Carbon Dioxide Laser Surgery in Gynecology Workup

  • Author: Janice L Bacon, MD; Chief Editor: David Chelmow, MD   more...
 
Updated: May 9, 2011
 

Laboratory Studies

The Papanicolaou test is the initial screening test for cervical cytologic abnormalities. It is a cost-effective cancer screening tool. Population screening has clearly led to a decline in the incidence of cervical carcinoma. However, by definition, it is a screening tool with a specificity of 95% and a sensitivity of 51%.[7]

  • The specimen is obtained with an appropriate collection device (brush combined with spatula, or broom with or without spatula). The specimens should be representative of the entire transformation zone.
  • The samples obtained may be smeared on a glass slide and sprayed with cell fixative or placed in a liquid-based medium for later cell preparation. The liquid-based evaluation technique may allow the sample to be used for more than cytologic testing. Additional studies that can be performed on the sample may include HPV typing or testing for gonorrhea, chlamydia, or herpes. Future improvements on liquid-based cytology may even allow testing for some other medical diseases.

Vaginal cytologic abnormalities may be detected at Papanicolaou testing or by visual inspection. The colposcope may be used for screening women with intraepithelial neoplasia abnormalities on the genitalia or cervix when visual inspection identifies a lesion or cytology reveals squamous abnormalities.

Vulvar lesions are usually identified by visual inspection following a history of therapy for condylomata or intraepithelial neoplasia elsewhere in the genitalia or upon patient complaints of irritation, itching, or a change in skin appearance (raised lesion, red lesion). The colposcope with use of adjunctive acetic acid may identify additional areas of VIN. Cytologic testing by traditional cytologic smear or liquid-based cytology is not indicated and is insufficient for diagnosis on the vulva. A possible exception is cytologic screening of the squamous tissue of the anus and the squamocolumnar junction of the anus and rectum. Colposcopy improves the inspection of the anus and rectum if symptoms are present or a lesion is seen.

All abnormal areas identified require biopsy if malignant or premalignant findings are suspected. Exclusion of malignancy is required prior to medical or surgical therapy.

Additional preoperative laboratory evaluations may be performed to ensure patient safety during anticipated anesthesia, especially in patients with a complex medical history (eg, cardiovascular disease, hypertension, diabetes).

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Other Tests

HPV typing is often discussed as a possible adjunctive test in the evaluation of cervical cytologic abnormalities. This test is most often used in conjunction with cytologic tests interpreted as ASCUS or used as follow-up testing instead of repeat cytology for select patients.

The most widely available commercial test is a polymerase chain reaction assay, but future studies may incorporate genotyping of HPV.

The 2006 American Society for Cytology and Cervical Pathology (ASCCP) Consensus Guidelines recommend use of high-risk HPV testing in the evaluation of women with the following findings:[8]

  1. Initial triage of women with ASCUS as an alternative to repeat cytology or colposcopy
  2. Women with ASC-H or LSIL cervical cytology tested 12 months after a colposcopic examination revealing no CIN 2 or CIN 3 (This recommendation includes pregnant women.)
  3. Initial evaluation of females with atypical glandular cells performed at the time of colposcopy with endocervical sampling

In 2003, the FDA approved the use of HPV typing as an adjunct to cervical cytologic screening in women aged 30 years or older. It may enhance the sensitivity to cytologic screening. Only high-risk HPV typing is useful in the management of cytologic abnormalities. HPV typing should not be used for screening in women younger than age 30.

HPV typing is not used for evaluation of abnormal lesions of the vulva or vagina except in a research setting. Treatment is based on histologic evaluation of biopsy specimens with consideration of additional medical problems (eg, immunosuppression).

No laboratory tests for adhesions or endometriosis are currently available. CA-125 levels may be elevated in some women with severe endometriosis, but findings are not consistent or specific enough to be used for diagnosis. Many other disease processes elevate CA-125 levels, rendering this test unsuitable for screening.

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Diagnostic Procedures

Preparation for CO2 laser therapy of dysplasia of the cervix, vulva, or vagina includes the following:

  • Reviewing results from cytology; colposcopic examination of the cervical transformation zone, vulva, or vagina; and indicated biopsies to ensure that malignancy is not present.
  • Visualizing the full extent of a lesion and ascertaining it is within the planned area of ablation or excision.
  • Choosing an alternate procedure if these criteria are not met. Lesions of the cervix considered for excision by laser conization alternatively may be considered for a LEEP or a cold-knife conization procedure.

The following steps should be taken prior to using the CO2 laser in the pelvis.

  • Preoperative clinical plans should fully assess the cause of symptoms. All pelvic structures, including the bowel, bladder, internal genital structures, and musculoskeletal system must be considered as possible sources of pain or disease and a decision should be made when to proceed to operative evaluation.
  • Intraoperative evaluation of pelvic pain should include careful laparoscopic inspection of the entire pelvis.
  • The risks and benefits of both diagnostic laparoscopy and intrapelvic CO2 laser ablation and/or excision must be reviewed by the physician with the patient prior to the procedure. The discussion of the extent of the operative procedure planned should be included.
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Contributor Information and Disclosures
Author

Janice L Bacon, MD  Professor and Chair, Department of Obstetrics and Gynecology, University of South Carolina School of Medicine

Janice L Bacon, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Association of Professors of Gynecology and Obstetrics, Association of Reproductive Health Professionals, North American Society for Pediatric and Adolescent Gynecology, and South Carolina Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Karen Loeb Lifford, MD  Director of General Gynecology, Associate Program Director, Department of Obstetrics and Gynecology, Instructor, Brigham and Women's Hospital, Harvard Medical School

Karen Loeb Lifford, MD is a member of the following medical societies: Association of Professors of Gynecology and Obstetrics, Massachusetts Medical Society, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Frederick B Gaupp, MD  Consulting Staff, Department of Family Practice, Hancock Medical Center

Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians

Disclosure: Nothing to disclose.

Chief Editor

David Chelmow, MD  Leo J Dunn Distinguished Professor and Chair, Department of Obstetrics and Gynecology, Virginia Commonwealth University Medical Center

David Chelmow, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Association of Professors of Gynecology and Obstetrics, Massachusetts Medical Society, Phi Beta Kappa, Sigma Xi, Society for Gynecologic Investigation, and Society for Medical Decision Making

Disclosure: Nothing to disclose.

References

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White lesion is cervical intraepithelial neoplasm, grade I (CIN I).
Cervical intraepithelial neoplasia, grades I and II (CIN I and II).
Cervix after laser conization.
Vulvar intraepithelial neoplasia, grade I (VIN I).
Table. The 4 Surgical Planes in Laser Surgery of the Vulva*
Parameter First Second Third Fourth
TissueSurface epitheliumDermal papillaePilosebaceous ductsPilosebaceous glands
Vaporization zoneProliferating layer of epidermisPapillary dermis (superficial)Upper reticular dermisMid-reticular dermis
Necrosis ZoneBasement membraneDeep papillary dermisMidreticular dermisDeep reticular dermis
HealingRapid/nonscarringRapid/nonscarringSlower/usually nonscarringSkin grafting required
Landmarks visualizedPink surface after removing charYellow, nonreflectiveWhite, fibrous arcuate vessels seenSkin appendages visible
*Adapted from Obstetrics and Gynecology Clinics of North America, Lasers in Gynecology[13]
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