Cervical conization: Use of a specific technique Gynecology in 200 consecutive cases

RICHARD H. SHERMAN, D.O. EDWIN ABBOTT, D.o. Columbus, Ohio

Conization of the has been a The value of cold conization of the cervix has controversial procedure for a been recognized for many years, but as the long time. Although the advantage of popularity of the procedure increased its high morbidity became obvious, and many surgeons cold conization in providing a attempted to develop techniques that would tissue specimen for diagnostic study has reduce morbidity while preserving the diag- long been recognized, the procedure nostic and therapeutic value of the procedure. heretofore has been accompanied Results still were not satisfactory, however, by significant morbidity. This article and many physicians have reserved the pro- describes experience with a cedure for cases in which the probability of malignant change is strong. technique for cold conization that has On the basis of experience with a technique both therapeutic and diagnostic developed by Layton S. Shaffer, D.O., however, value and little associated morbidity. The it appears that morbidity need not be high, cone obtained with this and the procedure may be used not only for procedure is large, averaging 2.1 the diagnosis of malignant change but as a cm. in width and 2.5 cm. in length. The form of therapy for chronic cervical infections that are not responsive to conservative mea- frequency of residual carcinoma sures. at after conization was 22 percent. The total morbidity Materials and methods was only 6.5 percent in 200 patients. The A retrospective study was made of 200 con- low incidence of significant secutive conizations performed by Dr. Shaffer blood loss is attributed to the use or one of his residents from the middle of 1966 to the latter part of 1968. of the Duprey tenacula for traction on The 200 women were private patients who the cervix, the cherry red, light complained of vaginal discharge, abnormal cautery employed, and packing with bleeding, amenorrhea, or pain or who had an Surgicel. The frequency of abnormal Papanicolaou smear without symp- cervical stenosis compares favorably toms referable to the genital tract. None of with that of other investigators. the patients were pregnant. More than half had Papanicolaou smears of Class I, and 35 The diagnostic reliability of percent had smears of Class II or higher. the technique is comparable to that Patients were admitted the day before con- reported elsewhere. The ization for routine laboratory work and work- therapeutic value of the procedure up and were given a regular diet. Cleansing is indicated by improvement in enemas were not used, and instead of the tra- cervical smears at postoperative ditional perineal shave only a perineal clip cytologic study. was done. Patients were directed to empty the bladder before being taken to the operating suite, and were not catheterized. Thiopental sodium with nitrous oxide and

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oxygen was given, and, after induction of anes- than 100 ml. for another 18 percent. For al- thesia, patients were placed in the lithotomy most 20 percent no record of blood loss was position and prepared with Betadine solution. made, but probably it was less than 100 ml. A Sims retractor was placed in the posterior Only three of 200 patients experienced signif- part of the vaginal vault. The anterior lip of icant bleeding in the first three days after the cervix was grasped with a tenaculum, and conization, and only one of these required traction was applied. Schillers iodine test was blood transfusion. Of the 177 patients who done on the cervix and , and was fol- did not require further operation after coniza- lowed by uterine sounding, dilation, and curet- tion, seven experienced significant bleeding tage. (Cervical dilation usually was necessary between the time of their discharge from the before conization by the technique used.) Then hospital and the fifteenth postoperative day. the cervix was grasped with Duprey tenacula None required blood replacement, and five at approximately four- and seven-oclock posi- were treated in the office by cautery or Sur- tions, so that the cervix could be held firmly in gicel packing. Two had to be hospitalized for all planes. This facilitated cutting and en- Surgicel packing and vaginal tamponade. sured uniformity of the cone. Conization was Two other patients were hospitalized for a performed with an Averbach knife, starting return of vaginal bleeding, which had been at about the four-oclock position and follow- their original complaint and which was found ing a continuous curve for 360 degrees. It at operation to originate not from the cervix often was necessary to pause for one or two but from the corpus uteri. seconds to allow the tissue to feed through the Study of the relation between cautery at opening in this type of knife. After the speci- the time of conization and early or late post- men was removed, major bleeding points were operative bleeding showed that all three pa- cauterized with a post or cherry cautery, but tients who experienced significant bleeding not the spark-gap type. in the immediate postoperative period had not In 142 patients cautery with the post-type been cauterized. Of the 177 patients who did not unit was done lightly at major bleeding points, require further operation, 130 had been cau- without charring of tissue. It was not required terized. Three of these were among the seven or was considered inadvisable because of the who experienced late bleeding; the other four possibility of malignant change in the other had not been cauterized. 58. Surgicel gauze (two by six inches) then Postoperative fever was rare. Only five pa- was packed into the site of conization, and tients (2.5 percent) had a rise in oral tem- the area was observed for bleeding. If only perature above 100 F., and none had a rise oozing was present, the tenacula and speculum above 101 F. Two were given antibiotics, and were removed, and the patient was transferred the others were treated with aspirin. No pa- to the recovery room. tient had pelvic cellulitis, abscess formation, Cones obtained averaged 2.1 cm. wide and cystitis, or other infection referable to the 2.5 cm. long, and most were in one piece. genitourinary system. The only signs of infec- tion were in the upper part of the respiratory After-effects tract. Rises in temperature, therefore, were Surgical blood loss was less than 50 ml. for not considered to represent surgical morbidity. more than 60 percent of the patients and less The hospital stay was short for all but the

