Procedimiento de escisión electro-quirúrgica por asa térmica y riesgo de parto prematuro: una revisión sistemática de la literatura / Loop electrosurgical excision procedure and risk of preterm delivery: a literature review

Antecedentes: A diferencia de la conización cervical por cono frío, no se ha podido demostrar una clara asociación entre el procedimiento de escisión electro-quirúrgica por asa térmica (LEEP) y el riesgo de parto prematuro. Objetivo: Análisis crítico de la literatura científica, en relación al riesgo de presentar un parto prematuro en pacientes que han sido sometidas a LEEP, y los resultados materno-perinatales asociados. Búsqueda sistemática en múltiples bases de datos. Resultados: Se encontraron sólo tres artículos que cumplían los criterios de inclusión, los cuales son incluidos en esta revisión. De éstos, el primero muestra que el LEEP no aumenta el riesgo de parto prematuro ni de recién nacidos de bajo peso. El segundo evidencia un aumento del riesgo de rotura prematura de membranas y parto prematuro secundario a esto, pero no de parto prematuro espontáneo. Sin embargo, el tercero, señala que el LEEP se asocia en forma significativa a riesgo aumentado de parto prematuro, parto prematuro secundario a rotura prematura de membranas y recién nacidos de bajo peso. Los tres estudios son de cohortes retrospectivas, lo cual les otorga un nivel de evidencia de tipo 2b. Conclusión: La evidencia indica que la excisión de la zona de transformación a través del uso de LEEP está asociada a un pequeño, pero real incremento del riesgo de presentar un parto de pretérmino.

Background: Unlike cold-knife conization, studies have shown conflicting results on the outcome of pregnancy following loop electrosurgical excision procedure (LEEP). Objective: Critical analysis of the literature to establish if the LEEP treatments increase risk of preterm delivery and its influence in maternal-perinatal results. Results: Only three studies were filling the inclusion criteria. The first study does not show that LEEP treatment increase risk of preterm delivery and low birth weight. The second study shows increased risk of premature rupture of membranes and the subsequent preterm delivery, but not spontaneous preterm delivery. Nevertheless, the third study shows increased risk of premature rupture of membranes and the subsequent preterm delivery, spontaneous preterm delivery and low birth weight. The three studies are based in retrospective cohorts, which grant them a level of evidence of type 2b. Conclusion: The evidence indicates that loop excision of the transformation zone by LEEP is associated with a small but real increase the risk of preterm delivery.

Cervical stenosis following electrosurgical conization / Estenose cervical após conização eletrocirúrgica

CONTEXT AND OBJECTIVE: Cervical stenosis is a postoperative complication of procedures for treating preinvasive lesions of the cervix and takes on particular importance due to the clinical repercussions associated with it. Furthermore, it causes limitations in relation to cytological and colposcopic follow-up. The aim here was to assess the incidence of cervical stenosis among a cohort of patients who underwent electrosurgical conization and to identify possible prognostic factors associated with its occurrence. DESIGN AND SETTING: Retrospective study at Gynecology and Obstetrics Department, Instituto Fernandes Figueira, Rio de Janeiro. METHODS:This was an observational study among a cohort of patients who underwent electrosurgical conization of the uterine cervix. The possible predictive variables were analyzed as bivariate means between the groups with and without stenosis. We also calculated the incidence density rate ratio for cervical stenosis in relation to each possible predictive variable and the respective confidence intervals (95 percent). Levels of 5 percent were considered significant. RESULTS: 274 patients who underwent electrosurgical conization of the uterine cervix with a minimum follow-up period of six months were included. The crude incidence of cervical stenosis was 7.66 percent and the incidence density was 3.3/1,000 patients-month. CONCLUSIONS: We did not find associations between the variables for stenosis. However, we observed borderline significance levels relating to hemorrhagic complications before and after the operation (p = 0.089).

