Loop Electrosurgical Excision Procedure for Treating Cervical Intraepithelial Neoplasia

CHAPTER 149 Loop Electrosurgical Excision Procedure for Treating Cervical Intraepithelial Neoplasia

Thomas C. Wright, Jr.

A variety of techniques can be used to treat cervical intraepithelial neoplasia (CIN). The appropriateness of a particular technique to treat a particular lesion depends on a number of factors, including lesion size, location, and extension into the endocervical canal. Many clinicians now use the loop electrosurgical excision procedure (LEEP) to treat most women with biopsy-confirmed CIN 2 or CIN 3. With LEEP, thin wire loop electrodes are used to excise the entire cervical transformation zone. This procedure is referred to by a number of different names, including loop electrosurgical excision procedure (LEEP), large loop excision of the transformation zone (LLETZ), and loop excision. Many clinicians subdivide LEEP into two procedures: (1) routine LEEP, which is used to excise lesions confined to the exocervix (or visible portion of the cervix), and (2) LEEP conization, which is used when lesions extend into the endocervical canal. LEEP has a number of advantages over other treatment modalities for CIN, including the following:

• The equipment is less expensive than laser equipment.
• The entire lesion is excised and can be assessed histologically to rule out invasive cancer.
• Patients can be diagnosed and treated in a single office visit.
• It allows cervical conization to be performed in the office at a significantly reduced cost (LEEP conization).
• Complications are few for the procedure itself, but it can affect future pregnancies.

Anatomy

The anatomy relevant to the LEEP is reviewed in detail in Chapter 137, Colposcopic Examination. As the procedure involves complete removal of the transformation zone, it is important to understand the anatomy of the cervix, including normal and abnormal appearances. In most circumstances, a colposcopy will be completed prior to the LEEP to define the anatomy of the cervix.

Indications

The following indications are based on the 2006 American Society for Colposcopy and Cervical Pathology (ASCCP) guidelines that are reproduced in Appendix K, Management Guidelines for Abnormal Cervical Cancer Screening Tests and Histologic Findings. Several options are given for treatment of most of these indications. This chapter presents the possible indications for the LEEP.

Routine LEEP

• Biopsy-confirmed CIN 2 or CIN 3 and a satisfactory colposcopy
• High-grade squamous intraepithelial lesion (HSIL) on referral cytologic examination that is immediately treated in a patient over age 20 (“screen and treat”)
• Persistent HSIL on screening for 6 to 12 months (without CIN 2 or 3 documented by biopsy)
• CIN 1 on biopsy after screening result of HSIL or atypical glandular cells–not otherwise specified (AGC-NOS)

When several treatment options exist with the treatment guidelines, LEEP is preferred over ablative therapies such as cryotherapy in the following conditions:

• High-grade lesion involving three or more quadrants
• Complex-appearing CIN 2 or 3 with prominent abnormal vessels
• Lesion is not covered by cryoprobe
• Ectocervix is irregular
• Patients have recurrent CIN after previous therapy (e.g., cone biopsy, LEEP, cryotherapy)

LEEP Conization

• Unsatisfactory colposcopy in women with biopsy-confirmed CIN of any grade (e.g., cannot see entire lesion, squamocolumnar junction [SCJ], or transformation zone [TZ])
• HSIL on referral cytologic examination and unsatisfactory colposcopy
• HSIL on referral cytologic examination with satisfactory colposcopy and either no CIN or only CIN I identified (“lack of correlation principle”)
• Positive endocervical sampling (e.g., neoplasia of any grade present)
• Microinvasive lesions on cervical biopsy

Contraindications

Relative

• Bleeding diathesis
• Patient exposed in utero to diethylstilbestrol
• Patient fewer than 12 weeks after delivery
• Equivocal cervical abnormalities
• Heavy menses
• A preexisting short cervix (clinician should consider referral)
• Patients with pacemakers (special precaution necessary)
• Severe cervicitis

Absolute

• Pregnancy
• Clinically apparent invasive carcinoma of the cervix
• Lack of expertise to control potential severe cervical bleeding

Equipment and Supplies

• Electrosurgical generator or unit (ESU) (Fig. 149-1) with the following features:
• Minimum output capability of 50 watts in both cutting and coagulation modes
• Rapid-start features
• Patient grounding pad monitor (beneficial if the patient is under anesthesia)
• Isolated circuitry

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Figure 149-1 Electrosurgical units used for loop electrosurgical excision procedure (LEEP). A, Utah Medical electrosurgical unit. The smoke evacuator is included in the basic unit. B, CooperSurgical LEEP unit. C, Ellman Surgitron with handpiece, electrodes, antenna plate, and foot pedal.

(A, Courtesy of Utah Medical Products, Inc., Midvale, UT. B, Courtesy of CooperSurgical, Trumbull, CT. C, Courtesy of Ellman International, Hewlett, NY.)

EDITOR’S NOTE: Although the Ellman Surgitron does not meet some of these qualifications, it has been used extensively for the LEEP.

