Conical hysterectomy (conization) is a procedure in which a portion of the cervix is removed in a conical shape from the outside to the inside. According to the authoritative view, the number of conical excision performed in a hospital can reflect its level of treatment for cervical cancer to some extent. However, some patients do not understand, thinking that it is going to become cancer, so why not just cut the uterus off, why suffer twice? But you can’t do that, at least in two ways.
On one hand, the reason why it is called precancerous lesion means that it is not cancer after all. It’s just that if it is not treated, it will become cancerous after a period of time (3-8 years on average). Moreover, “cervical lesion” is still a problem of the “cervix” itself after all, unless it develops into advanced cervical cancer, which usually does not hurt the uterus. Therefore, in most cases, conization is sufficient and there is no need to remove the uterus. In young women with precancerous cervical lesions, it would be over-treatment to remove the uterus!
On the other hand, for certain early stage cervical cancers (termed stage IA1, IA2, or IB1 in technical terms), if a direct hysterectomy is performed and it turns out to be stage IA1 cervical cancer, it is of course very lucky because a total hysterectomy is just right! But if unfortunately it is stage IA2 or IB1, then it is a problem. Because in this case, hysterectomy alone is not enough, some tissues next to the uterus should also be removed (i.e. extended hysterectomy). It is very difficult to perform further remedial surgery at this point and is very injury prone.
1. Cervical conization and colposcopic multi-point biopsy
At one time it was thought that the results of colposcopic multi-point biopsy were not different from the pathological results of conization and could replace the latter, but in recent years it is believed that the two cannot replace each other. First, cervical lesions are characterized by multicentric pathogenesis, and the difference between multi-point biopsy and conization series is similar to the difference between “point” and “surface”. Secondly, multi-point biopsy is often superficial, so it is difficult to judge the presence or absence of infiltration and the depth of infiltration.
2.General electric knife cervical conization, cold knife conization and LEEP
Initially, cervical conization was performed by scalpel (i.e. cold knife conization), which has the advantage of clear cutting edge and facilitates pathological examination. In recent years, loop electrosurgery of the cervix (LEEP) has been widely performed, with the advantage of being simple and easy to perform, but the adequacy of the cutting depth has been questioned, and LEEP itself has no cervical molding effect. Because of previous concerns about the electric current damaging the cutting edge, the electric knife conization has not been advocated. In recent years, it is believed that the effect of electrodebrider conization is comparable to that of cold knife conization, but with less bleeding. After adopting techniques such as submucosal injection of dilute epinephrine saline, control of electric knife power, vertical cutting and rapid cutting, the electric knife does not affect the observation of the cutting edge.
3.Surgical indications of cervical conization: therapeutic and prophylactic
The main target of therapeutic cervical conization is CIN2-3. for CIN1 and non-CIN lesions, conization is generally not recommended. The indications for diagnostic cervical conization include.
(1) Cervical biopsy does not exclude early invasive carcinoma, in order to clarify the diagnosis and determine the scope of surgery.
(2) Cytology and colposcopy do not match: cervical cytology reveals malignant cells, colposcopy is CIN1 or non-CIN lesion, cervical biopsy or segmental scraping of the cervical canal is negative;
(3) TCT reveals atypical glandular cells or suspected cervical adenocarcinoma.
4.The surgical scope of cervical conization: width and depth
In fact, the length of the cervical canal in infertile uterus is about 2 cm, and the cervical migration zone is closer to the ectocervix in young women under the influence of estrogen. Therefore, for young patients with CIN3/CIS, a cone height of 2 cm is theoretically sufficient for conization as a therapeutic purpose, and some studies even suggest that a cone height of more than 1.5 cm is sufficient. For patients suspected of early invasive cancer, conization is mainly to provide information for the follow-up treatment, and usually treatment is not completed by conization, so it is not necessary to cut too deep; for patients who need to preserve their fertility, too large a cone height may also increase the risk of postoperative cervical insufficiency, miscarriage and preterm delivery.
5, follow-up treatment of cervical conization: comprehensive consideration
The pathology of conization is the main basis for the selection of follow-up treatment, and should be combined with the patient’s age, fertility requirements, follow-up conditions and cutting edge.
(1) For patients with CIN2 or less lesions, follow-up is sufficient.
(2) For CIN3 and carcinoma in situ, if the patient is old, has poor follow-up conditions, and has no reproductive requirements, extra-fascial total hysterectomy is feasible; if the patient has reproductive requirements and has negative cut margins, follow-up is observed.
(3) For stage Ia1 invasive carcinoma of the cervix, if the patient is young or has fertility requirements and the cut margin is clean, follow up and promote fertility. If the cut margin is not clean, repeat conization and promote fertility; if the patient is old and has no fertility requirement, total hysterectomy is feasible.
(4) For patients with cervical invasive carcinoma stage Ia2 to Ib1, unless the patient has a very strong desire to have children, radical hysterectomy can be attempted, and extensive hysterectomy and pelvic lymph node dissection or radiotherapy should be performed.
Therefore, for patients with colposcopic biopsy diagnosis of cervical intraepithelial neoplasia (i.e., CIN) grade 2-3, conization is usually required for a full evaluation or as treatment. For those with colposcopic biopsy reports of carcinoma in situ, no exclusion of infiltration, or unclear depth of infiltration, it is even more important to determine the depth of infiltration by conization.