LEEP (Loop Electrosurgical Excision procedure)

Women with high-grade Papanicolaou (Pap) smears had a 45-65 percent chance of developing moderate–high-grade intraepithelial neoplasia on biopsy and a 2% chance of developing invasive cancer. Inconsistencies between Pap smear cytology and cervical biopsy histopathology, on the other hand, can create a clinical challenge. Patients with a High-Grade Squamous Intraepithelial Lesion Pap smear and cervical biopsies with Cervical Intraepithelial Neoplasia 1 histology or less are considered discrepant. When no disease or Cervical Intraepithelial Neoplasia 1 is discovered with acceptable colposcopy, the American Society for Colposcopy and Cervical Pathology formerly recommended an excisional technique for diagnosis in nonpregnant women. More patients are choosing conservative care as we gain a better understanding of Human papillomavirus infection, its course of the disease, and outcomes.

Because there is a concern that the high-grade lesion discovered on Pap smear was overlooked on the biopsy, a loop electrosurgical excisional technique (LEEP) is a suitable therapy choice for this discrepancy in non-adolescent patients. However, we know that up to 34% of women with High-Grade Squamous Intraepithelial Lesion will naturally regress, negating the need for an excisional technique. There hasn't been any research on how the period between the initial High-Grade Squamous Intraepithelial Lesions cytology and the LEEP affects the risk of identifying substantial pathology in the LEEP sample.

The goal of the studies was to see if the period between the initial High-Grade Squamous Intraepithelial Lesion Pap smear and the LEEP for discrepancy influences the pathologic grade of cervical intraepithelial neoplasia in the LEEP material. We expected that the likelihood of identifying Cervical Intraepithelial Neoplasia 2 and 3 in the LEEP sample would reduce as the time elapsed between the original High-Grade Squamous Intraepithelial Lesions Pap and later LEEP for discrepancy grew.

What is a LEEP?

The loop electrosurgical excision procedure (LEEP) removes cells and tissue from a woman's lower reproductive tract using an inoculating loop warmed by electric current. It's used to help doctors diagnose and treat unhealthy or malignant diseases.

The cervix and vagina are part of the lower genital tract. The vagina joins the cervix with the vulva, and the cervix is the lowest, narrower section of the uterus.

A tiny layer of diseased tissue is sliced away using LEEP by passing an electric current via a thin wire loop. This tissue is going to be sent to a laboratory for analysis. LEEP can also be used to eliminate diseased cells, allowing healthy cells to develop in their place.

When abnormal cells are discovered during a Pap smear or when cervical or vaginal issues are discovered during a pelvic examination, LEEP may be performed. LEEP can also be used to identify cervix or vaginal malignancy.

What is a Pap Smear?

Pap tests, also known as Pap smears, are crucial for detecting abnormal cells on the cervix that may progress to cervical cancer. Pap tests reveal cell alterations of human papillomavirus but not the virus itself.

Pap tests may be performed as part of a routine physical examination, pelvic exam, or well-woman exam. A metallic or plastic speculum is inserted into the vaginal canal during a Pap test by the doctor. The speculum expands up to permit them access to your cervix by separating the vaginal walls. Then doctors delicately extract cells from the cervix with a small picker – a tiny spatula or brush. The cells will be sent to and examined at a lab.

It merely takes a couple of minutes to perform a Pap test. They shouldn't bother, but when the doctor inserts the speculum inside you, you may feel some irritation or pressure. When doctors harvest cells from the cervix, you will feel a mild scraping.

Do I Need a Pap Smear?

The frequency with which you get evaluated is determined by the age, medical records, and the findings of your most recent Pap or human papillomavirus test. Generally speaking:

• If you are 20–24 years old, you have the option of undergoing a Pap test every three years or waiting until you are 25 years old.
• If you are between the ages of 24 and 65, obtain a human papillomavirus test every 5 years, or a Pap test and human papillomavirus test at the same time. You might only have a Pap test every three years if human papillomavirus tests aren't readily available in your area.
• If you're above 65, you may no longer require human papillomavirus/Pap tests.

