Correlation Between Persistent HPV Infection and Vaginal Microecological Imbalance After Treatment of Cervical High-Grade Squamous Intraepithelial Lesion.

Objective: To analyze the association between persistent human papillomavirus (HPV) infection and vaginal microecological imbalance after surgical treatment of cervical high-grade squamous intraepithelial lesion (HSIL). Methods: This is a retrospective study, 180 cervical HSIL patients admitted to our hospital from May 2019 to May 2021 were selected, of these, 84 were treated with loop electrosurgical excision procedure (LEEP) and 96 with cold knife conization (CKC). Patients were followed up for HPV infection 1 year after surgery. There is a division into a persistent infection group (positive group) and a negative group based on the presence or absence of HPV, the detection technique was PCR amplification. The two groups were compared regarding preoperative HPV infection, vaginal micro-ecological indicators 1 year after surgery, and the correlation between persistent HPV infection and vaginal microecological imbalance. Results: At 1 year after surgery, among 180 cervical HSIL patients, 64 (35.56%) were persistently infected with HPV, with an age of (40.20 ± 4.85) years, including 36 (56.25%) with cervical intraepithelial neoplasia (CIN) grade II, 28 (43.75%) with cervical intraepithelial neoplasia (CIN) grade III, 116 (64.44%) with HPV negative, with an age of (40.22 ± 5.15) years, including 67 (57.76%) with CIN grade II and 49 (42.24%) with CIN grade III, the differences in age and CIN classification between the two groups were not statistically significant (P > .05). Preoperatively, 53 people (82.81%) with HPV viral load >100 RLU/CO in the HPV persistent infection group and 76 people (65.52%) with HPV viral load >100 RLU/CO in the HPV negative group, with statistically significant differences between the two groups (P < .05); The difference in HPV virus typing and HPV infection type between the two groups was not statistically significant (P > .05). At 1 year after surgery, the composition ratio of flora density class IV and flora diversity class IV were significantly higher in the HPV persistent infection group than in the HPV negative group, and the dominant bacteria were mainly gram-positive large bacillus, accounting for 83.33%, the difference between the two groups was statistically significant (P < .05); The differences in Nugent scores and pH values between the two groups were not statistically significant (P > .05). Logistic regression analysis showed that flora density, flora diversity, and dominant bacteria were all independent risk factors for persistent HPV infection after treatment in patients with HSIL (P < .05). Conclusion: After treatment of HSIL patients, clinical attention should be paid to monitoring of HPV infection but also to the changes in vaginal microecology, as timely correction of vaginal microecology can facilitate HPV regression and improve the patient's prognosis.

Syringe or mask? Loop electrosurgical excision procedure under local or general anesthesia: a randomized trial.

BACKGROUND: Loop electrosurgical excision procedure may be performed under local anesthesia or general anesthesia, and practice patterns differ worldwide. No randomized head-to-head comparison has been published to confirm or refute either practice. OBJECTIVE: This study aimed to compare loop electrosurgical excision procedure under local anesthesia vs general anesthesia regarding patient satisfaction and procedure-related outcomes such as rates of involved margins, complications, pain, and blood loss. STUDY DESIGN: Consecutive women referred to our colposcopy unit were recruited. Loop electrosurgical excision procedure was performed under local anesthesia with 4 intracervical injections of bupivacaine hydrochloride 0.5% or under general anesthesia with fentanyl, propofol, and a laryngeal mask with sevoflurane maintenance. The primary endpoint was patient satisfaction assessed on the day of surgery and 14 days thereafter using a Likert scale (score 0-100) and a questionnaire. Secondary endpoints included rates of involved margins, procedure-related complications, pain, blood loss, and surgeon preference. Results were compared using nonparametric and chi-square tests. RESULTS: Between July 2018 and February 2020, we randomized 208 women, 108 in the local anesthesia arm and 100 in the general anesthesia arm. In the intention-to-treat analysis, patient satisfaction did not differ between the study groups directly after surgery (Likert scale 100 [90-100] vs 100 [90-100]; P=.077) and 14 days thereafter (Likert scale 100 [80-100] vs 100 [90-100]; P=.079). In the per-protocol analysis, women in the local anesthesia arm had significantly smaller cone volumes (1.11 cm3 [0.70-1.83] vs 1.58 cm3 [1.08-2.69], respectively; P<.001), less intraoperative blood loss (Δhemoglobin, 0.2 g/dL [-0.1 to 0.4] vs 0.5 g/dL [0.2-0.9]; P<.001), and higher satisfaction after 14 days (100 [90-100] vs 100 [80-100]; P=.026), whereas surgeon preference favored general anesthesia (90 [79-100] vs 100 [90-100], respectively; P=.001). All other secondary outcomes did not differ between groups (resection margin status R1, 6.6% vs 2.1% [P=.26]; cone fragmentation, 12.1% vs 6.3% [P=.27]; procedure duration, 151.5 seconds [120-219.5] vs 180 seconds [117-241.5] [P=.34]; time to complete hemostasis, 60 seconds [34-97] vs 70 seconds [48.25-122.25] [P=.08]; complication rate, 3.3% vs 1.1% [P=.59]). In a multivariate analysis, parity (P=.03), type of transformation zone (P=.03), and cone volume (P=.02) and not study group assignment, age, body mass index, and degree of dysplasia independently influenced the primary endpoint. CONCLUSION: Loop electrosurgical excision procedure under local anesthesia is equally well tolerated and offers patient-reported and procedure-related benefits over general anesthesia, supporting the preferred practice in some institutions and refuting the preferred practice in others.

