> Surgical procedures and complications
Surgical procedures and complications
LEEP procedures are usually performed with one of three loop sizes. The smaller the loop required to remove all the dysplasia, the less chance of surgical complications. In addition, increased experience of the doctor can improve your chances of escaping surgical complications. Perhaps the most frequent complication is just plain failure to cure the problem, and with each additional LEEP the chance of complications increases significantly.
A cone biopsy is done with a knife to remove the cervical tissue next to, and deeper into, the cervical canal.
LEEP and cone biopsy complications are relatively rare, but if they occur they can be disastrous. Usually your doctor will ask you to postpone pregnancy until one year after a LEEP or cone biopsy so that the cervix can fully heal from the surgery. Nevertheless, cervical incompetence sometimes occurs, in less than 5% of cases, and makes it difficult to carry pregnancies to term (resulting in miscarriages) because the cervix is too thin to keep the uterus closed during the later stages of pregnancy. Infection can occur following a LEEP or cone biopsy. Pelvic discomfort during the procedure and cramping afterwards is common. A cone biopsy may remove more tissue than a LEEP and is generally used when dysplasia in the cervical canal is suspected to go beyond the reach of the LEEP.
As far as complications from a LEEP are concerned, that is not as significant as the recurrence rate of cervical dysplasia. Stenosis, the most frequent complication, occurs in less than 5% of cases. Stenosis (shrinking of the cervical canal) can occur due to scarring. Stenosis is more common with a cone biopsy, however, because the cone biopsy does not allow for much control in respect to the incision depth and angle.
J Gynecol Obstet Biol Reprod (Paris) 1997;26(1):64-70:
Consequences and treatment of cervical stenoses after laser conization or loop electrosurgical excision.
Baldauf JJ, Dreyfus M, Wertz JP, Cuenin C, Ritter J, Philippe E. Service de Gynecologie Obstetrique I, Hopital de Hautepierre, Hopitaux Universitaires, Strasbourg.
"Objective: To assess the frequency and the consequences of cervical stenosis in patients treated by laser conization or loop electrosurgical excision procedure (LEEP) and to analyze the results of cervical enlargement plastic surgery or neostomia.
Methods: Two hundred and fifty-five women treated by laser conization and 277 by LEEP were regularly followed by postoperative colposcopy, for a mean period of 38 and 16 months, respectively. Stenosis was defined as cervical narrowing which could not admit a 2.5 mm-diameter Hegar's dilator.
Results: Stenosis complicated 10.2% of the laser conizations and 4.3% of the LEEP. Thus, 38 cases of cervical stenosis of which 7 were complete were diagnosed 2 to 40 months after treatment. Among the 34 non-menopaused women who developed a stenosis, 5 had a secondary amenorrhea, 6 a severe dysmenorrhea and one an infertility. In the patients with stenosis, endocervical cell retrieval was possible in 21 (55%) cases and in none the squamocolumnar junction was visible at colposcopy. Seven patients underwent an enlargement plastic surgery of the cervical canal for incomplete stenosis and two a neostomia for complete stenosis. Cervical restenosis has been observed in 7 of 9 cases in a mean delay of 12 months (3 to 48 months). Nevertheless, the endocervical cell retrieval remained possible in 8 of 9 cases and after a mean follow-up of 26 months no menstrual troubles recurred.
Conclusion: LEEP provides fewer cases of cervical stenosis than laser conization. The enlargement plastic surgery creates does relieve the menstrual troubles in spite of the very frequent restenosis."
Unfortunately, some women may be operated on several times a year until the dysplasia is gone for a while. I believe these procedures are effective in no more than 75% of cases when followed-up for a few years. Even a hysterectomy does not always cure the problem. Some women will continue to have abnormal Paps and dysplasia of the vaginal wall following a hysterectomy in which the entire cervix and uterus are removed because a hysterectomy does not remove the HPV.
The incidence of recurrence of cervical dysplasia following LEEPs is 15% in women with clear margins in the specimen and 39% in those women without clear margins. Therefore, it does not appear that the removal of all infected tissue is absolutely critical. What is important is that some of the cells harboring the HPV virus are disrupted during surgery thus allowing the host's T-cells a good look at the HPV virus. If the T-cells are able to identify the HPV, then they can make specific transfer factor against that virus and attack it inside the cells. This is why all these surgical procedures work to some degree and one is not significantly more successful than the other. It may be more effective if the surgeon were to use a fine wire brush and just scraped up the cervix a bit, thus disrupting the cervical epithelial cells and exposing the HPV.
Cervical epithelial cells are referred to as poor APCs (antigen presenting cells) because they do not do a good job of presenting the antigen (HPV in this case) to the T-cells. Even though some doctors are not able to remove all the obviously infected cervical tissue during a LEEP, it really does not matter as far as recurrence is concerned. It is impossible to tell during the procedure where the margins are in every case. The pathologist looks at the specimen under a microscope and can easily tell what he has, but during surgery it is another matter altogether. If you decide to have surgery, I would recommend laser vaporization or cryosurgery, because less damage is usually done to the cervix.
I prefer cryotherapy to other surgical methods, if surgery must be done for cervical dysplasia, because it does not cause cervical incompetence. Following cryotherapy, most doctors will advise patients to avoid sex for 4-6 weeks during which time patients will experience a watery/bloody discharge. Cryotherapy actually improves the cervical mucus characteristics which increases fertility:
Fertil Steril 1985 Jan;43(1):86-9:
Treatment of cervical ectropion by cryosurgery: effect on cervical mucus characteristics.
Baram A, Paz GF, Peyser MR, Schachter A, Homonnai ZT.
"Eighteen women with cervical ectropion and 12 women with ectropion and vaginal discharge were treated by cryosurgery. Evaluation of the cervical mucus characteristics by cervical score and in vitro penetration test was performed before treatment and 2 months later. It appears that cryosurgery improves the cervical mucus characteristics. It is recommended that infertile patients with hostile cervical mucus and ectropion will be treated by cryosurgery."
The effect of cryotherapy on the ability to carry pregnancies to term was evaluated in the following study:
Br J Obstet Gynaecol 1982 Aug; 89(8):675-7:
Outcome of third trimester pregnancies after cryotherapy of the uterine cervix.
"A retrospective study was undertaken to assess the effect of cryotherapy of the uterine cervix on the outcome of third trimester pregnancies. It was concluded that cryosurgery of the cervix had no effect on the onset or progress of labor, or on the infant, an important advantage compared with cold-knife conization as a therapy for young women with cervical intraepithelial neoplasia."