If you've had previous cervix disorders, have a compromised immune system, or if your mother used the drug DES when she was carrying you, you may have to be examined more frequently. The doctor will advise you on the tests you require and how frequently you should have them performed.

What if I Have abnormal Pap Smear Findings?

Don't be alarmed if your Pap testing results are abnormal. Uncertain or abnormal Pap test findings are rather frequent. It usually does not imply that you have cervical cancer.

A positive test that’s equivocal indicates that your cervical cells appear to be abnormal. It's unclear whether this is related to human papillomavirus or anything else. Equivocal, inconclusive, or atypical squamous cells of undetermined significance (ASC-US) findings are all terms for findings that are unclear.

An abnormal Pap test result indicates that the cervix has abnormal cell alterations. This does not necessarily imply that you have cervical cancer. Changes can be minor (low-grade) or substantial (high-grade). Precancerous alterations are referred to as such since they are not currently cancer but may develop into it in the future.

If your Pap test result is uncertain or abnormal, you may need additional tests and/or therapy, which may include:

• Another Pap tests.
• A human papillomavirus test looks for high-risk strains of the virus that can lead to precancerous cells.
• A colposcopy is a particular checkup that looks at the cervix more carefully to see whether there are any precancerous lesions.

You will almost certainly need therapy if the doctor discovers precancerous cells after the colposcopy. Cryotherapy and LEEP are two common procedures.

LEEP Indications

The following are the indications for LEEP surgical removal:

• Colposcopy that isn't up to par (the transformation zone isn't visible), particularly if a high-grade lesion is detected.
• Microinvasion is expected.
• There is no association between cytology and biopsies, especially when a high-grade lesion is detected.
• The lesion has progressed into the endocervical canal.
• Cervical intraepithelial neoplasia or glandular abnormalities showed by endocervical curettage
• Possible adenocarcinoma in situ (In this case, cold-knife conization may be preferred because there is a larger chance of positive borders and recurrence with LEEP than with cold-knife conization)
• The colposcopist was unable to exclude the presence of invasive malignancy.
• Following an ablative or prior excisional surgery, If there is a recurrence.

Making a Treatment Decision

It is critical to understand the technique, including the advantages, concerns, and side effects, before making a treatment choice. Your colposcopist should go over these with you and answer any questions you might have. You might also wish to discuss with your family or friends your alternatives.

It may be beneficial to prepare a set of questions and bring it with you to the consultation. You might want to consider the following inquiries:

• What kinds of treatments am I eligible for?
• What is the purpose of the treatment?
• What happens if I refuse to receive treatment?
• How long will it go to complete the therapy?
• Is there anything I have to bring to the appointment?
• Will I be able to return home on my own following therapy?
• What physical side effects may I have as a result of treatment?
• What emotional side effects might I have as a result of treatment?

Preoperative Preparation

Anesthesia

LEEP procedure is typically performed in the clinic under local anesthetic. A vasoactive solution combined with a local anesthetic is generally sufficient. A needle is used to administer the solution deep into the cervix circularly outside the zone to be excised. After the administration, the cervix should become pale.

Procedure Equipment

The following items are included within the equipment:

• Electrosurgical generator
• Grounding pad
• Smoke evacuation system
• Insulated vaginal speculum with smokey evacuation tubing
• Various sizes of LEEP excisor electrodes
• Ball electrode
• Single-tooth tenaculum
• Monsel’s solution
• Acetic acid solution
• Pitressin and 1% lidocaine solution
• Needle with a syringe

Patient Positioning

The grounding patch is placed on the upper thigh and the patient is positioned in dorsal lithotomy posture.

How is a LEEP Done?

General Approach

The entire transformation zone is removed with the LEEP excisional cylinder. The size and morphology of the excision should be adapted to the specific circumstances. This is necessary to avoid either insufficient excision of the lesion or excising a specimen that is too huge, both of which can result in short- and long-term consequences. Just before the LEEP excision, the doctor can do a colposcopy in the treatment room or operating theatre to assess the upper vagina and vulva.