• Loop electrodes of the appropriate size and a ball electrode for fulguration (Fig. 149-2). (These electrodes can be either of the disposable or of the reusable variety.)

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Figure 149-2 Wire loop electrodes for loop electrosurgical excision procedure (LEEP). A, Loop electrodes come in a variety of sizes and shapes. B, Ellman electrodes. C, Utah Medical electrodes with an optional adjustable stop to limit depth (middle, green-handled loop). D, Fischer electrode, which removes more of a conical piece.

(A–C, Courtesy of The Medical Procedures Center, PC, John L. Pfenninger, MD.)

It is recommended that clinicians use only the shallow loop electrodes (i.e., either 0.8 or 1.0 cm deep) for routine LEEP. Larger electrodes can be used with large cervices or when lesions extend into the endocervical canal (e.g., LEEP conization). A variation is the Fischer electrode, which provides a true “cone” specimen.

• Electrode handle and a patient return electrode (grounding pad or antenna).
• Nonconductive speculum (either coated with a nonconductive material or made of plastic) capable of being used in conjunction with a smoke evacuator (Fig. 149-3).
• Smoke evacuator equipped with an adequate viral and odor filter.
• Colposcope capable of low magnification (4× to 7.5×).
• Nonsterile gloves.
• Acetic acid (5%).
• Full-strength aqueous Lugol’s solution.
• Cotton balls and large OB-GYN applicators.
• Ring forceps.
• Syringe (5 mL) with 4-inch needle extender and image-inch, 25-gauge needle as well as 5 mL of 2% lidocaine with epinephrine, or dental type of syringe equipped with a 25- to 27-gauge needle at least image inches long with two 1.8-mL ampules of 2% lidocaine with 1:100,000 epinephrine (Fig. 149-4).
• Coated vaginal sidewall retractor (arrow, see Fig. 149-3).
• Kevorkian endocervical curette.
• Monsel’s paste, which is made by allowing Monsel’s solution to evaporate until it forms a thick yellow paste.
• Containers of histologic fixative (usually 10% formalin).
• A 12-inch needle holder and 2-0 Vicryl suture material together with a vaginal pack in the event that large-vessel bleeding occurs.
• Power examination table with adjustable height (recommended).
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Figure 149-3 Coated instruments to prevent electrical shocks. Vaginal sidewall retractors (arrow) are essential in many cases to avoid lacerating the vaginal walls. Three different vaginal speculums are on the left, each with a vented tube to attach to the smoke evacuator tubing.

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Figure 149-4 A, Needle extender (5 inch). B, Needle extender placed on the end of a 5-mL syringe with 25-gauge, image-inch needle attached.

(Courtesy of The Medical Procedures Center, PC, John L. Pfenninger, MD.)

Precautions

It is imperative that the LEEP not be used to excise the TZ indiscriminately in women with atypical Papanicolaou (Pap) smears. The procedure should be reserved to treat advanced lesions as per the established indications, not just atypical Pap smears or CIN 1. CIN 1 has a high rate of regression and should usually be observed or treated with less invasive options. Cryotherapy is less expensive, has fewer complications, and has equal outcomes in properly selected patients (while at the same time removing less tissue) (see Chapter 138, Cryotherapy of the Cervix). Cold-knife conization is preferred when conization is being performed for a glandular abnormality.

Preprocedure Patient Education

• Provide a patient education handout (see the sample patient education handout online at www.expertconsult.com).
• Instruct the patient to take 600 to 800 mg of ibuprofen or a preferred nonsteriodal anti-inflammatory drug 1 to 2 hours before the procedure.
• Obtain informed consent.

Procedure

The procedure is best performed immediately after menses so that any vaginal bleeding is not confused with menses.

1 Have the patient undress from the waist down and lie on the gynecologic examination table. It is important that the patient not move, cough, or change position once the excision is started. Thus, a cooperative patient is essential.
2 Attach the patient return electrode grounding pad to the patient’s thigh and connect the grounding pad to the ESU (or place the “antenna plate” under the hip).
3 Insert a nonconductive speculum with the smoke evacuator attachment into the vagina and connect it to the smoke evacuator. It is important that the speculum be large enough to allow complete, unobstructed visualization of the cervix. If the vaginal sidewalls remain in the way, use a vaginal sidewall retractor (Fig. 149-5, and see Fig. 149-3).
4 Apply the acetic acid solution, examine the cervix colposcopically, and identify all lesions and the TZ.
5 Apply full-strength Lugol’s solution to the cervix (this lasts longer than acetic acid). Use cotton balls or a large OB-GYN applicator.
6 Inject approximately 0.5 to 1.5 mL of 2% lidocaine with epinephrine 1 : 100,000 intracervically (submucosally) at each of the 12, 3, 6, and 9 o’clock positions (to a total of 2 to 6 mL), usually just outside the TZ. Take care to inject the cervix superficially, only 3 to 5 mm deep. Additional injections may be needed at intervals between those noted previously, depending on the size of the cervix.

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May 14, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Loop Electrosurgical Excision Procedure for Treating Cervical Intraepithelial Neoplasia

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