LLETZ make it simple: Anxiety, pain and treatment outcomes with outpatient large loop excision of the transformation zone under local anaesthesia.

BACKGROUND: Large loop excision of the transformation zone (LLETZ) is the preferred treatment for cervical intraepithelial neoplasia due to its effectiveness and ability to be performed in an outpatient setting under local anaesthesia (LA). Although current guidelines recommend that most LLETZ can be performed under LA, there is paucity in clinical data of patients' perspectives of outpatient LLETZ. AIM: Determining patient acceptability of outpatient LLETZ through assessment of anxiety and pain scores, and comparing treatment outcomes with current standards in terms of margins status, negative histology, short-term morbidity rates and follow-up attendance. MATERIALS AND METHODS: This study was conducted at a tertiary hospital over two years (2014-2016). Patients undergoing outpatient LLETZ completed a three-part questionnaire (before, immediately after and 4-6 weeks post-procedure). RESULTS: One hundred and five patients underwent outpatient LLETZ. Mean pain score was 2 (range 0-8). Pre-procedure anxiety was common but most resolved post-procedure. Women who did not have a prior LLETZ discussion were more likely to report moderate-severe anxiety levels pre-procedure, compared with women who did (odds ratio 3.00, 95% CI 1.11-8.09, P = 0.030). There were no differences found in pain scores when comparing pre-procedure anxiety levels, prior discussion of LLETZ or mode of anaesthesia. Specimen margins were involved in 42.9%. No association was found between positive cervical margin status and age, pre-procedure anxiety or post-procedure pain scores. Most patients were satisfied and attended follow-up appointments. CONCLUSION: Large loop excision of the transformation zone under LA is a well-tolerated procedure with high satisfaction and follow-up rates. Clinicians need to initiate early discussions regarding treatment to minimise procedure-related anxiety.

Early experiences in integrating cervical cancer screening and treatment into HIV services in Zomba Central Hospital, Malawi.

Background: Malawi has the highest rate of cervical cancer globally and cervical cancer is six to eight times more common in women with HIV. HIV programmes provide an ideal setting to integrate cervical cancer screening. Methods: Tisungane HIV clinic at Zomba Central Hospital has around 3,700 adult women receiving treatment. In October 2015, a model of integrated cervical cancer screening using visual inspection with acetic acid (VIA) was adopted. All women aged 20 and above in the HIV clinic were asked if they had cervical cancer screening in the past three years and, if not, were referred for screening. Screening was done daily by nurses in a room adjacent to the HIV clinic. Cold coagulation was used to treat pre-cancerous lesions. From October 2016, a modification to the HIV programme's electronic medical record was developed that assisted in matching numbers of women sent for screening with daily screening capacity and alerted providers to women with pre-cancerous lesions who missed referrals or treatment. Results: Between May 2016 and March 2017, cervical cancer screening was performed in 957 women from the HIV clinic. Of the 686 (71%) women who underwent first ever screening, 23 (3.4%) were found to have VIA positive lesions suggestive of pre-cancer, of whom 8 (35%) had a same-day cold coagulation procedure, seven (30%) deferred cold coagulation to a later date (of whom 4 came for treatment), and 8 (35%) were referred to surgery due to size of lesion; 5/686 (0.7%) women had lesions suspicious of cancer. Conclusion: Incorporating cervical cancer screening into services at HIV clinics is feasible. A structured approach to screening in the HIV clinic was important.

A retrospective review of the type of anaesthesia used for LLETZ: proposal for a categorisation audit tool.

BACKGROUND: Large loop excision of the transformation zone (LLETZ) is the most common form of treatment for cervical pre-cancer. The majority of procedures should be performed under local anaesthesia (LA) in an outpatient setting. AIM: To review the reasons behind choice of general anaesthesia (GA) for LLETZ and to devise a categorisation tool for audit purposes. METHODS: Review of the type of anaesthesia and histopathological findings for all cases of LLETZ performed at Wexford General Hospital between January 2010 and June 2013 inclusive. RESULTS: Of the 970 cases reviewed, 829 (85.5 %) were performed under LA and 141 (14.5 %) under GA. In five of the 141 GA cases the indication could not be established. The remaining 136 cases could be classified into three categories based on their indications for choosing GA: Category I: 46 cases (33.8 %) where there was associated pathology requiring treatment under GA. Category II: 56 cases (41.2 %) where the colposcopist anticipated difficulty with the procedure and decided on GA. Category III: 34 remaining cases (25 %), where GA was requested by the patient. During the study period the GA rate decreased significantly from 19.4 to 10 % due to a decrease in category II numbers. Higher rates of complete excision of pre-cancer were not found in the GA group. CONCLUSIONS: The use of GA for LLETZ rarely confers benefits in terms of diagnostic or therapeutic quality indicators. The categorisation we propose is a simple audit tool that could be adopted by all colposcopy units to reduce the rate of GA.

Harms of cervical cancer screening in the United States and the Netherlands.

We studied harms related to cervical cancer screening and management of screen-positive women in the United States (US) and the Netherlands. We utilized data from four US integrated health care systems (SEARCH), the US National Health Interview Survey, New Mexico state, the Netherlands national histopathology registry, and included studies on adverse health effects of cervical screening. We compared the number of Papanicolaou (Pap) smear tests, abnormal test results, punch biopsies, treatments, health problems (anxiety, pain, bleeding and discharge) and preterm births associated with excisional treatments. Results were age-standardized to the 2007 US population. Based on SEARCH, an estimated 36 million Pap tests were performed in 2007 for 91 million US women aged 21-65 years, leading to 2.3 million abnormal Pap tests, 1.5 million punch biopsies, 0.3 million treatments for precancerous lesions, 5 thousand preterm births and over 8 million health problems. Under the Netherlands screening practice, fewer Pap tests (58%), abnormal test results (64%), punch biopsies (75%), treatment procedures (40%), preterm births (60%) and health problems (63%) would have occurred. The SEARCH data did not differ much from other US data for 2007 or from more recent data up to 2013. Thus compared to the less intensive screening practice in the Netherlands, US practice of cervical cancer screening may have resulted in two- to threefold higher harms, while the effects on cervical cancer incidence and mortality are similar. The results are also of high relevance in making recommendations for HPV screening. Systematic collection of harms data is needed for monitoring and for better incorporation of harms in making screening recommendations.

Pain relief for women with cervical intraepithelial neoplasia undergoing colposcopy treatment.

BACKGROUND: Pre-cancerous lesions of cervix (cervical intraepithelial neoplasia (CIN)) are usually treated with excisional or ablative procedures. In the UK, the National Health Service (NHS) cervical screening guidelines suggest that over 80% of treatments should be performed in an outpatient setting (colposcopy clinics). Furthermore, these guidelines suggest that analgesia should always be given prior to laser or excisional treatments. Currently various pain relief strategies are employed that may reduce pain during these procedures. OBJECTIVES: To assess whether the administration of pain relief (analgesia) reduces pain during colposcopy treatment and in the postoperative period. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 2), MEDLINE (1950 to March week 3, 2016) and Embase (1980 to week 12, 2016) for studies of any design relating to analgesia for colposcopic management. We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field. SELECTION CRITERIA: Randomised controlled trials (RCTs) that compared all types of pain relief before, during or after outpatient treatment to the cervix, in women with CIN undergoing loop excision, laser ablation, laser excision or cryosurgery in an outpatient colposcopy clinic setting. DATA COLLECTION AND ANALYSIS: We independently assessed study eligibility, extracted data and assessed risk of bias. We entered data into Review Manager 5 and double checked it for accuracy. Where possible, we expressed results as mean pain score and standard error of the mean with 95% confidence intervals (CI) and synthesised data in a meta-analysis. MAIN RESULTS: We included 19 RCTs (1720 women) of varying methodological quality in the review. These trials compared a variety of interventions aimed at reducing pain in women who underwent treatment for CIN, including cervical injection with lignocaine alone, lignocaine with adrenaline, buffered lignocaine with adrenaline, prilocaine with felypressin, oral analgesics (non-steroidal anti-inflammatory drugs (NSAIDs)), inhalation analgesia (gas mixture of isoflurane and desflurane), lignocaine spray, cocaine spray, local application of benzocaine gel, lignocaine-prilocaine cream (EMLA cream) and transcutaneous electrical nerve stimulation (TENS).Most comparisons were restricted to single trial analyses and were under-powered to detect differences in pain scores between treatments that may or may not have been present. There was no difference in pain relief between women who received local anaesthetic infiltration (lignocaine 2%; administered as a paracervical or direct cervical injection) and a saline placebo (mean difference (MD) -13.74; 95% CI -34.32 to 6.83; 2 trials; 130 women; low quality evidence). However, when local anaesthetic was combined with a vasoconstrictor agent (one trial used lignocaine plus adrenaline while the second trial used prilocaine plus felypressin), there was less pain (on visual analogue scale (VAS)) compared with no treatment (MD -23.73; 95% CI -37.53 to -9.93; 2 trials; 95 women; low quality evidence). Comparing two preparations of local anaesthetic combined with vasoconstrictor, prilocaine plus felypressin did not differ from lignocaine plus adrenaline for its effect on pain control (MD -0.05; 95% CI -0.26 to 0.16; 1 trial; 200 women). Although the mean (± standard deviation (SD)) observed blood loss score was less with lignocaine plus adrenaline (1.33 ± 1.05) compared with prilocaine plus felypressin (1.74 ± 0.98), the difference was not clinically as the overall scores in both groups were low (MD 0.41; 95% CI 0.13 to 0.69; 1 trial; 200 women). Inhalation of gas mixture (isoflurane and desflurane) in addition to standard cervical injection with prilocaine plus felypressin resulted in less pain during the LLETZ (loop excision of the transformation zone) procedure (MD -7.20; 95% CI -12.45 to -1.95; 1 trial; 389 women). Lignocaine plus ornipressin resulted in less measured blood loss (MD -8.75 ml; 95% CI -10.43 to -7.07; 1 trial; 100 women) and a shorter duration of treatment (MD -7.72 minutes; 95% CI -8.49 to -6.95; 1 trial; 100 women) than cervical infiltration with lignocaine alone. Buffered solution (sodium bicarbonate buffer mixed with lignocaine plus adrenaline) was not superior to non-buffered solution of lignocaine plus adrenaline in relieving pain during the procedure (MD -8.00; 95% CI -17.57 to 1.57; 1 trial; 52 women).One meta-analysis found no difference in pain using VAS between women who received oral analgesic and women who received placebo (MD -3.51; 95% CI -10.03 to 3.01; 2 trials; 129 women; low quality evidence).Cocaine spray was associated with less pain (MD -28.00; 95% CI -37.86 to -18.14; 1 trial; 50 women) and blood loss (MD 0.04; 95% CI 0 to 0.70; 1 trial; 50 women) than placebo.None of the trials reported serious adverse events and majority of trials were at moderate or high risk of bias (13 trials). AUTHORS' CONCLUSIONS: Based on two small trials, there was no difference in pain relief in women receiving oral analgesics compared with placebo or no treatment (MD -3.51; 95% CI -10.03 to 3.01; 129 women). We consider this evidence to be of a low to moderate quality. In routine clinical practice, intracervical injection of local anaesthetic with a vasoconstrictor (lignocaine plus adrenaline or prilocaine plus felypressin) appears to be the optimum analgesia for treatment. However, further high quality, adequately powered trials should be undertaken in order to provide the data necessary to estimate the efficacy of oral analgesics, the optimal route of administration and dose of local anaesthetics.

