Effects of Ball Cauterization Following Loop Excision and Follow-up Colposcopy
Effects of Ball Cauterization Following Loop Excision and Follow-up Colposcopy
abstract & commentary
Synopsis: Extensive cauterization of the base of a loop electroexcision defect leads to subsequent unsatisfactory colposcopic examinations.
Source: Paraskevaidis E, et al. Obstet Gynecol. 2001;97:617-620.
Loop electroexcision has become one of the most common methods of treatment of significant CIN. It is routine to perform diathermy ball cauterization to the excision defect at the time of the initial procedure. However, the extent of ball diathermy which is appropriate has not previously been investigated, according to Paraskevaidis and colleagues.
Paraskevaidis et al enrolled 101 consecutive woman from their colposcopy clinic who had a satisfactory colposcopic examination and an abnormal Pap smear. In their clinic the "see and treat" methodology was used rather than colposcopy and biopsy followed by loop excision at a later date, if indicated. Paraskevaidis et al alternately assigned the study participants to 2 groups: The first group received extensive ball cauterization of the entire loop excision defect. The second group also received ball cauterization, but a 2-3 mm zone around the new endocervical os was avoided.
The patients had a cytologic sample obtained at 3 months postprocedure and a colposcopic examination 4 months postprocedure. At that time the location of the squamocolumnar junction was identified. Paraskevaidis et al used microcolpohysteroscopy as an adjunct to determine whether the transformation zone extended into the endocervical canal. The patients were asked to "grade" their discomfort during the microcolpohysteroscopy and Paraskevaidis et al used increasing discomfort as a measure of possible cervical stenosis.
Among those women who received extensive ball cauterization, only 24% had a satisfactory colposcopic examination at follow-up compared to 92% of the women who received less extensive cauterization (P < .001). Seventy-three percent of the women with extensive cautery complained of moderate or severe pain doing microcolpohysteroscopy compared to only 6% of women in the less extensively cauterized group (P < .001). There was no difference in abnormal cytology or colposcopic persistence of CIN in the 2 groups.
Paraskevaidis et al conclude that extensive diathermy ball cauterization should be avoided after loop electroexcision, unless significant bleeding is encountered during the procedure, to allow for better visualization of the transformation zone at subsequent follow-up.
Comment by Kenneth L. Noller, MD
This is an important paper that certainly suggests that there is no indication for routine extensive diathermy ball cauterization of the base of a loop electroexcision defect. The rate of subsequent unsatisfactory colposcopic examinations is markedly higher when extensive cautery is performed.
It is interesting to reflect that when loop electroexcision was first introduced it was taught that only cauterization of the exocervical edge (squamous epithelial edge) of the defect be performed. Deep cauterization was not recommended on a routine basis. Although it may often appear that blood is coming from deep within the excision crater, if the edge of the defect is cauterized first, very often there is no further bleeding. The "deep" bleeding is often only blood running into the defect from the squamous margin.
Somewhere along the line, some gynecologists have begun to cauterize the base of the loop excision crater extensively. I have several times questioned individuals who practice this approach and they usually state that the reason they do so is to decrease the risk of persistent disease. This article found no difference in persistence of CIN between extensive cautery and less-aggressive tissue destruction.
Paraskevaidis et al did a good job of explaining their procedure, of blinding the colposcopist to the initial procedure at the follow-up examinations, and blinding the microcolpohysteroscopy procedures. It was surprising, therefore, that they chose an alternate assignment method of patients rather than a random assignment method. Though Paraskevaidis et al attempt to rationalize their use of alternate assignments in the last paragraph of the paper, it always is an inferior technique to use random assignment.
Why is that so? Specifically, there is far to great a likelihood, with alternative assignment, that in the actual clinical setting a different "type" of patient will be selected by the clinicians for assignment to one specific arm. For example, a clinician in the colposcopy clinic in this study could recognize a name on the clinic patient list and know that she has had abnormal Pap smears for a long period of time. The clinician might decide that such a patient is the "ideal" person for extensive cautery and manipulate the sequence for the day so that this patient receives extensive ball cautery. The net result, if spread over the entire study, would be that the patients with extensive cautery would, on average, have more extensive lesions than those with less-aggressive cautery. In this study there does not appear to be such patient selection—it would have been so easy to perform random assignment of patients—I cannot imagine why Paraskevaidis et al did not do so.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.