1191/70 patients who needed further medical or sur- Almost half the patients who were found gical treatment. Three percent of the patients to have carcinoma in situ were among the ten left on the first postoperative day and 50.5 percent who had had no complaint referable percent on the second. More than 80 percent to the genital tract but who had been referred had been discharged by the third day. for conization because of an abnormal Papani- Cervical stenosis was a late complication in colaou smear. The smear was of Class III or three patients, two of whom required only IV for 72 percent of the patients with car- office dilation. The third was not seen for two cinoma in situ. months after operation; she then required A comparison of results of Papanicolaou hysterectomy for severe stenosis and hema- smear and conization showed that Class IV tometra. smears were indicative of carcinoma in situ Twenty-three patients required chemical or in 100 percent of patients, while Class III electrical cautery late in the postoperative pe- smears signaled malignant change in 40 per- riod for minor bleeding or imperfections in cent and dysplasia in 25 percent. Class II healing. smears indicated some form of cellular abnor- Only 13 of 200 patients (6.5 percent) were mality in slightly less than 50 percent of pa- considered to have experienced significant tients, and Class I smears were evidence of postoperative morbidity. such abnormality in 30 percent, most of whom Of 55 patients who underwent conization had squamous metaplasia. and were available for cytologic study from six to 11 months later, 24 showed improve- Comment ment in smears; 30 showed no change, and one Conization of the cervix, since its introduction showed progression from Class I to Class II. more than 150 years ago, has been a source All patients with smears of Class II or higher of controversy. Although first described by before conization had Class I smears after- Lisfranc, it was not popularized until 1916, ward. when Sturmdorf2 frequently performed the Of 18 patients who underwent hysterectomy operation. The severe complications of stenosis for carcinoma in situ within a few months and hemorrhage caused its popularity to wane after conization, only four showed residual over the years. carcinoma in the surgical specimen. Fourteen In the last several decades, however, cyto- other patients required hysterectomy for other logic investigations of the uterine cervix have reasons. stimulated new interest in cold conization, be- cause tissue diagnosis is necessary to confirm Findings at conization the suspicions aroused by cytologic study be- Benign inflammatory disease, with or without fore further treatment can be given. This re- retention cysts of the endocervical glands, was newal of interest accentuated the complica- seen in 60 percent of patients at conization; tions and necessitated development of safe 31 percent showed basal cell hyperplasia, meta- methods. Different methods of circumventing plasia, or dysplasia; and nine percent showed or decreasing the complications were tried.3-7 carcinoma in situ of the cervix. Microscopic Both shallow and deep cones were made with evidence of invasive cancer was not seen in a variety of instruments. A variety of agents, any specimen. from sterile water to oxytoxic agents to

