Cervical Conization

If abnormal intraepithelial changes in the cells covering the cervix are found during a cytological examination, there is a high risk that if left untreated, these changes may develop into cervical precancerous conditions or possibly even cancer.

Procedure Overview

The final diagnosis of precancerous changes is made through the histological examination of cervical tissue removed surgically. Removal of cervical intraepithelial lesions is performed using an electrical loop, during which the altered cervical tissue is excised. Recovery after this procedure is between 95% and 98%. In 2% to 5% of cases, the disease may recur, requiring the removal of altered tissue again. The procedure is performed under intravenous, regional, or local anesthesia while the patient lies on a gynecological examination table. The external genitalia and the vaginal portion of the cervix are disinfected, and Lugol’s solution (an iodine solution) is applied to the cervix to highlight the limits of the lesions. The affected tissue is removed using an electric loop or a scalpel in a circular, shallow cone shape, cutting just outside the boundary of healthy tissue. Bleeding is stopped by cauterization or occasionally by suturing the blood vessels. After conization, a small sharp curette is used to collect samples from the cervical canal and the uterine lining for examination.

In choosing a surgical approach for cervical diagnostics and treatment, excisional cervical procedures are preferred, with cervical conization by diathermic loop being the most common, aimed at removing the transformation zone (see image). The advantages of this treatment technique include shorter operation time, less blood loss, a smoother postoperative recovery, lower complication risks, and complete removal of the pathological area, which allows for thorough examination of the transformation zone and assessment of the radicality of the surgical treatment.

Alternative Treatment Methods for Cervical Intraepithelial Lesions:

  • Laser Treatment:
    Laser therapy involves burning or vaporizing the affected cells, turning them into smoke when heated. This treatment is typically performed in an outpatient gynecology clinic under local anesthesia.
  • Electrosurgical Loop (LLETZ and LEEP):
    The electrosurgical loop (LLETZ – large loop excision of the transformation zone; LEEP – loop electrosurgical excision procedure) is a simple and commonly used instrument. A metal wire loop heated by electricity is used to excise the altered tissue. This procedure is also performed under local anesthesia.

Pre-Operative Instructions:

  • Complete the tests prescribed by your doctor at least two weeks before the surgery.
  • Inform your doctor of any health conditions (e.g., allergies, heart conditions, congenital or chronic diseases) before the operation.
  • Fast for at least 6 hours before surgery if it is to be done under intravenous anesthesia, to prevent stomach content aspiration.
  • Consult your doctor about whether you can take your regular medications before the operation. If you take medications for high blood pressure or other conditions, you should take them with a small amount of water no later than 2 hours before the procedure.
  • If you have bleeding disorders or take blood-thinning medications, inform your surgeon, preferably during the first visit. Avoid aspirin (or any medications containing aspirin) for two weeks before surgery.
  • Notify your doctor about any unexpected health changes before the surgery (e.g., cold, cough, fever, infection, or flare-up of chronic diseases). The surgery might need to be postponed for your safety.
  • Inform your doctor if you are pregnant or suspect that you might be.

Complications

Like any surgical procedure, cervical conization may lead to complications, which can be classified into:

  1. Early complications (during or immediately after the procedure):
    • Severe bleeding that cannot be controlled may require a more extensive surgery.
  2. Late complications:
    • Persistent vaginal bleeding (2-8%).
    • Foul-smelling vaginal discharge (2-11%).
    • Fever and/or chills (0.2-2.1%).
    • Lower abdominal pain (3-4%).
    • Cervical stenosis or spasms, leading to blood accumulation in the uterus and pain (0.45-2.3%).
    • Endometriosis of the cervix (0.11-2.4%).
    • Cervical stenosis (3-8%).
    • Rare, but severe complications due to hypersensitivity to anesthesia medications, including anaphylactic shock or clinical death due to sudden cardiac arrest.
    • Cone biopsy may increase the risk of infertility and pregnancy complications due to changes and scarring in the cervix.

Post-Operative Instructions for the Patient:

  • Most women feel well after the procedure and return to their daily activities the same or the next day.
  • Expect mild bleeding for 3-4 weeks after treatment. During this period, it is recommended to:
    • Avoid sexual intercourse for about 4 weeks.
    • Do not use tampons during your first menstruation after the procedure.
    • Watch for any reactions that may occur, such as watery discharge that may persist for up to 3-4 weeks or mild bleeding as the scab falls off.
    • Foul-smelling discharge indicates an infection, which should be treated with vaginal suppositories or, sometimes, antibiotics.
  • Follow a mild recovery regimen: avoid baths, swimming pools, or open water bodies; shower only. Avoid direct sun exposure, tanning, or saunas, as these could provoke excessive bleeding.
  • If you experience heavy bleeding, fever, or severe abdominal pain, contact your healthcare provider immediately.
  • A follow-up cervical cytology (PAP smear) should be performed after the procedure. The frequency of further PAP tests depends on the results of the histological examination.

 

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