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Meta-Analysis
. 2013 Dec 4;2013(12):CD001318.
doi: 10.1002/14651858.CD001318.pub3.

Surgery for cervical intraepithelial neoplasia

Pierre P L Martin-Hirsch  1 , Evangelos Paraskevaidis, Andrew Bryant, Heather O Dickinson
Affiliations
Meta-Analysis

Surgery for cervical intraepithelial neoplasia

Pierre P L Martin-Hirsch et al. Cochrane Database Syst Rev. .

Abstract

Background: Cervical intraepithelial neoplasia (CIN) is the most common pre-malignant lesion. Atypical squamous changes occur in the transformation zone of the cervix with mild, moderate or severe changes described by their depth (CIN 1, 2 or 3). Cervical intraepithelial neoplasia is treated by local ablation or lower morbidity excision techniques. Choice of treatment depends on the grade and extent of the disease.

Objectives: To assess the effectiveness and safety of alternative surgical treatments for CIN.

Search methods: We searched the Cochrane Gynaecological Cancer Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE and EMBASE (up to November 2012). We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of included studies.

Selection criteria: Randomised controlled trials (RCTs) of alternative surgical treatments in women with cervical intraepithelial neoplasia.

Data collection and analysis: Two review authors independently abstracted data and assessed risks of bias. Risk ratios that compared residual disease after the follow-up examination and adverse events in women who received one of either laser ablation, laser conisation, large loop excision of the transformation zone (LLETZ), knife conisation or cryotherapy were pooled in random-effects model meta-analyses.

Main results: Twenty-nine trials were included. Seven surgical techniques were tested in various comparisons. No significant differences in treatment failures were demonstrated in terms of persistent disease after treatment. Large loop excision of the transformation zone appeared to provide the most reliable specimens for histology with the least morbidity. Morbidity was lower than with laser conisation, although the trials did not provide data for every outcome measure. There were not enough data to assess the effect on morbidity when compared with laser ablation.

Authors' conclusions: The evidence suggests that there is no obvious superior surgical technique for treating cervical intraepithelial neoplasia in terms of treatment failures or operative morbidity.

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Conflict of interest statement

