What is the difference between a Loop Electrosurgical Excision Procedure (LEEP) and a Cold Knife Conization (CKC)?

Differences Between LEEP and Cold Knife Conization (CKC)

LEEP and CKC are both excisional procedures for cervical dysplasia, but CKC provides superior specimen quality for pathological evaluation, while LEEP offers advantages of less bleeding, shorter procedure time, and outpatient capability. 1

Procedural Differences

• LEEP (Loop Electrosurgical Excision Procedure) uses a thin wire loop with electrical current to remove abnormal cervical tissue, can be performed in an outpatient setting under local anesthesia 1, 2
• Cold Knife Conization (CKC) uses a scalpel to remove a cone-shaped section of the cervix, typically performed in an operating room setting 1, 2
• LEEP procedures are significantly faster (average 9.5 minutes shorter), cause less intraoperative bleeding (42.4 mL less on average), and result in shorter hospital stays (1.5 days less) compared to CKC 2
• CKC specimens are typically larger with greater depth and volume compared to LEEP specimens, which may be important when evaluating for invasive disease 2, 3

Specimen Quality and Diagnostic Accuracy

• CKC is preferred when there is concern for adenocarcinoma in situ (AIS) due to superior specimen quality 4
• LEEP specimens are more likely to have tissue fragmentation (45.2% vs. 8.5% for CKC) and uninterpretable surgical margins (10.4% vs. 2.7% for CKC) 5
• LEEP can create thermal artifacts that may compromise pathologic evaluation of tissue specimens, particularly important when evaluating for microinvasive cervical cancer 1
• The National Comprehensive Cancer Network recommends CKC for microinvasive biopsy findings due to superior specimen quality 1

Clinical Indications and Effectiveness

• Both procedures are effective for treating cervical intraepithelial neoplasia (CIN), with similar rates of persistent/recurrent disease (15.6% for LEEP vs. 7.38% for CKC) 2
• CKC is preferred when:
  • Evaluating for adenocarcinoma in situ (AIS) 6, 4
  • Endocervical glandular involvement is present 6
  • Microinvasive disease is suspected 1
• LEEP is preferred when:
  • Colposcopy is unsatisfactory 4
  • Treating persistent low-grade squamous intraepithelial lesions (LSIL) 4
  • The lesion is preceded by high-grade squamous intraepithelial lesions (HSIL) or atypical glandular cells (AGC) cytology 4

Post-Procedure Considerations

• LEEP is associated with fewer complications including less cervical stenosis and fewer unsatisfactory examinations during follow-up 2
• Both procedures carry potential risks for future pregnancies, particularly increased risk of preterm birth 4
• Follow-up after either procedure depends on margin status and histology findings 1
• For patients with endocervical glandular involvement, CKC is superior to repeat LEEP and provides an intact specimen with interpretable margins 6

Important Clinical Considerations

• For women of reproductive age, the risk of preterm birth should be discussed before either procedure, though LEEP generally has fewer complications 4, 2
• For adenocarcinoma in situ, approximately 30% of patients have residual disease on subsequent hysterectomy even with negative margins of excision, making CKC the preferred initial approach 6
• When microinvasive cervical cancer is suspected, CKC is favored as LEEP's thermal artifacts may compromise pathologic evaluation 1
• For routine CIN treatment with satisfactory colposcopy, either procedure is acceptable, with LEEP offering advantages of outpatient setting, less bleeding, and shorter recovery 1, 2