China is the most affected area by cervical cancer, with about 130,000 new patients with invasive cancer each year, accounting for a quarter of the total cases worldwide. In recent years, with the popularity of cervical cytology screening and humanpapillomavirus (HPV) high-risk type testing and increased social awareness, many potential cervical cancer patients have been detected and treated at the precancerous or microscopic early infiltration stage. Since these patients are often young and have fertility requirements, the ancient procedure of cervical conization has gained new widespread attention and application. CKC and LEEP history Cervical conization is the use of scalpel cone to remove part of the cervical tissue, the traditional procedure is coldknifeconization (CKC), which has been used for the diagnosis and treatment of cervical lesions for hundreds of years. . After colposcopy became popular, many tried colposcopic multipoint biopsy instead of most CKC, and the introduction of physical therapy such as freezing and laser in the 1960s led to a decline in the number of CKC procedures. In subsequent practice, there have been occasional reports of missed invasive cancers. benedet et al [1] found that 15.9% of microinvasive cancers and 10.4% of stage Ib cervical cancers were missed in examinations considered satisfactory by colposcopists. wun et al [2] found 11 cases (4.4%) of cervical cancers missed at conization in 248 patients who had undergone hysterectomy. There is a growing awareness of the irreplaceable nature of conization. The LoopElectrosurgical Excision Procedure (LEEP), a conical excision of cervical tissue using a metal ring with high-frequency current, was introduced by Cartier in 1981 and modified by Prendiville et al. in 1989 with the use of a large electric ring to excise the migrating zone of the cervix ( LargeLoop Excision of Transformation (LLETZ). Because LEEP is easy to perform and has few complications, it has been widely used at home and abroad in the last 20 years, replacing most CKC as an important procedure for the treatment of CIN and diagnosis of cervical cancer. The simplicity of LEEP has led to the relaxation of the indications for conization, and it has even been abused in some benign cervical lesions, and there is a lack of corresponding treatment norms for cervical conization in China. The main purpose of conization is to treat cervical precancerous lesions and diagnose early cervical cancer, therefore, it is very important to clarify the concept of precancerous lesions. The concept of cervical precancerous lesions originated from the cervical intraepithelial neoplasia (CIN) and its grading proposed by Richart in 1967. After it was clear that HPV plays an important role in the development of cervical cancer, it was found that only CIN grade II, grade III and cervical invasive cancer were associated with high-risk HPV and only 1% of untreated CIN grade I lesions progressed to invasive cancer; grade II and III lesions progressed to invasive cancer in 5% and more than 12%, respectively [3], therefore, it is now commonly considered that cervical precancerous lesions include only CIN grade II and CIN grade III. In the 2014 WHO classification of the female reproductive system, squamous intraepithelial lesion (SIL) is recommended for nomenclature and is divided into two grades: low-grade squamous intraepithelial lesion (LSIL) and high-grade squamous intraepithelial lesion (High gradesuamous intraepithelial lesion ,HSIL) [4]. At the initiative of pathologists, CIN grade II and III were aligned with HG SIL in the TBS cytology report, but cytologic diagnosis of HG SIL cannot replace colposcopic biopsy and cone histology as a diagnostic basis for cervical precancerous lesions. Third, the surgical indications of conization literature reports that the cure rate of conization for CIN is 87-98%, in addition, conization is also an important means to diagnose early cervical cancer staging. Based on the three-step process of cervical cancer screening: cervical cytology screening colposcopic multi-point biopsy cone biopsy, conization is the last line of defense against cervical cancer, therefore, its indications are based on colposcopic biopsy pathology, including: ① patients with CIN grade II and III lesions clearly diagnosed by colposcopy and requiring uterine preservation; ② unsatisfactory colposcopy, meaning that the migrating zone cannot be fully exposed. mostly in older patients; ③ lesions located in the cervical canal, which are difficult to diagnose clearly by colposcopy; ④ TCT results do not match with colposcopic biopsy pathology, such as multiple HG SIL, which is not supported by colposcopic biopsy; ⑤ positive cervical canal scraping, suggesting that lesions may be located in the cervical canal; ⑥ colposcopic pathology suspicious of invasive carcinoma, in order to clarify the depth and breadth of lesions; ⑦ pathology suggesting microfocal invasive carcinoma (stage Ia1 cervical cancer) or adenocarcinoma in situ of the cervix that requires preservation of reproductive function. There are controversies about the contraindications of conization. Some believe that conization should be avoided in patients with highly suspicious invasive carcinoma to avoid inflammatory edema after conization, which may cause difficulties in radical surgery, but most physicians believe that total hysterectomy for suspicious invasive carcinoma may lead to inappropriate scope of surgery, and conization is necessary to clarify the extent of the lesion. In fact, due to vaginal manipulation, severe vaginal stenosis and cervical atrophy, especially in postmenopausal patients without vaginal trial or delivery, conization is difficult to perform and becomes a de facto contraindication, when careful and meticulous imaging evaluation becomes the only option to avoid improper surgical scope in the case of suspicious invasive carcinoma. The surgical steps of CKCCKC include: 1. EndocervicalCurettage (ECC); 2. Iodine staining of the cervix with Lugol’s solution to determine the iodine unstained area; 3. Tapered excision of the cervical tissue at 7.5 px outside the iodine unstained area to a depth beyond the squamocolumnar junction; 4. 