[Evaluation of satisfaction after in-office conization under local anesthesia]. / Évaluation de la satisfaction des patientes après conisation en consultation sous anesthésie locale.

OBJECTIVES: Treating cervical intraepithelial neoplasia is essential in cervix carcinoma prevention and conization is the standard treatment. In the current medical and economic context, which advocates the simplification of procedures, loop excision conization is well adapted to an in-office procedure. Therefore, we evaluated the patient satisfaction after an in-office conization. METHOD: We conducted an observational study at the Besançon University Medical Centre. Between November 2013 and October 2014, all patients treated by an in-office conization were included. Global satisfaction of patient was retrospectively collected by answering a telephone questionnaire. RESULTS: Seventy patients were treated by in-office conization and answered the questionnaire. Global satisfaction was 88.6%. Moreover, 75.7% of patients declared to have felt no pain or moderate pain during the conization. Most of the patients (91.4%) would advise this in-office care to their relatives. The rate of positive margins for dysplasia was 31.4% and postoperative haemorrhage occurred in 7.1%. CONCLUSION: In this context of medical care cost reduction, conization seems to be perfectly adapted to in-office surgery. It was also found to be well accepted by patients without raising neither positive margins rate nor postoperative haemorrhage risk.

Pain relief for women with cervical intraepithelial neoplasia undergoing colposcopy treatment.

BACKGROUND: Pre-cancerous lesions of cervix (cervical intraepithelial neoplasia (CIN)) are usually treated with excisional or ablative procedures. In the UK, the NHS cervical screening guidelines suggest that over 80% of treatments should be performed in an outpatient setting (colposcopy clinics). Furthermore, these guidelines suggest that analgesia should always be given prior to laser or excisional treatments. Currently various pain relief strategies are employed that may reduce pain during these procedures. OBJECTIVES: The aim of this review was to assess whether the administration of pain relief reduced pain during colposcopy treatment and in the postoperative period. SEARCH METHODS: We searched the Cochrane Gynaecological Cancer Review Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL - May 2011) (2011, Issue 2), MEDLINE (1950 to May week 2, 2011), EMBASE (1980 to week 20, 2011) for studies of any design relating to analgesia for colposcopic management. We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field. SELECTION CRITERIA: Randomised controlled trials (RCTs) that compared all types of pain relief before, during or after outpatient treatment to the cervix, in adult women with CIN undergoing loop excision, laser ablation, laser excision or cryosurgery in an outpatient colposcopy clinic setting. DATA COLLECTION AND ANALYSIS: We independently assessed study eligibility, extracted data and assessed risk of bias. We entered data into RevMan and double checked it for accuracy. Where possible, the results were expressed as mean pain score and standard error of the mean with 95% confidence intervals (CI) and the data were synthesised in a meta-analysis. MAIN RESULTS: We included 17 RCTs (1567 women) of varying methodological quality in the review. These trials compared a variety of interventions aimed at reducing pain in women who underwent treatment for CIN, including cervical injection with lignocaine alone, lignocaine with adrenaline, prilocaine with felypressin, oral analgesics (non-steroidal anti-inflammatory drugs (NSAIDs)), inhalation analgesia (gas mixture of isoflurane and desflurane), lignocaine spray, cocaine spray, local application of benzocaine gel, lignocaine-prilocaine cream (EMLA cream) and transcutaneous electrical nerve stimulation (TENS).Most comparisons were restricted to single trial analyses and were under-powered to detect differences in pain scores between treatments that may or may not have been present. There was no significant difference in pain relief between women who received local anaesthetic infiltration (lignocaine 2%; administered as a paracervical or direct cervical injection) and a saline placebo (2 trials; 130 women; MD -13.74; 95% CI -34.32 to 6.83). However, when local anaesthetic was combined with a vasoconstrictor agent (one trial used lignocaine combined with adrenaline while the second trial used prilocaine combined with felypressin), significantly less pain (on visual analogue scores) occurred compared with no treatment (2 trials; 95 women; MD -23.73; 95% CI -37.53 to -9.93). Comparing two preparations of local anaesthetic plus vasoconstrictor, prilocaine combined with felypressin did not differ from lignocaine combined with adrenaline for its effect on pain control (1 trial; 200 women; MD -0.05; 95% CI -0.26 to 0.16). Although the mean observed blood loss score was less with lignocaine plus adrenaline (1.33 ± 1.05) as compared with prilocaine plus felypressin (1.74 ± 0.98), the difference was not clinically significant as the overall scores in both groups were low (1 trial; 200 women; MD 0.41; 95% CI 0.13 to 0.69). Inhalation of gas mixture (isoflurane and desflurane) in addition to standard cervical injection with prilocaine plus felypressin resulted in significantly less pain during the LLETZ (loop excision of the transformation zone) procedure (1 trial; 389 women; MD -7.20; 95% CI -12.45 to -1.95). Lignocaine plus ornipressin resulted in significantly less measured blood loss (1 trial; 100 women; MD -8.75; 95% CI -10.43 to -7.07) and a shorter duration of treatment (1 trial; 100 women; MD -7.72; 95% CI -8.49 to -6.95) than cervical infiltration with lignocaine alone.One meta-analysis found no statistically significant difference in pain using visual analogue scores between women who received oral analgesic and those who received placebo (2 trials; 129 women; MD -3.51; 95% CI -10.03 to 3.01; Analysis 6.1).Cocaine spray was associated with significantly less pain (1 trial; 50 women; MD -28; 95% CI -37.86 to -18.14) and blood loss (1 trial; 50 women; MD 0.04; 95% CI 0 to 0.70) than placebo.No serious adverse events were reported in any of the trials and majority of trials were at moderate or high risk of bias (n = 12). AUTHORS' CONCLUSIONS: Based on two small trials, there was no significant difference in pain relief in women receiving oral analgesics compared with placebo or no treatment (129 women; MD -3.51; 95% CI -10.03 to 3.01). We consider this evidence to be of a low to moderate quality. In routine clinical practice, intracervical injection of local anaesthetic with a vasoconstrictor (lignocaine plus adrenaline or prilocaine plus felypressin) appears to be the optimum analgesia for treatment. However, further high-quality, adequately powered trials should be undertaken in order to provide the data necessary to estimate the efficacy of oral analgesics, the optimal route of administration and dose of local anaesthetics.