If the transformation zone and lesions are in the endocervical tract and the ectocervix looks normal, a lesser resection may be done to help avoid long-term consequences. If the lesions and transformation zone are limited to the ectocervix and the endocervical tract looks to be normal, the excision can be broad and superficial with minimum endocervical canal excision.

The Procedure

To visualize the cervix, the patient is positioned in a dorsal lithotomy position with an insulated speculum and a gaseous evacuation tube implanted in the vagina. An anesthetic solution is injected into the cervix. Acetic acid or Lugol's solution is applied to the cervix to let the doctor view the full lesion and choose the right loop electrode. On blend, the electrosurgical machine is adjusted at 30-50 watts.

The lesion should be removed in one shot if possible. The loop should be properly moved around and under the transformation zone at the same time. To a thickness of 4-9 mm, the complete transformation zone should be removed. The loop should slip through the cervix for the optimum outcomes. This permits the tissue to be divided by the slicing current. Additional thermal injury happens when the loop runs too slowly. If the loop is drawn through the cervix too quickly, it will slip, twist, or stick to the tissue, leading to a specimen that is too superficial. Making repeated passes to thoroughly eliminate all diseases may be essential in patients with big lesions or extensive cervix. More tissue is removed with a narrower rectangular loop if the lesion goes deeper than 4-9 mm into the endocervical tract.

After the operation, a colposcopic review might be done to determine that the excision was enough. After excision, an endocervical curettage may be done, but it is frequently unnecessary because the outcome has no influence on the subsequent care. With a Ball electrode, hemorrhage is usually easily managed. Monsel's solution should also be applied to the cone bed.

Patient Education

For the next 3-4 weeks, patients are advised to stop intercourse and place nothing in the vaginal area. She should also avoid bathing and swimming at the same period. She will be seen again in five weeks to check endocervical patency and proper healing. Cervical cytology is evaluated as previously stated.

Postoperative Long-term Monitoring

Cervical dysplasia patients must be monitored for a longer period of time after treatment. The majority of recurrent or persistent cervical intraepithelial neoplasia is discovered within the first 2-5 years after diagnosis. The ASCCP recommendations are used to guide follow-up monitoring.

Bogani et al analyzed the risk of recurrence after LEEP in patients with high-grade cervical dysplasia in a 5-year follow-up analysis. The only factor linked to an increased incidence of recurrence after LEEP was the persistence of human papillomavirus infection.

LEEP Complications

LEEP is usually effective, with over 90 percent of patients experiencing no further cell abnormalities. Cell alterations will occur in less than 10 percent of people.

The advantage of LEEP is that it inhibits cervical cancer from growing, which outweighs the hazards in many situations. LEEP, like all therapies, comes with risks, and you may experience physical or emotional side effects as a result of it.

If you are concerned about any concerns, speak with your doctor before beginning therapy. They can assist you and answer your concerns. Your physician or a specialty doctor will be able to provide support after therapy.

Postoperative Hemorrhage

After LEEP, about 85 percent of patients experience bleeding. Only about 15 percent of individuals do not experience any bleeding. This is common following LEEP and can last anywhere from two to four weeks.

The soft patch that forms on the cervix where the cells were excised may cause bleeding. It's possible that this will bleed while it cures.

The bleeding is normally similar to that of a period; however, it may be a little thicker. Bleeding may become more severe on the10th day following therapy. This is a common occurrence and indicates that the scab is curing. It's possible that the first period following therapy will be heavier or out of rhythm with your typical cycle.

Essentially, You must inform the doctor if you are using blood thinners or have a hematologic problem since you may have an increased risk of bleeding following LEEP. Call the number provided by the hospital staff if the bleeding is soaking through a period pad each hour. Delayed hemorrhaging is a term used to describe this condition. The hospital staff will be able to assist you and ensure that you receive the best possible care.

