix and the endocervical canal appears to be free of disease, then the cone is taken wide enough to clear the transformation zone with minimal resection of the endocervical canal (figure 1).
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- OPERATIVE TECHNIQUE
- Cold knife conization
- Laser conization
- Loop electrosurgical excision procedure
- POSTOPERATIVE INSTRUCTIONS
- COMPARISON OF METHODS
- Intraoperative bleeding
- Uterine perforation
- Postoperative bleeding
- Late complications
- Cone margins
- Microinvasive disease or adenocarcinoma in situ
- Planned hysterectomy
- PREGNANT WOMEN
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS