Everything Surgeons Need to Know About Loop Electrosurgical Excision Procedure (LEEP)

The Loop Electrosurgical Excision Procedure (LEEP) is a widely used technique in gynecological surgery, primarily for the treatment of cervical dysplasia. This minimally invasive procedure utilizes a thin wire loop that carries an electrical current to remove abnormal tissue from the cervix. Due to its precision, effectiveness, and relatively low risk, LEEP has become a standard approach in the management of precancerous cervical lesions. This article provides an in-depth exploration of LEEP, covering its indications, preoperative evaluation, contraindications, surgical techniques, postoperative care, potential complications, different techniques, prognosis, alternative options, costs, and recent advancements.

Indications for LEEP

LEEP is primarily indicated for the treatment of cervical intraepithelial neoplasia (CIN), which is a precancerous condition of the cervix. CIN is classified into three grades:

• CIN 1 (Mild Dysplasia): Abnormal cells confined to the lower third of the epithelium.
• CIN 2 (Moderate Dysplasia): Abnormal cells extending into the middle third of the epithelium.
• CIN 3 (Severe Dysplasia to Carcinoma in Situ): Abnormal cells occupying more than two-thirds of the epithelium, up to the full thickness.

LEEP is most commonly performed for CIN 2 and CIN 3 lesions, as these have a higher risk of progression to invasive cervical cancer if left untreated. It may also be used in cases of persistent CIN 1 when there is evidence of progression or when the patient desires definitive treatment. Additionally, LEEP can be employed for the diagnosis and treatment of microinvasive carcinoma.

Preoperative Evaluation

A thorough preoperative evaluation is essential to ensure the appropriateness of LEEP for each patient. The evaluation typically includes the following steps:

1. History and Physical Examination:
   • Detailed gynecological history, including menstrual, sexual, and obstetric history.
   • Assessment of risk factors for cervical dysplasia, such as human papillomavirus (HPV) infection, smoking, and immunosuppression.
   • Physical examination focusing on the pelvic region.
2. Cervical Cytology (Pap Smear):
   • Performed to screen for abnormal cells in the cervix.
3. Colposcopy:
   • A colposcope is used to magnify the cervical tissue, allowing for detailed examination and identification of abnormal areas.
   • Biopsies may be taken from suspicious areas to confirm the diagnosis.
4. HPV Testing:
   • High-risk HPV types, particularly HPV 16 and 18, are strongly associated with cervical cancer. Testing for HPV helps to stratify the risk and guide management.
5. Endocervical Curettage (ECC):
   • Performed to evaluate the endocervical canal, particularly if colposcopy is inadequate or if there is suspicion of glandular involvement.
6. Informed Consent:
   • Discuss the nature of the procedure, potential risks, benefits, and alternatives with the patient.
   • Obtain written informed consent.

Contraindications

While LEEP is a relatively safe procedure, it is contraindicated in certain situations:

1. Pregnancy:
   • LEEP is generally avoided during pregnancy unless there is a high suspicion of invasive cancer that cannot be delayed.
2. Active Pelvic Infections:
   • Acute cervicitis or pelvic inflammatory disease should be treated before performing LEEP.
3. Invasive Cervical Cancer:
   • If invasive cancer is suspected or confirmed, LEEP is not the appropriate treatment, and referral to a gynecologic oncologist for further management is necessary.
4. Severe Vaginal Atrophy:
   • In postmenopausal women with significant vaginal atrophy, LEEP may be challenging due to difficulty in visualizing the cervix and increased risk of complications.
5. Bleeding Disorders:
   • Patients with coagulopathies or those on anticoagulant therapy may require special consideration and management before undergoing LEEP.

Surgical Techniques and Steps

LEEP is typically performed in an outpatient setting under local anesthesia, although sedation or general anesthesia may be used in certain cases. The procedure involves the following steps:

1. Preparation:
   • The patient is positioned in the lithotomy position, and a speculum is inserted to visualize the cervix.
   • The cervix is cleansed with an antiseptic solution, and local anesthesia (usually lidocaine with epinephrine) is injected into the cervix to minimize discomfort and reduce bleeding.
2. Electrosurgical Loop Selection:
   • The appropriate loop size is selected based on the size and location of the lesion. Loops come in various shapes and sizes, including square, oval, and round.
3. Excision:
   • The electrosurgical loop is activated and passed through the cervix, removing the abnormal tissue in a single or multiple passes. The excised tissue is carefully removed and sent for histopathological examination.
4. Hemostasis:
   • After the excision, the cervical bed is inspected for bleeding. Hemostasis is achieved using electrocautery or the application of a hemostatic agent such as Monsel’s solution or silver nitrate.
5. Completion:
   • The cervix is cleaned, and a vaginal pack may be inserted if necessary. The patient is then allowed to recover and monitored briefly before discharge.

