Interventions for preventing blood loss during the treatment of cervical intraepithelial neoplasia

BACKGROUND

Cervical intraepithelial neoplasia (CIN) is the most common pre-malignant lesion. Surgical treatments for CIN are commonly associated with blood loss.

OBJECTIVES

To assess the effectiveness and safety of interventions for preventing blood loss during the treatment of CIN.

SEARCH STRATEGY

We searched the Cochrane Gynaecological Cancer Group Trials Register, MEDLINE, EMBASE and CENTRAL up to April 2009. We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of included studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of vasopressin, tranexamic acid, haemostatic sutures, Amino-Cerv or Monsel's solution in women undergoing surgery for CIN.

DATA COLLECTION AND ANALYSIS

Two reviewers independently abstracted data and assessed risk of bias. Risk ratios comparing adverse events in women who received one of the interventions were pooled in a random-effects meta-analyses or included in single trial analyses.

MAIN RESULTS

Twelve RCTs (N = 1602, of whom 1512 were assessed) were included.Vasopressin significantly reduced perioperative bleeding (mean difference (MD) = -100.80, 95% confidence interval (CI) -129.48 to -72.12) and was associated with a decreased risk of bleeding that required haemostatic sutures or further vasopressin, compared to placebo (risk ratio (RR) = 0.39, 95% CI 0.27 to 0.56).Tranexamic acid significantly reduced risk of secondary haemorrhage (RR = 0.23, 95% CI 0.11 to 0.50), but not primary haemorrhage (RR = 1.24, 95% CI 0.04 to 38.23) after knife and laser cone biopsy, compared with placebo. There was also a statistically significant reduction in postoperative blood loss compared with placebo (MD = -55.60, 95% CI -94.91 to -16.29).Packing with Monsel's solution resulted in less perioperative blood loss (MD = -22.00, 95% CI -23.09 to -20.91) and decreased the risk of dysmenorrhoea (RR = 0.37, 95% CI 0.16 to 0.84), unsatisfactory colposcopy (RR = 0.43, 95% CI 0.30 to 0.63) and cervical stenosis (RR = 0.35, 95% CI 0.25 to 0.49) compared to routine suturing, but was not statistically different to sutures for risk of primary and secondary haemorrhages.Amino-Cerv antibiotic gel failed to make a difference on secondary haemorrhage but was associated with significantly less vaginal discharge at 2 weeks compared with routine care (RR = 0.27, 95% CI 0.09 to 0.86).There was no significant difference in blood loss between women who received ball electrode diathermy and those who received Monsel's paste (MD = 4.82, 95% CI -3.45 to 13.09).

AUTHORS' CONCLUSIONS

Bleeding associated with surgery of the cervix appears to be reduced by vasopressin, used in combination with local anaesthetic. Tranexamic acid appears to be beneficial after knife and laser cone biopsy. There are insufficient data to assess the effects on primary haemorrhage. There is some evidence that haemostatic suturing has an adverse effect on blood loss, cervical stenosis and satisfactory colposcopy.

Surgery for cervical intraepithelial neoplasia

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 STRATEGY

We searched the Cochrane Gynaecological Cancer Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE and EMBASE (up to April 2009). 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.