What is involved in a Loop Electrosurgical Excision Procedure (LEEP)?

Loop Electrosurgical Excision Procedure (LEEP)

A LEEP procedure is an outpatient electrosurgical technique that uses a thin wire loop electrode with high-frequency electrical current to excise suspicious cervical tissue, primarily for the diagnosis and treatment of cervical intraepithelial neoplasia (CIN). 1

Procedure Overview

The LEEP procedure involves:

1. Patient Preparation

   • Typically performed in an outpatient setting
   • Usually requires only local anesthesia
   • Patient positioned in lithotomy position

2. Visualization and Assessment

   • Colposcopic examination after application of 3-5% acetic acid solution 2
   • Identification of the transformation zone and any suspicious lesions
   • Lugol's iodine may be applied to further delineate abnormal areas

3. Excision Technique

   • A thin wire loop electrode connected to an electrosurgical unit is used
   • The transformation zone is excised in one piece when possible
   • Depth of excision is typically 20-25 mm with a 2-3 mm margin 3
   • The size of the loop and extent of excision depends on the lesion size:
     • LEEP-A: For lesions ≥2/3 of cervical area
     • LEEP-B: For lesions ≥1/3 but <2/3 of cervical area
     • LEEP-C: For lesions <1/3 of cervical area
     • LEEP-D: For endocervical canal resection 3

4. Specimen Handling

   • The excised tissue is preserved for histopathological examination
   • Proper orientation of the specimen is important for margin assessment

5. Hemostasis

   • Ball electrode may be used to achieve hemostasis at the excision site
   • Some practitioners apply Monsel's solution to control bleeding

Indications for LEEP

LEEP is indicated for:

• Diagnostic excision of suspicious cervical lesions
• Treatment of cervical intraepithelial neoplasia (CIN)
• Obtaining tissue specimens for pathological examination 1

Specific scenarios where LEEP is recommended:

• CIN II or III identified on cervical biopsy 2
• Persistent CIN I lesions that require treatment
• Discrepancy between cytology and colposcopic findings
• Unsatisfactory colposcopy with ASC-H or HSIL cytology 2

Benefits and Advantages

• Provides tissue for histopathological examination
• Can be performed in an outpatient setting
• Usually requires only local anesthesia
• Lower blood loss compared to cold-knife conization
• Shorter operative times
• High success rates (85-99%) for treatment of CIN 4, 3

Limitations and Considerations

• Cold knife conization (CKC) is preferred over LEEP for:

  • Patients at risk for adenocarcinoma in situ (AIS)
  • Cases where microinvasion is suspected 2
  • When more precise margin assessment is needed

• LEEP has been associated with increased incidence of positive excision margins in AIS cases 2

• Potential impact on fertility and pregnancy outcomes:

  • Larger excisions (LEEP-A) may lead to adverse obstetric outcomes 3
  • Pregnancy rates two years after LEEP are significantly higher with smaller excisions (LEEP-C and LEEP-D) compared to larger excisions (LEEP-A) 3

Post-Procedure Follow-Up

• For CIN II or III lesions with negative margins:

  • Cervical cytology at 6 months or HPV DNA testing at 12 months 2

• For CIN II and III lesions with positive margins, options include:

  1. Cervical cytology at 6 months (ECC can be considered)
  2. Reexcision, especially if invasion is suspected
  3. Consider hysterectomy 2

• If repeat cervical cytology or HPV DNA testing is negative, screening as per guidelines may be resumed 2

Complications

• Overall complication rate is approximately 5-8% 4, 5
• Common complications include:
  • Postoperative bleeding
  • Pain
  • Infection (uncommon)
  • Cervical stenosis (rare)

Effectiveness

• Overall concordance of colposcopic biopsy and cone histology is approximately 85.8% 4
• Success rates for treating CIN with a single LEEP treatment range from 88.9% to 100% 5, 3
• Recurrence rates are low, typically 1.5-8.3% 4, 6

LEEP is a valuable procedure that balances diagnostic accuracy with therapeutic effectiveness while minimizing morbidity compared to more invasive procedures like cold knife conization.