CONTEXTO E OBJETIVO: A estenose cervical é uma complicação pós-operatória dos procedimentos para tratamento das lesões pré-invasivas do colo uterino e assume importância particular tanto pelas repercussões clínicas associadas como pela limitação causada nos acompanhamentos citológico e colposcópico. O objetivo foi verificar a incidência da estenose cervical em uma coorte de pacientes submetidas a conização eletrocirúrgica do colo uterino e apontar possíveis fatores prognósticos associados. TIPO DE ESTUDO E LOCAL: Estudo retrospectivo, observacional realizado no Instituto Fernandes Figueira, Departamento de Ginecologia, Rio de Janeiro, Brasil. MÉTODOS: Estudo observacional em uma coorte de pacientes submetidas à conização eletrocirúrgica do colo uterino. As variáveis possivelmente preditoras foram analisadas de forma bivariada entre os grupos com e sem estenose. Calculou-se também a razão de taxas de incidência-densidade da estenose cervical para cada variável possivelmente preditora e os respectivos intervalos de confiança (95 por cento). O nível de significância considerado foi de 5 por cento. RESULTADOS: Foram incluídas 274 pacientes submetidas a conização eletrocirúrgica do colo uterino com um tempo mínimo de seis meses de acompanhamento após o procedimento. A incidência bruta de estenose cervical foi de 7,66 por cento e a incidência-densidade foi de 3,3/1000 pacientes-mês. Não houve diferença estatisticamente significativa entre as características clínico-demográficas dos grupos. CONCLUSÃO: Não se encontrou associação entre as variáveis e a estenose, porém observou-se um nível de significância limítrofe em relação às complicações hemorrágicas do peri e pós-operatório (p = 0,089).

Appropriate interval for repeat excision in women undergoing prior loop electrosurgical excision procedure for cervical neoplasia.

The objective of the present study was to evaluate the impact of intervals on complications and pathological examination in women undergoing a repeat loop electrosurgical excision procedure (LEEP) for cervical neoplasia. During October 2004 and January 2007, 78 women who had undergone repeat LEEP at Chiang Mai University Hospital, were prospectively evaluated. The mean age was 47.5 years (range; 27-69 years). The mean duration of uncomplicated vaginal bleeding was 4.4 days (range; 1-20 days). The occurrence of persistent vaginal bleeding was noted in 9 women. Among 78 women, 2 (2.56%) and 7 (8.97%) experienced intraoperative and postoperative hemorrhage, respectively. Six (7.69%) had postoperative infection. These complications were not significantly different from those observed in women undergoing first LEEP in the same period (P=0.56). There was no significant difference in the incidence of perioperative complications and the incidence of non-evaluable cone margins among women who undergoing repeat LEEP within 4-6 weeks, between 6-8 weeks, and more than 8 weeks after first LEEP. In conclusion, repeat LEEP could be safely performed 4-12 weeks after the first procedure without any impact on pathological specimen examination.

Comparación entre conización con bisturi frio y radiocirugía de alta frecuencia / Comparison to conization with cold knife and high frecuency radiosurgery

Se revisan dos series de pacientes operadas a bisturí frío (B.F.) y con radiocirugía de alta frecuencia ambas con al menos 1 año de seguimiento. Sendas series, eran pacientes con neoplasia intraepiteliales de alto grado (NIE), o canal positivo o disrelación cito colpohistológica con biopsia previa. En el procedimiento con B.F. hay 83,3 por ciento de suficiencia y en RAF 50,9 por ciento, pero en RAF se puede repetir el procedimiento. En B.F. hubo 16,7 por ciento de histerectomía no así en RAF. En B.F. hay 4 hematometras y las series son similar en complicaciones hemorrágicas. Con B.F. hay biopsia de endometrio no así en RAF.En RAF se necesitan a veces 2 ó 3 procedimientos lo que no existe en B.F. El RAF es ambulatorio, menos costoso y exige más observación en el tiempo. Hoy en nuestro Centro de Patología Cervical se practica casi exclusivamente el RAF. El BF se usa solo en cáncer microinvasor 11 A de difícil diagnóstico