A comparative study of efficacy and outcomes of large loop excision of the transformation zone procedure performed under general anaesthesia versus local anaesthesia.

BACKGROUND: Although Australian National Health and Medical Research Council (NHMRC) guidelines do not specify targets for mode of anaesthesia for large loop excision of the transformation zone (LLETZ) procedures, UK NHS Cervical Screening Programme (NHSCSP) guidelines recommend that >80% of LLETZ procedures be performed under local anaesthesia. There is a paucity of clinical data regarding both the proportion of women receiving general anaesthesia for treatment, factors underpinning this choice and the impact of mode of anaesthesia on treatment outcomes. AIMS: To identify the proportion of women who have a LLETZ under general anaesthesia and to establish the impact of mode of anaesthesia on outcomes including treatment efficacy, overtreatment (negative histology), short-term morbidity and attendance for follow-up. METHODS: Single-centre retrospective analysis of all women treated with LLETZ for suspected cervical dysplasia between 1, May 2005 and 1, May 2009. RESULTS: Thirty-three percent of a total 465 LLETZ procedures were carried out under general anaesthesia, although the reason for anaesthesia choice was not recorded in 52% of cases. There were no significant differences in the primary outcomes of unclear LLETZ margins or negative LLETZ histology, or in the secondary outcomes of depth and surface area of LLETZ specimen, short-term morbidity or rates of incomplete follow-up. CONCLUSIONS: Although reasons underpinning selection of anaesthesia mode remain elusive, at this centre, outcomes following LLETZ procedure for the management of suspected cervical dysplasia are not affected by the mode of anaesthesia used.

Physician and patient factors associated with follow up of high grade dysplasias of the cervix: a population-based study.

