The risk of subsequent premature delivery is known to be related to the depth of excision, and it is significantly increased with the cone depth. However, there is growing evidence suggesting that even more so than the depth, the volume of the specimen could particularly be associated with the risk of subsequent premature delivery. Thus, when performing a LLETZ, every effort should be made to minimize not only the depth of the specimen, but also the volume, while obtaining negative margins, in order to achieve the exact balance between the highest efficacy of treatment and minimal pregnancy-related morbidity. The aim was to assess whether direct colposcopic vision (DCV) of the cervix during large loop excision of the transformation zone (LLETZ) is associated with a decrease in the volume and dimensions of specimens, or affects margin status at histology.
A prospective multicenter observational study of 216 women who underwent LLETZ for grade 2-3 cervical intraepithelial neoplasia (CIN) was conducted. The volume and dimensions (circumference, length and thickness) of the surgical specimens were measured before fixation. Data were compared according to the use of colposcopy during LLETZ. Three groups were considered: LLETZ performed without colposcopy (n=91), LLETZ performed immediately after colposcopy (n=51) and LLETZ performed under DCV (n=74).
Patient characteristics were comparable with regards to age, parity, history of excision, indication of the procedure, and the size of the cervix. We found a significant decrease in all dimensions of the specimens obtained under DCV (p<.001). Margin status was not affected. After adjusting for confounders, the mean volumes were significantly lower in the DCV group (adjusted mean difference -0.66mL, 95%CI -1.17 to -0.14). The probability that negative margins would be achieved together with the attainment of a volume below 5mL and a thickness below 10mm was the highest in the DCV group (adjusted OR 2.80, 95%CI 1.13 to 6.90).
DCV is associated with a significant decrease in the volume and in all dimensions of LLETZ specimens with no compromise in the margin status. By allowing for the precise location of both the upper and lateral limits of the abnormal transformation zone, colposcopy is likely to be the ideal tool for the optimization of LLETZ procedure.