Cold Knife Conization of the Uterine Cervix

Introduction

Cervical conization refers to the surgical excision of a cone-shaped portion of the uterine cervix surrounding the endocervical canal and including the entire transformation zone and all or most of the cervical canal. It has been used for years for both diagnosis and treatment of cervical intraepithelial neoplasia. Screening for cervical dysplasia using cytology has resulted in a significant decrease in the incidence and mortality of cervical cancer. Once a patient has had an abnormal Papanicolaou (Pap) smear, the clinician should move forward to colposcopy with directed biopsies in an attempt to establish a histologic diagnosis. Conization of the cervix is indicated for the following: an unsatisfactory colposcopy (i.e., the entire squamocolumnar junction or the full extent of lesions cannot be visualized); colposcopic biopsy shows a lesion that is CIN (cervical intraepithelial neoplasia) II or CIN III and is not amenable to less invasive measures; cytologic and/or histologic findings are suggestive of possible invasive disease; recurrent disease after more conservative therapy; and discrepancy between the Pap results and colposcopic findings.
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Anesthesia for the procedure may be regional or general. There are a number of ways to perform cervical conization, including laser, LEEP (loop electrosurgical excision procedure), and cold knife cone (CKC). This chapter focuses on cold knife conization.

Equipment

Urinary catheter
Weighted speculum
Right-angle retractor
Single-tooth tenaculum
Long-handled scalpel
No. 11 blade
Allis clamps
Electrocautery unit
Mayo scissors
Kevorkian endocervical curette
Delayed absorbable sutures (optional)
Absorbable gelatin sponge (Gelfoam) (optional)

Indications

Colposcopy is unsatisfactory:
- Entire TMZ (transformation zone) cannot be visualized
- Entire lesion cannot be visualized and/or extends into the cervical canal beyond the ability to visualize
Cytologic and/or histologic findings show possible invasive disease.
Two-grade difference is found between the Pap results and the colposcopic findings (e.g., the Pap shows high-grade squamous intraepithelial lesion [HSIL], but the colposcopy is normal).
Biopsy shows microinvasion.
Positive endocervical curettage (ECC) has been performed.
Adenocarcinoma in situ is present.

Contraindications

Pregnancy (relative): conization should be done only in the case of cervical cancer and should be performed by a gynecological oncologist.
Cervical cancer is beyond stage IA1.

The Procedure

Step 1
Place the patient in the dorsal lithotomy position in candy cane stirrups.

PITFALL: Do not do a digital vaginal exam at this time because it may cause bleeding and obscure the field.
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Step 2
Perform a colposcopy with 3% to 5% acetic acid or Lugol 's solution and examine the cervix. Some clinicians choose not to do this when there is a colposcopic diagram available that shows the areas of dysplasia. See Colposcopy and Directed Cervical Biopsy.

PEARL: Be gentle when preparing the cervix and vagina to prevent trauma to the cervix that may lead to difficulty in histologic interpretation of the cervix.
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Step 3
Grasp the anterior lip of the cervix, and inject diluted vasopressin or epinephrine into the cervical stroma just lateral to the area that is to be coned.

PITFALL: Always let the anesthesiologist know when you inject a vasoconstrictor.
PEARL: Some clinicians place absorbable sutures at 3 o 'clock and 9 o 'clock positions in the cervix at the cervicovaginal junction to impede flow to the cervical branches of the uterine arteries. One must take care not to place the sutures too deep so that they will not be inadvertently cut during excision.
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Step 4
Use a long-handled scalpel with a no. 11 blade to make a circumferential incision just lateral to the TMZ. Start posteriorly, and insert the scalpel blade at the desired depth, angling toward the endocervical canal. It is also reasonable to make a superficial circumferential incision initially and then go deep.
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Step 5
Use an Allis clamp to grasp the specimen, taking care not to obscure the specimen.
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Step 6
With either Mayo scissors or a scalpel, completely excise the specimen. Label the specimen with a stitch so that the pathologist will be properly oriented (e.g., place a stitch at 12 o 'clock).
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Step 7
Perform a curettage of the endocervix to exclude residual disease. The cone bed can be made hemostatic with electrocautery. Some clinicians place Gelfoam in the cone bed when sutures are used. The ends of the suture are then tied over the Gelfoam.
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Complications

Immediate

Bleeding (intraoperative or postoperative)
Infection
Uterine perforation

Long Term

Cervical stenosis
Cervical incompetence

Pediatric Considerations

Advanced cervical dysplasia and especially cancer are very rare in the pediatric population. However, the indications and procedure are similar, except CIN2 and diagnostic mismatches may be followed with colposcopy in the adolescent population.

Postprocedure Instructions

The patient is instructed to place nothing into her vagina (tampons, douching, intercourse) for 4 weeks. She should also avoid immersing herself in water (e.g., by taking a bath or swimming) for 4 weeks.
Pain from the procedure is minimal and very seldom requires narcotics. A discharge is normal and may last for up to 4 weeks. Patients with no surgical complications may return to work within a day of surgery.
Assessment of cervical cytology and colposcopy are performed 4 to 6 months postoperatively. Specimens should not be obtained before 3 months because the inflammation makes pathology difficult to interpret.

Coding Information and Supply Sources

View Large CPT Code Description 2008 Average 50th Percentile Fee Global Period 57520 Conization of the cervix, w/wo fulguration, w/wo D&C, w/wo repair, cold knife or laser $1,230.00 90 CPT is a registered trademark of the American Medical Association.2008 average 50th Percentile Fees are provided courtesy of 2008 MMH-SI 's copyrighted Physicians ' Fees and Coding Guide.
Typical gynecological instruments may be obtained from surgical supply houses and hospital supply sources, and many are listed in Appendix H.

Bibliography

1
Berek SJ, Hacker NF.
Practical Gynecologic Oncology.
Philadelphia: Lippincott Williams & Wilkins, 2004. 2
Clinical Management Guidelines for Obstetrician-Gynecologist
. Washington, DC: American College of Obstetricians and Gynecologists; 2005. ACOG Practice Bulletin 66. 3
Hoffman M, Mann W. Procedures for cervical conization: technique and outcome. http://www.utdol.com/. Accessed December
6, 2007. 4
Reich O, Pickel H, Lahousen M, et al. Cervical intraepithelial neoplasia III: long-term outcome after cold-knife conization with clear margins.
Obstet Gynecol
. 2001;97(3):428 " 430. [View Abstract]
5
Webb M. Mayo Clinic Manual of Pelvic Surgery.
Webb M (ed.). Philadelphia: Lippincott Williams & Wilkins, 2000. 6
Wright TC Jr, Cox JT, Massad LS, et al. Consensus guidelines for the management of women with cervical cytological abnormalities and cervical cancer precursors, part I: cytological abnormalities.
JAMA
. 2002;287(18):2120 " 2129. [View Abstract]
7
Wright TC, Cox JT, Massad LS, et al. Consensus guidelines for the management of women with cervical intraepithelial neoplasia.
Amer J Obstet Gynecol
. 2003;189:295 " 304. [View Abstract]
8
2008 MAG Mutual Healthcare Solutions, Inc. 's
Physicians ' Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc.
2007.

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