12-point biopsy of the pathological specimen. Avoid destroying the marginal tissue of the excised specimen with electrocautery during surgery to avoid affecting the pathological judgment. In order to prevent intraoperative bleeding, some physicians adopt thick silk sutures in the lower branches of the uterine artery at 3 and 9 points of the cervix before conization to prevent bleeding. Postoperative pressure with iodoform gauze is mostly used to stop bleeding, or ruffled sutures are used to stop bleeding. In patients who do not undergo ECC at colposcopy, if the cervical lesion can be adequately exposed, ECC is not a mandatory step for CKC and should be routinely performed if the squamocolumnar junction is located in the cervical canal. Despite the clear indications and positive efficacy, the disadvantages of conization are also very prominent, and complications such as bleeding, infection and cervical sclerosis, cervical insufficiency, and preterm delivery have been reported in the literature [5], and in younger patients because of uterine better blood flow, the complication rate is higher. In contrast, in clinical applications, the pathological diagnosis of conization for cervical invasive carcinoma is often returned only a few days after surgery, when the inflammation and edema of the surrounding tissues caused by the procedure adds to the difficulty of further radical surgery. In addition, there is a risk of lesion remnant and recurrence after conization. Due to the infection of high-risk HPV, the possibility of reoccurrence of invasive carcinoma after conization in CIN patients treated with conization is 4-5 times higher than that in normal population, with an average of 8 years of occurrence, so patients with CIN treated with conization should be followed up for up to 10 years. Although fertility can be preserved, conization has many effects on subsequent pregnancies, and the rate of spontaneous abortion, preterm birth and low birth weight babies are significantly higher in women after conization. V. LEEPLEEP is a conical biopsy using a high-frequency electric knife. With different sizes and shapes of electric cutting rings, different sizes of tissues can be removed to achieve the purpose of eradicating CIN. Compared with CKC, LEEP has outstanding advantages, easy to operate, no anesthesia is needed, the operation can be carried out in the outpatient clinic, because the hemostasis while cutting, less bleeding, fast healing of the postoperative wound, the inflammation and edema of the pelvic tissue caused by it is also very light, which creates good conditions for future radical surgery again. In addition, the greatest advantage of LEEP is that the cervical interstitium is preserved as much as possible, which can effectively reduce cervical insufficiency. Studies have found that all indicators of preterm delivery, low birth weight babies, and cesarean delivery in postoperative pregnancies are better in LEEP patients than in CKC patients. Many reports have shown that LEEP does not lead to secondary infertility and adverse pregnancy outcomes [6]. The cure rate of LEEP for CIN, which is similar to that of CKC, is between 81% and 98% for the same conization technique. Based on these advantages, LEEP is undoubtedly the best choice for the treatment of cervical precancerous lesions. However, due to the limitation of LEEP excision depth, it is debatable whether it can replace CKC for patients with extensive CIN grade III lesions that do not completely exclude invasive carcinoma and for patients who cannot fully expose the migratory zone. The reasons for this are twofold: 1) the impact on pathology and 2) the limitation of resection depth. Although the high-frequency electrical energy of LEEP can rapidly solidify the tissue, many pathologists still believe that the heat and electrical energy destroy the marginal tissue of the specimen to a certain extent, which makes it more difficult to determine whether the margins are cut cleanly, especially for specimens with highly suspicious invasive carcinoma, which requires higher accuracy for pathological diagnosis and margin determination. Similarly, the limitation of the depth of LEEP resection is not suitable for patients who cannot adequately expose the migrating zone or whose lesions are located in the cervical canal. The literature reports that approximately 60% of CIN grade I lesions degenerate and only 1% progress to invasive cancer, and many foreign sites do not treat CIN grade I patients aggressively. In China, patients in many areas have difficulty doing close review and often use physical therapy for patients with CINI grade I. After the introduction of LEEP, many places have