Postoperative Care

Postoperative care is crucial for ensuring proper healing and minimizing complications. Patients should be provided with detailed instructions regarding self-care and what to expect during recovery:

1. Activity Restrictions:
   • Patients should avoid strenuous physical activity, heavy lifting, and sexual intercourse for approximately 4-6 weeks to allow for complete healing of the cervix.
2. Vaginal Discharge:
   • A watery, sometimes blood-tinged discharge is common for a few weeks following LEEP. Patients should be advised to use sanitary pads instead of tampons.
3. Pain Management:
   • Mild cramping or discomfort is expected and can be managed with over-the-counter analgesics such as ibuprofen or acetaminophen.
4. Follow-Up:
   • Patients should have a follow-up appointment within 4-6 weeks to ensure proper healing and discuss the pathology results.
   • Further follow-up with cervical cytology and/or colposcopy may be required, typically at 6 and 12 months post-procedure, to monitor for recurrence.

Possible Complications

While LEEP is generally safe, complications can occur, including:

1. Immediate Complications:
   • Bleeding: Most common complication; usually minor and controlled with local measures.
   • Infection: Rare but can occur, presenting with fever, foul-smelling discharge, or pelvic pain.
2. Delayed Complications:
   • Cervical Stenosis: Scarring can lead to narrowing of the cervical canal, which may affect menstruation and fertility.
   • Cervical Incompetence: Rare, but LEEP may weaken the cervix, increasing the risk of preterm birth in future pregnancies.
3. Recurrence of CIN:
   • Recurrence of dysplasia may occur, necessitating further treatment.

Different Techniques

Various modifications of the standard LEEP procedure have been developed to suit specific clinical scenarios:

1. Large Loop Excision of the Transformation Zone (LLETZ):
   • Similar to LEEP but typically involves a larger excision, useful for larger or more extensive lesions.
2. Cold Knife Conization:
   • A surgical alternative to LEEP, involving the removal of a cone-shaped portion of the cervix using a scalpel. This is often reserved for cases where LEEP is inadequate or when there is a need for a more extensive tissue sample.
3. Laser Conization:
   • Uses a laser to excise abnormal tissue; offers precision and minimal thermal damage but requires specialized equipment.

Prognosis and Outcome

The prognosis following LEEP is generally excellent, with high success rates in eradicating CIN and preventing progression to invasive cancer. Studies have shown that LEEP has a cure rate of approximately 90-95% for CIN 2 and CIN 3. Regular follow-up is essential to monitor for recurrence, which occurs in about 5-10% of cases. The outcome is favorable when LEEP is performed with adequate margins and in patients who adhere to follow-up protocols.

Alternative Options

Several alternative treatments to LEEP are available, depending on the severity of the dysplasia, patient preference, and clinical judgment:

1. Cryotherapy:
   • Involves freezing the abnormal tissue, leading to necrosis and eventual shedding. Suitable for small, well-defined lesions but less effective for larger or more severe dysplasia.
2. Laser Ablation:
   • Uses a laser to vaporize abnormal tissue. It is precise and has minimal impact on surrounding tissue but does not provide a tissue sample for histological analysis.
3. Watchful Waiting:
   • In selected cases of CIN 1, especially in young women, close monitoring with repeat cytology and colposcopy may be an option, as spontaneous regression is common.
4. Hysterectomy:
   • Reserved for recurrent or persistent CIN, particularly in women who have completed childbearing. It is a definitive treatment but carries the risks associated with major surgery.

Average Cost

The cost of LEEP can vary significantly depending on the geographic location, healthcare setting, and insurance coverage. On average, the cost ranges from $500 to $2,000 in the United States. This includes the procedure, anesthesia, and pathology fees. Insurance often covers the procedure, especially if it is performed for medically necessary reasons, such as the treatment of CIN.

Recent Advances

Recent advancements in LEEP and related technologies have focused on improving precision, reducing complications, and enhancing patient outcomes:

1. Advanced Imaging Techniques:
   • Integration of high-resolution colposcopy and digital imaging has improved the accuracy of lesion identification and excision.
2. HPV Vaccination:
   • Widespread HPV vaccination has led to a reduction in the incidence of CIN, potentially decreasing the need for procedures like LEEP.
3. Molecular Testing:
   • The use of molecular markers to assess the risk of progression in CIN lesions may help in better patient selection for LEEP, reducing overtreatment.
4. Non-Surgical Approaches:
   • Ongoing research into non-surgical treatments, such as topical immunomodulators, offers the potential for less invasive management of CIN.