None

Figures

1
1
Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.
2
2
Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
1.1
1.1. Analysis
Comparison 1 Single freeze cryotherapy versus double freeze cryotherapy, Outcome 1 Residual Disease within 12 months.
2.1
2.1. Analysis
Comparison 2 Laser ablation versus cryotherapy, Outcome 1 Residual Disease (All Grades of CIN).
2.2
2.2. Analysis
Comparison 2 Laser ablation versus cryotherapy, Outcome 2 Residual Disease (CIN1, CIN2, CIN3).
2.3
2.3. Analysis
Comparison 2 Laser ablation versus cryotherapy, Outcome 3 Peri‐operative Severe Pain.
2.4
2.4. Analysis
Comparison 2 Laser ablation versus cryotherapy, Outcome 4 Peri‐operative Severe Bleeding.
2.5
2.5. Analysis
Comparison 2 Laser ablation versus cryotherapy, Outcome 5 Vaso‐motor Symptoms.
2.6
2.6. Analysis
Comparison 2 Laser ablation versus cryotherapy, Outcome 6 Malodorous Discharge.
2.7
2.7. Analysis
Comparison 2 Laser ablation versus cryotherapy, Outcome 7 Inadequate Colposcopy at Follow‐up.
2.8
2.8. Analysis
Comparison 2 Laser ablation versus cryotherapy, Outcome 8 Cervical Stenosis at Follow‐up.
3.1
3.1. Analysis
Comparison 3 Laser conisation versus knife conisation, Outcome 1 Residual Disease (All Grades of CIN).
3.2
3.2. Analysis
Comparison 3 Laser conisation versus knife conisation, Outcome 2 Primary Haemorrhage.
3.3
3.3. Analysis
Comparison 3 Laser conisation versus knife conisation, Outcome 3 Secondary Haemorrhage.
3.4
3.4. Analysis
Comparison 3 Laser conisation versus knife conisation, Outcome 4 Inadequate Colposcopy at Follow‐up.
3.5
3.5. Analysis
Comparison 3 Laser conisation versus knife conisation, Outcome 5 Cervical Stenosis at Follow‐up.
3.6
3.6. Analysis
Comparison 3 Laser conisation versus knife conisation, Outcome 6 Significant Thermal Artifact Prohibiting Interpretation of Resection Margin.
4.1
4.1. Analysis
Comparison 4 Laser conisation versus laser ablation, Outcome 1 Residual Disease (All Grades of Disease).
4.2
4.2. Analysis
Comparison 4 Laser conisation versus laser ablation, Outcome 2 Peri‐operative Severe Bleeding.
4.3
4.3. Analysis
Comparison 4 Laser conisation versus laser ablation, Outcome 3 Secondary Haemorrhage.
4.4
4.4. Analysis
Comparison 4 Laser conisation versus laser ablation, Outcome 4 Inadequate Colposcopy at Follow‐up.
5.1
5.1. Analysis
Comparison 5 Laser conisation versus loop excision, Outcome 1 Residual Disease.
5.2
5.2. Analysis
Comparison 5 Laser conisation versus loop excision, Outcome 2 Duration of Procedure.
5.3
5.3. Analysis
Comparison 5 Laser conisation versus loop excision, Outcome 3 peri‐operative severe bleeding.
5.4
5.4. Analysis
Comparison 5 Laser conisation versus loop excision, Outcome 4 Peri‐operative Severe Pain.
5.5
5.5. Analysis
Comparison 5 Laser conisation versus loop excision, Outcome 5 Secondary Haemorrhage.
5.6
5.6. Analysis
Comparison 5 Laser conisation versus loop excision, Outcome 6 Significant Thermal Artefact on Biopsy.
5.7
5.7. Analysis
Comparison 5 Laser conisation versus loop excision, Outcome 7 Depth of Thermal Artifact.
5.8
5.8. Analysis
Comparison 5 Laser conisation versus loop excision, Outcome 8 Inadequate Colposcopy.
5.9
5.9. Analysis
Comparison 5 Laser conisation versus loop excision, Outcome 9 Cervical Stenosis.
5.10
5.10. Analysis
Comparison 5 Laser conisation versus loop excision, Outcome 10 Vaginal discharge.
6.1
6.1. Analysis
Comparison 6 Laser ablation versus loop excision, Outcome 1 Residual Disease.
6.2
6.2. Analysis
Comparison 6 Laser ablation versus loop excision, Outcome 2 Peri‐operative Severe Pain.
6.3
6.3. Analysis
Comparison 6 Laser ablation versus loop excision, Outcome 3 Primary Haemorrhage.
6.4
6.4. Analysis
Comparison 6 Laser ablation versus loop excision, Outcome 4 Secondary Haemorrhage.
7.1
7.1. Analysis