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adrenalin, were injected into the cervix. The eschar, which can lead to heavy late bleeding. cervix was cauterized with heat, electricity, A recently introduced method which is receiv- and chemicals, and tourniquets were applied ing increasing attention is cervical cryother- to it. Packing procedures varied from use of a apy. 11-14 This modality has several advantages: small strip of cervical gauze to full cervico- It is performed rapidly, needs no anesthetic, vaginal packing. Each change was made in an and rarely causes bleeding or stenosis. On the honest attempt to lower the morbidity of this other hand, it requires expensive equipment, important procedure. and the malodorous and often profuse dis- Our technique is offered in the hope that it charge which the patient must cope with for will lower the morbidity without reducing the up to six weeks can be distressing. Moreover, effectiveness of a diagnostic and therapeutic many patients are weakened for several weeks, procedure that can be performed easily and probably because of electrolyte imbalance, and rapidly by the surgeon. no tissue is obtained for histologic diagnosis. Today there is no argument over whether As mentioned previously, these alternative cold conization is the best method of diagnosis methods provide either no specimen or only of carcinoma."• There are several reasons a small one for histologic study, and Graham15 for this: First, few physicians in this country has stated that cytologic study is only 90 per- today are trained in adequate as a cent accurate on the first smear. The possi- diagnostic modality. Second, four-quadrant bility of missing diagnosis of carcinoma when biopsy and even random biopsy have their own only benign disease is thought to be present is complications, along with a diagnostic failure apparent. rate of at least eight percent, even if adequate It seems logical that the best method of tissue is taken.8 Third, hot conization, or elec- treating benign disease of the cervix surgically troconization, produces a charred piece of tis- is a procedure with relatively low morbidity sue which is often beyond histologic recogni- and high therapeutic and diagnostic value. tion and of no diagnostic value. ? It can, This technique appears to meet these specifi- therefore, be concluded that cold conization cations. offers the best and most reliable method of Fleming8 stated that the therapeutic value diagnosing cellular abnormality. of cold conization in restoring a diseased cer- Concerning therapeutic conization, there re- vix to health is of great importance, not only mains an area of controversy in the surgical for relief of symptoms but for eradication of management of benign cervical disease. Many cellular abnormality and restoration of cellular gynecologists agree that a large number of stability. The improvement in cervical smears patients with benign cervical disease are un- at postoperative cytologic study in the present responsive to conservative therapy. 8,10 These series is evidence of the therapeutic value of patients deserve a relatively safe operative the procedure. procedure that offers a high cure rate. Hot The results of the technique used in the conization, unfortunately, is probably at pres- present study compared favorably with those ent the most frequent treatment. It does not reported by other authors. The importance of produce adequate tissue for histologic diag- obtaining a cone of adequate length and depth nosis but often produces stenosis, which may cannot be overestimated, since carcinoma may interfere with future pregnancies, and a deep be either high in the endocervix or far out in

1193/72 the ectocervix. This is most important for than that of Hester and Read,° who reported young patients who wish to add to their fam- 11 patients with cervical stenosis among 155 ilies and therefore undergo only conization. who had undergone conization. In three of the Specimens obtained by our method averaged 11 patients with stenosis, hematometra oc- 2.1 cm. wide and 2.5 cm. long, compared with curred, and in two there was secondary dys- from 6 to 8 mm. width and 1.5 cm. length menorrhea. reported by other authors.5.7,5 Total morbidity in our series was 6.5 per- The diagnostic reliability of the technique cent, compared with from 12 to 22 percent in our series also was comparable with that complications in other series. 5,5 This reduction reported elsewhere. Cancer was seen in the in morbidity suggests that conization may be cone specimen in 100 percent of patients with a safe and effective method of relieving the Class IV smears and 40 percent of those with symptoms of chronic cervical infection, as Class III. Schiffer and associates 5 reviewed well as a method of histologic diagnosis. the results of various authors and reported The 22 percent frequency of residual car- that their conizations had shown from 45 to cinoma at hysterectomy after conization also 51 percent carcinoma in situ or invasive car- compared favorably with other studies, in cinoma among patients who had Class III which the frequency varied from 10 to 50 per- smears. cent.5,°,5," Probably the size of the cone ob- Blood loss was low, probably as a result of tained was responsible for this. traction on the cervix by the Duprey tenacula, which could occlude the vessels partially and Conclusions stop bleeding immediately, and of the ease and A technique of cold conization which provides rapidity with which bleeding can be stopped a large specimen of tissue for study and re- with the cherry red cautery, compared with duces the morbidity rate adds considerably the spark-gap cautery. to the value of the procedure both in diagnosis The occurrence of significant bleeding in and in treatment. the early part of the postoperative period also It must be remembered that cold conization, was lower than that reported by other au- even when done therapeutically, produces a thors.57 The use of light cautery as well as pathologic specimen and, therefore, is inval- packing with Surgicel probably contributed uable in diagnosis of unsuspected cellular dis- to this result. Surgicel helped to form a ma- ease or even cellular cancer. When carcinoma trix for clotting and prevented early bleeding. in situ is discovered, the wide and deep cone The Surgicel not absorbed in the healing obtained by this technique effectively decreases process usually was passed in a few days. The the chance that part of the carcinoma will re- frequency of late bleeding also compared fa- main. This becomes an important considera- vorably with results reported by other inves- tion when hysterectomy is not desirable. tigators.5,5,9," In no case was the cervix sutured for early Summary or late bleeding. A technique of cold conization which reduces The frequency of cervical stenosis after con- the morbidity rate substantially is presented ization was comparable with that of some in detail, and results in 200 consecutive cases other investigators,5,5 but considerably lower of cold conization are reviewed. The need for

