What is the procedure and aftercare for a LEEP (Loop Electrosurgical Excision Procedure) biopsy for cervical dysplasia?

LEEP Biopsy: Procedure and Aftercare

LEEP (Loop Electrosurgical Excision Procedure) is performed using a thin wire loop with electrical current to remove abnormal cervical tissue under local anesthesia in an outpatient setting, followed by cervical cytology at 6 months or HPV DNA testing at 12 months for surveillance. 1

Procedure Details

Technique

• LEEP uses a thin wire loop electrode with electrical current to excise the transformation zone of the cervix 1
• Standard excision depth is 6 mm ectocervically, with an additional 3 mm central endocervical excision 2
• The procedure is performed under local anesthesia without requiring general anesthesia, and patients typically experience minimal pain 3
• An endocervical curettage (ECC) should be performed after the excision to assess for residual disease 2

Indications for LEEP

• CIN II or CIN III confirmed on colposcopic biopsy requires treatment with LEEP, cryotherapy, cold-knife conization, or laser ablation 4
• LEEP is preferred over ablative methods when colposcopy is unsatisfactory, endocervical sampling shows dysplasia, or there is persistent/recurrent LSIL after previous ablative therapy 1
• For unsatisfactory colposcopy with CIN II or III on ECC, LEEP or cold-knife conization is recommended for definitive diagnosis 4

LEEP vs. Cold-Knife Conization

• LEEP offers advantages of less bleeding, shorter procedure time, and outpatient capability 1
• However, LEEP can create thermal artifacts that may compromise pathologic evaluation, particularly when microinvasive cervical cancer is suspected 4, 1
• Cold-knife conization is favored when microinvasive disease is suspected due to superior specimen quality for pathological evaluation 1
• Both procedures show similar efficacy with no statistical difference in treatment outcomes when performed for unsatisfactory colposcopy 2

Post-Procedure Management

Immediate Follow-Up Based on Margin Status

For CIN II or III with negative margins:

• Cervical cytology at 6 months OR HPV DNA testing at 12 months is recommended 4
• If repeat testing is negative, resume screening per standard guidelines 4

For CIN II or III with positive margins, three options exist:

1. Cervical cytology at 6 months (endocervical curettage can be considered as category 2B) 4
2. Re-excision, especially if invasion is suspected 4
3. Consider hysterectomy 4

Surveillance Strategy

• If HPV DNA testing at 12 months is positive, colposcopy is recommended 4
• If repeat cervical cytology shows ASC-US or greater, follow screening recommendations for abnormal cytology 4
• Studies show 78.5% of patients have negative HPV testing at 3-6 months after surgery, indicating clearance of infection 5

Clinical Outcomes and Complications

Efficacy

• Complete excision of lesions is achieved in 84.3% of cases 5
• Overall recurrence rate is low at 1.5%, with 3.4% showing persistent disease at 3 months 5
• Concordance between colposcopic biopsy and LEEP histology is 85.8%, with higher concordance for CIN 2/3 (95.1%) compared to CIN 1 (63.2%) 5

Complications

• Overall complication rate is 5.4%, mainly consisting of postoperative bleeding and pain 5
• No major complications such as fever, wound infection, massive bleeding, or cervical stenosis have been reported in standard series 3

Important Clinical Considerations

Margin Assessment

• Endocervical margins can be accurately assessed pathologically by marking with ink during the procedure 6
• Positive margins predict persistent dysplasia in 63% of cases 6
• When both endocervical margin and ECC are positive, 75% (9/12) have residual dysplasia 6
• With negative margins and negative ECC, only 2.6% (1/38) show dysplasia during 1-year follow-up 6

Special Populations

• Women of reproductive age should be counseled about potential increased risks of preterm birth before undergoing LEEP 1
• For adolescents and young women, observation rather than immediate treatment is often recommended due to high regression rates of cervical lesions 1
• Conservative management is recommended for women aged 21 to 24 years and those who are pregnant 4

Pitfalls to Avoid

• Do not perform LEEP when microinvasive cancer is strongly suspected—use cold-knife conization instead to avoid thermal artifact compromising pathologic evaluation 4, 1
• Do not use ablative procedures when colposcopy is unsatisfactory—excisional procedures are required 4
• Ensure adequate excision depth (6 mm ectocervical, 3 mm additional endocervical) to minimize positive margins 2