OBJECTIVE: This population-based study characterizes available physician and patient factors involved in the follow up of abnormal Pap smear results. METHODS: Women with a first time high grade diagnosis on Pap smear between 2000 and 2005 were identified utilizing a centralized cervical screening database. Databases containing information on healthcare delivery and physician practice characteristics in a setting of universal health care were linked. Follow up is defined as referral to colposcopy or any excisional procedure associated with management of severe dysplasia. Multivariate analysis followed by logistic regression was performed addressing follow up as the dependant factor. RESULTS: The study population contained 43,792 women with a first time high grade cervical abnormality. The loss to follow up rate was 26%. Physician factors significantly associated with follow up included practice duration of less than 5 years OR 1.28 CI (1.09-1.5); a non-gynecologic practice was associated with lower follow up, OR 0.69 CI (0.65-0.73). Patient factors associated with lower follow up included older age OR 0.97 CI (0.97-0.98) and a lower comorbidity score OR 0.58 CI (0.48-0.7); a lower socioeconomic status was associated with a higher rate of follow up OR 1.17 CI (1.1-1.2). CONCLUSIONS: While patient and physician factors impact appropriate follow up for women with abnormal Pap smears, none of those captured have a high level of influence other than a gynecologic practice. In order to improve upon the high loss to follow up rate, more information is needed on the practice settings of physicians and the screening program components and policies.

Long-term cytological and histological outcomes in women managed with loop excision treatment under local anaesthetic for high-grade cervical intraepithelial neoplasia.

OBJECTIVE: This study examines the impact of excision margin status after large loop excision of the transformation zone (LLETZ) under local anaesthetic for high-grade cervical intraepithelial neoplasia (HG-CIN) on the cytological and histological outcomes up to 5 years after treatment. METHODS: Prospective cytological and histological data were obtained by examination of the colposcopy database at Addenbrooke's Hospital, Cambridge, UK. All women aged between 19 and 50 years who underwent treatment for HG-CIN by LLETZ under local anaesthetic were included in the study. Patients without follow-up data were excluded from the study. The excision margin status was correlated with the subsequent cytological and histological outcomes. RESULTS: A series of 967 women with CIN2 and CIN3 underwent LLETZ excision under local anaesthetic. Overall, 42% of women had disease present at the excision margin following LLETZ. Women with CIN3 were more likely than those with CIN2 to have an involved excision margin (P<0.0001). Cytological recurrence was highest at 12 months (16%) and did not correlate with the CIN grade or excision margin status. Histological recurrence/persistence was also highest at 12 months follow-up (15%) and this correlated with grade of CIN and margin status (P<0.0001). CONCLUSIONS: Histological recurrence/persistence correlates with grade of CIN and excision margin status. Management of HG-CIN in an outpatient setting under local anaesthetic is safe, cost effective and yields a favourable long-term outcome.

A randomised controlled trial comparing two different local anaesthetic injection techniques prior to LLETZ.

The aim of this study was to compare two different anaesthetic injection techniques and assess whether one was less painful than the other when used prior to LLETZ. A total of 60 women undergoing LLETZ were randomised into two groups. The control group received local anaesthesia by deep injection into the substance of the cervix. The study group received an equivalent amount of local anaesthetic but this was injected superficially prior to deep injection into the cervix. Pain was assessed using a visual analogue scale. Women in the study arm experienced less pain than controls during injection of local anaesthetic.

Resección electroquirúrgica ambulatoria del CIN / CIN's ambulatory electroquirurgical resection

En la patología preinvasiva cervical interesa que el tratamiento sea menos agresivo pero que pueda erradicar totalmente la lesión. El cáncer de cuello uterino no puede aparecer después de anomalías en el epitelio malpighiano. El objetivo de este trabajo es presentar los primeros resultados de tratamiento de la patología cervical con asa diatérmica y anestesia local

A randomized study of local or general anesthesia for laser conization of the cervix.

Laser Conization of the cervix was performed in both inpatient and outpatient settings with either local or general anesthesia. All of the patients included had abnormal cervical smears, abnormal colposcopic findings and were allocated to one of two groups, A and B. Patients in group A had general anesthesia while patients in group B had only local anesthesia. A standard operative technique, was used and all patients had estimation of blood loss, recording of operative time, surgical suite time, anesthesia induction time, and assessment of postoperative pain and morbidity. Statistical analysis was performed using the student t-test. We concluded that laser conization of the cervix can be performed more cheaply with local anesthesia than with general anesthesia and with little discomfort, less nausea, and vomitting.

[Laser conization guided by endocervical staining with methylene blue]. / Conizzazione laser guidata mediante colorazione endocervicale con blu di metilene.

