Conization of the cervix or cone biopsy is a surgical procedure that involves the removal of a cone-shaped wedge from the cervix (mouth of the uterus). It may be performed for the diagnosis of abnormal areas in the cervix, which may be cancerous or potentially cancerous. Conization is most commonly performed to examine such areas and then take a biopsy for microscopic examination. The cervix grows back after conization. Following the procedure, the new tissue grows back in the cervix in 4-6 weeks.
There are several techniques to perform conization, such as with a scalpel (cold knife conization), laser, or electrosurgical loop. The choice of technique depends on the extent of the disease, the general condition of the patient, and the surgeon’s decision.
Understanding the anatomy:
The cervix is approximately 2.5 cm long. It communicates with the uterus above and with the vagina below. The cervical canal is lined by columnar epithelium, which also forms the endocervical glands. The region where the two types of epithelia meet is called but the squamocolumnar junction and forms a zone containing irregular areas with a mix of different types of squamous epithelium. It is also referred to as the transformation zone and varies between 2-15 mm in length. The blood supply of the cervix originates mainly from the cervical branches of the uterine artery and from branches of the vaginal and pudendal arteries, through which cervical cancer can spread. Tumors of the cervix commonly arise from the transitional zone. carcinoma in situ (CIN) typically arises in the transformation zone and extends to a depth of up to 7 mm.
Why is conization done?
Conization may be performed for diagnostic and/or treatment purposes.
- Finding the presence of abnormal cells (potentially cancerous), such as high-grade squamous intraepithelial lesions (HSIL) or low-grade squamous intraepithelial lesions (LSIL), when lesions are not visible to the naked eye or during other diagnostic tests like colposcopy.
- Unsatisfactory colposcopy due to inability to view the entire cervix by the doctor
- To diagnose the presence or absence of spread cervical tumors
- To detect the presence of cancer or potentially cancerous areas
- To confirm a diagnosis if the biopsy (testing of a small piece of sample tissue) results are inconsistent
- Therapeutic conization is the treatment of choice to treat grades 2 and 3 of cervical intraepithelial neoplasia (cancers that have not yet spread). All the available techniques and approaches of conization are effective.
- In addition to conization, carcinoma in situ (CIN) can also be treated by performing a hysterectomy (surgical removal of the uterus and cervix) or by other destructive procedures. The decision to combine conization with other procedures depends on the extent of the disease, the general condition of the patient’s condition, the patient’s age, and the desire for child rearing.
What happens during conization?
Conization is usually performed under general anesthesia. A small cone-shaped tissue is removed by the surgeon from the cervix for diagnosis, or the surgeon may use the procedure to remove diseased tissue. The cervical tissue may be removed using a wire loop heated by electrical current, also called LEEP (loop electrosurgical excision procedure), cryotherapy (freezing), a scalpel (also called cold knife biopsy), or a laser. Cryotherapy, cold knife, or LEEP is preferable when no treatment is being done. Laser conization can be excisional or destructive by vaporization, and hence, it can be used for treatment as well. The cervical canal above the region of cone biopsy may also be scraped to remove cells for evaluation. This is called endocervical curettage (ECC).
After the procedure:
Patients experience pain and discomfort for which painkillers would be administered. Antibiotics may be given to prevent infection. Patients are usually discharged the same day or the next day. Patients usually have vaginal bleeding for a few days after the procedure; they would have to use sanitary napkins (tampons can increase the risk of infection). Most patients can resume their daily activities the next day. Specific activities like sexual intercourse, sports, and exercise may be resumed after consulting with the surgeon.
Is conization safe?
Conization is generally a safe procedure but is usually avoided during pregnancy because it is associated with significant risks during pregnancy, such as postpartum hemorrhage (severe blood loss) and fetal loss. Rarely conization may be performed during pregnancy in invasive cancer if it’s during the first or second trimester.
Some possible risks that may be associated with the conization procedure include:
- Cervical incompetence (which may lead to miscarriages or preterm delivery)
- Scarring of the cervix, which can cause painful periods, preterm delivery, and infertility
- Damage to the bladder or rectum
- Reaction to anesthesia
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