Postoperative Pain

LEEP causes pain in about 66 percent of patients. About 34 percent of patients are pain-free.

Pain might last anywhere from two days to four weeks after therapy. The intensity of the pain differs from person to person, but it should not be excessive. It's typically described as a period-like cramping discomfort. You can discuss over-the-counter medications with the doctor to see if they can improve this pain.

Vaginal discharge changes

The vaginal discharge of about 67 percent of people has changed. About 33 percent of people have no alterations in their vaginal secretions.

Vaginal discharge variations can last up to four weeks. You may get a watery, dark vaginal discharge right after therapy.

You may notice a cappuccino granule-like vaginal discharge 9 days after treatment. This is typical and indicates that your cervix’s fragile patch is healing.

Importantly, After LEEP, 1 to 14 percent of persons develop an infection. If the vaginal discharge odor becomes unpleasant or turns yellow or green in color, consult the doctor. Antibiotics will be administered if there is a risk you have an infection.

Preterm birth or late abortion

Because of the procedure, about 2% of women who become pregnant following LEEP will deliver birth before 37 completed weeks of gestation (prematurely). Because of the procedure, about 98 percent of women will not give birth preterm.

If you have had LEEP more than once or had more than 10mm of the cervix excised, you are more likely to give birth early. The majority of LEEP treatments only remove about 10mm of the cervix.

If you become pregnant after receiving LEEP, notify your doctor or midwife about it. They may recommend you to a preterm birth prevention consultant.

Cervical stenosis

Following LEEP, the entrance of the cervix can constrict or close, scarring the cervix. Cervical stenosis is the medical term for this condition. If this occurs, the womb-vaginal channel may become partially or completely obstructed. According to studies, the chances of this happening are between 2 and 15 percent.

Cervical stenosis is more common in the following situations:

• If you smoke, you're more prone to get cervical stenosis.
• A woman who has reached menopause.
• Have undergone multiple LEEP procedures.
• Have had a substantial portion of your cervix removed during therapy.

Cervical stenosis may not cause any symptoms. Menstrual cycles may become irregular or uncomfortable if you have them. If you are attempting to conceive, the sperm might not be able to reach the uterus. Cervical screening may become more difficult for the doctor or nurse in the future; however, you can be sent to a colposcopist (a doctor who examines your vagina and cervix with an endoscope) if this occurs. Cervical stenosis is occasionally managed with cervical dilators, which assist enlarge the cervix.

Persistent Pelvic Pain

After LEEP, you should predict some pelvic pain for a few days, although it could last beyond. We do not even know if this is due to the therapy or other problems or lifestyle factors that have occurred following the therapy.

It's critical to see a doctor if you're having persistent pelvic pain. They can look into the source of the discomfort and provide the necessary assistance.

How to Prevent Complications?

When executing the LEEP treatment, three electrosurgery concepts should be taken into consideration to avoid problems and increase specimen integrity. These factors involve electrode dimensions, current waveform, and incision speed.

Dimensions of the Electrode

Thinner wires allow for more current concentration. Because of the high energy density, the cutting action is better and the thermal dispersion is reduced.

Current Waveform

As the stream is merged, the thickness of coagulation deepens. Cutting and coagulating currents are combined in a mixed current. There is more coagulating current and hence more thermal injury with higher mixes.

Incision speed

The smaller the incision and the less thermal distortion in the sample, the faster the wire is transported through the cervical tissue. The more slowly the wire passes through the tissue, the more heat damage it causes. However, while this improves coagulation of the cone base, it also increases tissue necrosis and postoperative scars.

In addition to lowering the likelihood of cervical stenosis, cutting as little tissue as feasible is critical. Cervical stenosis is more likely with incision depths of less than 1 cm.

Conclusion

In conclusion, compared to cryotherapy, LEEP therapy was linked with a dramatically reduced risk of persistent disease at 5 months and recurrent disease at 11 months in women with cervical intraepithelial neoplasia.