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cold conization as a therapeutic and diagnostic 12. Ostergard, D.R., Townsend, D.E., and Hirose, F.M.: Treat- ment of chronic cervicitis by cryotherapy. Amer .1 Obstet Gynec measure is discussed. 102:426-32, Oct 68 13. Collins, R.J., et al.: Cryosurgery of the human uterine cervix. Obstet Gynec 30:660-7, Nov 67 14. Pappas, H.J., Collins, R.J., and Paloucek, F.P. Cryosurgical treatment of chronic cervicitis. Int Surg 49:513-5, Jun 68 1. Lisfranc. J., cited by Scott, J.W., Welch, W.B., and Blake, 15. Graham, R.M.: The cytologic diagnosis of cancer. Ed. 2. W. B. T.F.: Bloodless technique of ccld knife conization (ring biopsy). Saunders Co., Philadelphia, 1963 Amer J Obstet Gynec 79:62-6. Jan 60 2. Sturmdorf, A.: Tracheloplastic methods and results. A clinical Sherman, R.H. • and Hardy J.C.: Carcinoma in situ of the uterine study based upon the physiology of the mesometrium. Surg Gynec cervix. A statistical survey in a 350-bed general hospital. JAOA Obstet 22:93-104, Jan 16 67:1382-93, Aug 68 3. Tulloch, J.A.: Conization of the cervix and its complications. Harper Hosp Bull 21:65-8. Mar-Apr 63 4. Bushnell, L.F.: Prevention of complications in cervical coniza- tion. Obstet Gynec 22:190-8. Aug 63 5. Schiffer, M.A., et al.: Cervical conization for diagnosis and treatment of carcinoma in situ. Amer J Obstet Gynec 93:889-95, 15 Nov 65 6. Villasanta, U., and Durkan, J.P.: Indications and complica- tions of cold conization of the cervix. Observations on 200 con- secutive cases. Obstet Gynec 27:717-23, May 66 7. Offen. J.A., and Ferguson, J.H.: Cold conization of the cervix. Practical technic for maximum hemostasis. Obstet Gynec 15:396- 400, Mar 60 8. Fleming, A.R.: Advantages of cold conization. Introduction of a new instrument. JAMA 168:886-9, Oct 58 9. Doran, T.A., and Shier, C.B.: Conization of the cervix. Review at the Toronto General Hospital (1956-1961). Amer J Obstet Gynec 88:367-74, 1 Feb 64 10. Hester, L.L., Jr., and Read. R.A.: An evaluation of cervical At left is Dr. Abbott: at right. Dr. Sherman. conization. Amer J Obstet Gynec 80:715-21, Oct 60 Dr. Sherman, 2008 Magnolia Drive, Rocky River. 11. Ostergard, D.R., Townsend, D.E., and Hirose, F.M.: Compari- Ohio 44116. son of electrocauterization and cryosurgery for the treatment of benign disease of the uterine cervix. Obstet Gynec 83:58-63. Jan 69

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