Comparison 7 Knife conisation versus loop excision, Outcome 1 Residual Disease.
7.2
7.2. Analysis
Comparison 7 Knife conisation versus loop excision, Outcome 2 Primary Haemorrhage.
7.3
7.3. Analysis
Comparison 7 Knife conisation versus loop excision, Outcome 3 Inadequate Colposcopy at Follow‐up.
7.4
7.4. Analysis
Comparison 7 Knife conisation versus loop excision, Outcome 4 Cervical Stenosis.
8.1
8.1. Analysis
Comparison 8 Radical diathermy versus LLETZ, Outcome 1 Duration of blood loss.
8.2
8.2. Analysis
Comparison 8 Radical diathermy versus LLETZ, Outcome 2 Blood stained / watery discharge.
8.3
8.3. Analysis
Comparison 8 Radical diathermy versus LLETZ, Outcome 3 Yellow discharge.
8.4
8.4. Analysis
Comparison 8 Radical diathermy versus LLETZ, Outcome 4 White discharge.
8.5
8.5. Analysis
Comparison 8 Radical diathermy versus LLETZ, Outcome 5 Upper Abdominal Pain.
8.6
8.6. Analysis
Comparison 8 Radical diathermy versus LLETZ, Outcome 6 Lower Abdominal Pain.
8.7
8.7. Analysis
Comparison 8 Radical diathermy versus LLETZ, Outcome 7 Deep Pelvic Pain.
8.8
8.8. Analysis
Comparison 8 Radical diathermy versus LLETZ, Outcome 8 Vaginal Pain.
9.1
9.1. Analysis
Comparison 9 Knife cone biopsy: haemostatic sutures versus none, Outcome 1 Primary Haemorrhage.
9.2
9.2. Analysis
Comparison 9 Knife cone biopsy: haemostatic sutures versus none, Outcome 2 Secondary Haemorrhage.
9.3
9.3. Analysis
Comparison 9 Knife cone biopsy: haemostatic sutures versus none, Outcome 3 Cervical Stenosis.
9.4
9.4. Analysis
Comparison 9 Knife cone biopsy: haemostatic sutures versus none, Outcome 4 Inadequate Colposcopy at Follow‐up.
9.5
9.5. Analysis
Comparison 9 Knife cone biopsy: haemostatic sutures versus none, Outcome 5 Dysmenorrhoea.
10.1
10.1. Analysis
Comparison 10 Bipolar electrocautery scissors versus monopolar energy scalpel, Outcome 1 Peri‐operative bleeding.
10.2
10.2. Analysis
Comparison 10 Bipolar electrocautery scissors versus monopolar energy scalpel, Outcome 2 Duration of procedure.
10.3
10.3. Analysis
Comparison 10 Bipolar electrocautery scissors versus monopolar energy scalpel, Outcome 3 Primary haemorrhage.
11.1
11.1. Analysis
Comparison 11 LEEP versus cryotherapy, Outcome 1 Residual disease at 6 months.
11.2
11.2. Analysis
Comparison 11 LEEP versus cryotherapy, Outcome 2 Residual disease at 12 months.
11.3
11.3. Analysis
Comparison 11 LEEP versus cryotherapy, Outcome 3 Primary haemorrhage.
11.4
11.4. Analysis
Comparison 11 LEEP versus cryotherapy, Outcome 4 Secondary haemorrhage.
11.5
11.5. Analysis
Comparison 11 LEEP versus cryotherapy, Outcome 5 Offensive discharge.
11.6
11.6. Analysis
Comparison 11 LEEP versus cryotherapy, Outcome 6 Watery discharge.
11.7
11.7. Analysis
Comparison 11 LEEP versus cryotherapy, Outcome 7 Peri‐operative severe pain.
12.1
12.1. Analysis
Comparison 12 Pure cut setting versus blend setting when performing LLETZ, Outcome 1 Residual disease at 6 months.
12.2
12.2. Analysis
Comparison 12 Pure cut setting versus blend setting when performing LLETZ, Outcome 2 Depth of thermal artefact at deep stromal margin.
13.1
13.1. Analysis
Comparison 13 LLETZ versus NETZ, Outcome 1 Residual disease at 36 months.
13.2
13.2. Analysis
Comparison 13 LLETZ versus NETZ, Outcome 2 Peri‐operative pain.
13.3
13.3. Analysis
Comparison 13 LLETZ versus NETZ, Outcome 3 Peri‐operative blood loss interfering with treatment.
13.4
13.4. Analysis
Comparison 13 LLETZ versus NETZ, Outcome 4 Bleeding requiring vaginal pack.
13.5
13.5. Analysis
Comparison 13 LLETZ versus NETZ, Outcome 5 Cervical stenosis at follow‐up.
14.1
14.1. Analysis
Comparison 14 Knife conisation versus NETZ, Outcome 1 Residual disease at 36 months.
15.1
15.1. Analysis
Comparison 15 LLETZ versus Knife conisation, Outcome 1 Residual disease at 36 months.
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