included CIN grade I in LEEP treatment. How to grasp it can be referred to the CIN treatment consensus published by Bethesda in 2006. Since the vast majority of degeneration of CIN grade I occurs within 2 years, the indications for diagnostic conization of CIN grade I are: (i) CIN grade I lasting 2 years with satisfactory colposcopy can be treated with physical therapy or diagnostic conization; (ii) CIN grade I lasting 2 years with unsatisfactory colposcopy should be treated by conization without physical therapy; ③CINI grade should be treated by conization if HG SIL or AGCNOS is suggested in repeated TCT review. The risk of residual lesion and recurrence exists after conization, and it is generally considered that CIN found within 3 months after conization is considered as residual lesion, and after 3 months is considered as recurrence. It was observed that the margins of the conization specimens mostly had CIN, and the recurrence rate was 20-29%. If the margins are found to be unclear, whether to choose conservative observation or further treatment should be carefully considered whether there are high-risk factors, including: ① The level of residual lesions: if advanced lesions remain in the margins, most scholars advocate that secondary LEEP or CKC treatment should be performed to avoid missing invasive carcinoma. ) were IA1 microinvasive carcinomas. For marginal residual low-grade lesions (CIN grade I) the literature reports no significant difference in the cure and recurrence rates, so conservative observation is advocated. ②HPV test: If negative, then conservative observation is possible; if positive, then there is a high possibility of residual disease and high risk of recurrence, and active management is advocated. ③Tumor extent and growth pattern: It was found that patients with positive ECC and spherical root-like growth of tumor with central necrosis are more likely to have residual lesions and risk of recurrence. For patients with uncut margins and the above-mentioned high-risk factors, re-cone or total hysterectomy is a feasible treatment option. In addition, patients with HPV infection and cervical cancer are still at high risk after conization, and the literature reports that 40~90/100,000 women with CIN develop invasive cancer after treatment, which is 4~5 times more than the normal population, with an average of 8 years. After 2 years, the follow-up should be once a year. The follow-up includes cervical smear, colposcopy, endometrial biopsy, etc. The chance of lymph node metastasis in highly differentiated FIGO stage Ia1 cervical cancer without lymphovascular space invasion (LVSI) is almost zero, therefore, the NCCN guidelines point out that stage Ia1 cervical cancer patients with fertility requirements without LVSI can be treated by conization, if Negative cut margins can be followed up and observed. It is worth emphasizing that the pathological type of tumor includes squamous cell carcinoma, adenocarcinoma or adenosquamous carcinoma, and small cell neuroendocrine tumors should be excluded. Domestic and foreign literature reported that the long-term recurrence rate of cervical conization for the treatment of stage Ia1 cervical cancer is 0.35%~10.3%. VIII. Other conization treatments for early cervical cancer Due to the rejuvenation of cervical cancer in recent years, the treatment of early cervical cancer to preserve reproductive function has become a great challenge for gynecologic oncologists. In recent years, it has been reported [8] that in patients with early-stage cervical cancer, approximately 65% of the lesions have been completely removed after diagnostic conization, and the incidence of parametrial infiltration is only 0.6% when the tumor lesion is ≤2 cm, the depth of infiltration is ≤1 cm, and there is no metastasis in the lymph nodes; therefore, some physicians advocate that for some low-risk patients such as those with tumor lesions <50px< span="">, the patients with better cell differentiation and no LVSI to perform non-extensive hysterectomy, i.e. surgery with pelvic lymph node (or sentinel lymph node) dissection first, followed by major conization or simple hysterectomy if no metastasis is detected. Although not well reported, preliminary data suggest that the results are comparable to those of extensive hysterectomy.Rob et al [9] originally proposed this procedure in 2007, performing laparoscopic sentinel lymph node biopsy and pelvic lymph node dissection in patients with stage IA1IB1 (lesions <50px< span="">) to ensure no lymph node metastases, followed by macroconjunctomy in 10 patients (stage IA1 with LVSI and IA2) and 24 patients underwent simple hysterectomy (IB1), and after a mean follow-up of 47 months, only 1 recurrence, 17 pregnancies and 11 deliveries were recorded. This procedure has been explored by both domestic and foreign clinical workers, and in general, the feasibility and pregnancy rate of this procedure are high, but because of the small number of cases, there is no clear evidence on safety, and prospective and bulk studies are expected. In conclusion, conization is still an irreplaceable main treatment for CIN and an important diagnostic method for cervical cancer, and despite the outstanding advantages of LEEP, it is still not a complete substitute for the traditional CKC procedure. Strictly grasping the indications and correctly performing conization are important measures for the prevention and treatment of cervical cancer.