The authors report their experience of the use of a vital stain--methylene blue--as a surgical guide in laser cervical conization for CIN2-CIN3/CIS. During the period 1 October 1991-31 December 1992 a total of 40 laser cervical conizations were performed under local anesthesia using a CO2 laser connected to a microhandpiece and colposcope in patients with exo-endocervical lesions which were histologically positive for CIN2-CIN3/CIS. In 33/40 patients an aqueous solution of 1% methylene blue was introduced preoperatively in the endocervix using a cotton-wool bud with consequent impregnation of the pseudoglandular crypts: laser biopsy was performed along the guidelines of the stain itself. This enabled the direction of resection to be varied: in 3 patients due to an anomalous and eccentric direction of cervical canal; in 10 patients to remove glandular structures surrounding or underneath lesions; in 8 patients following pseudoglandular section to carry out deep vaporization (3 patients) or correct cutting edges (5 patients). The apex and edges of the cone were always intact. Fourteen patients completed a 12-month follow-up and a further 6 were followed up for 9 months; only 1/14 patients (with AIDS) showed recidivation after 1 year. In the authors' experience the use of a vital stain as a guide during laser cervical cone biopsy is an easily used method which ensures the greatest possible respect for healthy cervical structures, also in order to preserve fertility in young patients.

A study on the usefulness of local anaesthesia for the laser vaporization of conizations in the uterine cervix.

The purpose of our study is to evaluate the need to use anaesthesia during laser ablation treatment of cervical intraepithelial neoplasia (CIN) in populations of Asian women. Forty patients who were to undergo the ablation of CIN grade 1 or 2 were randomly divided into two groups. One group of patients was treated without any anaesthesia and the other group was treated using a paracervical block with lidocaine. The patients' experience of pain during the procedure was measured. These evaluations included an objective assessment made by the surgeons during the procedure using an objective pain scoring system, and a subjective estimation made by the patients themselves after the procedure using a visual analogue scale. Patients' feelings concerning the acceptability of either procedure were also elicited. Our results show that the case distribution of objective pain scores between the two groups of patients is not statistically different (p > 0.05). The mean visual analogue score of the patients who were not given anaesthesia (24.1%, SD 9.4) does not differ statistically from that of the patients who were administered a paracervical block (25.0%, SD 10.0, p > 0.05). Further, the acceptability rates of both groups are high (85% with paracervical block, 90% without anaesthesia), and the overall rates of the two groups are not statistically different (p > 0.05). These results imply that there may be differences in pain perception between Eastern and Western women. We conclude that in populations of Asian women, it is unnecessary to use anaesthesia during cervical laser ablation.

Local anesthesia for cryosurgery on the cervix.

Forty-five patients were evaluated in a prospective, randomized study to determine the effectiveness of a local injection of lidocaine in reducing pain during cervical cryosurgery. Study patients received a submucosal cervical injection of 1% lidocaine with a 1:100,000 dilution of epinephrine. Control patients did not receive an injection. Both groups received a single dose of naproxen sodium or ketoprofen prior to the procedure. The patient and the observing nurse recorded the pain experienced with a visual analog scale (VAS). Nurse and patient response for the control and study groups showed a high correlation (r = .573 and P < .01, r = .673 and P < .001, respectively). The mean VAS score recorded for the 26 control patients was 4.27, significantly greater than the mean score for the 19 study patients, 1.16 (P < .001). These findings indicate that a submucosal local injection of lidocaine with epinephrine is effective in reducing pain during cervical cryosurgery.

[Electrosurgical loop excision as diagnostic and simultaneously therapeutic intervention in cervical intraepithelial neoplasia]. / Elektrochirurgische Schlingenexzision als diagnostischer und gleichzeitig therapeutischer Eingriff bei der zervikalen intraepithelialen Neoplasie.

109 women referred to our center for colposcopy because of suspicious cervical cytology and in whom an abnormal epithelial pattern was diagnosed on colposcopy, or in whom a discrepancy between cytology and colposcopy was encountered, concomitantly underwent loop electrosurgical excision procedure as an outpatient procedure. All removed specimens were examined and no invasive cancer was found in any of them. No serious complications occurred. Ambulatory loop electrosurgical excision procedure appears to be a cost-effective and well tolerated treatment modality for the management of women with cervical intraepithelial neoplasia, with the advantage that this conservative procedure allows histologic examination of the removed tissue.