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1. CRYOTHERAPY AND ELECTROCAUTERY
Roy Yustin Simanjuntak
Division of Gynecologic Oncology
Department of Obstetrics and Gynecology
Faculty of Medicine, Universitas Sumatera Utara
Solo, August 5th 2016

2. Normal CIN Cancer
Pap test
Colposcopy + biopsy/LEEP
Histopathology
Treatment

3. COLPOSCOPY
Abnormal colposcopy
Satisfactory unsatisfactory
Diagnostic Conization
CIN Invasive
Biopsy/loop
Destruction
Excision
See and treat
Invasive CIN
free margin
FU
CIN 1 : FU
CIN 2 : Cryosurgery/ LEEP/LLETZ
CIN 3 : LLETZ

4. Treatment for CIN
depend on : Size and nature
of the lesion.
Excision
Conization (cold
knife, laser)
LEEP/LLETZ.
Hysterectomy
Ablative
Cryotherapy
Cold Coagulation
Laser ablation
Sauvaget C, Muwonge R, Sankaranarayanan R. Meta-analysis of the effectiveness of cryotherapy in the treatment
of cervical intraepithelial neoplasia. International Journal of Gynecology and Obstetrics 120 (2013):218–223

5. Definition
Cryotherapy is :
freezing of the abnormal areas of the cervix by the
application of a very cold disc to them.
WHO technical specifications: cryosurgical equipment for the treatment of precancerous cervical
lesions and prevention of cervical cancer. 2012

6. Cryotherapy
 Crisp 19671
 The most popular treatment for CIN (developing country)
 Destruction of tissue: –200C to –300C, but Gage and Baust2
suggests that -50°C is the appropriate temperature for
ensuring destruction of cancerous tissue.
 CO2 (-680C) , N2O (-890C) : core of the ice ball3
1. Crisp WE, Asadourian L, Romberger W. Obstet Gynecol 1967;30:668
2. Gage A, Baust J. Cryobiology, 1998;37(3):171– 86.
3. Sellors JW, Sankaranarayanan R. IARCPress.2002

7. Cryotherapy
 Freezing thawing  Intracellular crystalization  cell rupture
 The 5 mechanisms:
Dehydration and toxic concentration of electrolytes due to
removal water from solution
Crystallization with rupture of cell membrane
Denaturation of liquid-protein molecules within cell
membranes
Thermal shock
Vascular statis
Charles EH, Savage EW. Cryosurgical treatment of cervical intraepithelial neoplasia. Obstet
Gynecol Surv 1980;35:539

8. cervix
0 0C
- 20 0C 2 mm
5 mm
probe
- 85 0C
Recovery zone
Lethal zone
Ice ball thickness 7 mm
0 to -20 0C : recovery zone
-20 to -85 0C : lethal zone
Cannot destroy lesion
> 5 mm deep
Recovery zone

9. Comparison of depth of necrosis

10. Effectiveness of Cryotherapy
Depend on:
 The temperature
 Freezing time
 Type & Extend of probe
 Size & grade of cervical lesion

11. Eligibility Criteria for Cryotherapy
Acetowhite lesion in a non-pregnant patient :
 Covers <75% of transformation zone (envelops two quadrant
or less)
 Completely visualized (Clear margin)
 Cervix with normal shape
 Covered by largest available cryoprobe
 No abnormal vessels (punctations, mosaicism, atypical) => No
suspicion of micro-invasive or adenocarcioma
 No clinical evidence of acute pelvic infection or severe
cervicitis
 Given informed consent
Sellors JW, Sankaranarayanan R. Colposcopy and treatment of cervical intraepitheilal neoplasia: a beginners’
manual. Lyon, IARCPress, 2002

12. Indication
 IVA positif
 Low Grade SIL (CIN 1)
 High Grade SIL (CIN 2, 3) ?
 CIN 3Cryo Double Freeze

13. Cryotherapy Equipment/Instrumentation
Cryoprobes
Cryogun
Tank gas pressure
Sellors JW, Sankaranarayanan R. Colposcopy and treatment of cervical intraepitheilal neoplasia: a beginners’
manual. Lyon, IARCPress, 2002

14. Components of Cryotherapy Equipment
Sellors JW, Sankaranarayanan R. Colposcopy and treatment of cervical intraepitheilal neoplasia: a beginners’
manual. Lyon, IARCPress, 2002

15. Illustration of dimensions of cryotips
WHO technical specifications: cryosurgical equipment for the treatment of precancerous cervical
lesions and prevention of cervical cancer. 2012

16. Range of high pressure gas cylinder sizes
OHYG BOC Gas Cylindersafety.pdf, p. 10
The most common and useful sizes for cryosurgery are D and E.

17. Normal Cervix
Acetowhite Cervical Lesion
Sellors JW, Sankaranarayanan R. Colposcopy and treatment of cervical intraepitheilal neoplasia: a beginners’
manual. Lyon, IARCPress, 2002

18. Good Cryotherapy Candidate Poor Cryotherapy Candidate

19. Preparation the Equipment
 Check the cryo probes, cryo gun, pressure gauge, gas
tank, stop watch, vaginal wall retractor, saline, water
soluble gel.
 Prepare the connection between probe, cryo gun and
the gas tank.
 Check the tank pressure (≥20 psi), the indicator on
green zone

20. Preparation the patient
Counseling the indication, technique, side effects, success
rate, timing procedure.
Please don’t be a worry if she get a profuse watery vaginal
discharge, spotting.
Pregnancy (-)
Empty bladder

21. Before the Procedure
• Explain the procedure, ensure that the woman has understood and
obtain informed consent.
• Show her the cryotherapy equipment and explain how you will use it to
freeze the abnormal areas on the cervix.
• Prepare the patient for a gynaecological examination (speculum
examination)
• If there is no evidence of infection, proceed with cryotherapy.
• If there is a cervical infection  treat
WHO technical specifications: cryosurgical equipment for the treatment of precancerous cervical
lesions and prevention of cervical cancer. 2012

22. Positioning of the cryoprobe tip
Sellors JW, Sankaranarayanan R. Colposcopy and treatment of cervical intraepitheilal neoplasia: a beginners’
manual. Lyon, IARCPress, 2002

23. After the Procedure
• Provide a sanitary pad.
• Instruct the woman to abstain from intercourse and not to use
vaginal tampons for 4 weeks, until the discharge stops completely.
This to avoid infection.
• Provide condoms for use if she cannot abstain from intercourse as
instructed. Teach her how to use them.
• return in 2–6 weeks to be checked for healing, and again in 6
months for a repeat Pap smear and possible colposcopy.
• Normally, the wound is totally healed within 6-8 weeks
WHO technical specifications: cryosurgical equipment for the treatment of precancerous cervical
lesions and prevention of cervical cancer. 2012

24. Immediately after Cryotherapy
2 weeks after Cryotherapy
Sellors JW, Sankaranarayanan R. Colposcopy and treatment of cervical intraepitheilal neoplasia: a beginners’
manual. Lyon, IARCPress, 2002

25. 3 months after Cryotherapy
1 year after Cryotherapy
Sellors JW, Sankaranarayanan R. Colposcopy and treatment of cervical intraepitheilal neoplasia: a beginners’
manual. Lyon, IARCPress, 2002

26. 1 month follow up
• Talk to patient about problems or concerns since
procedure
• If needed, repeat speculum exam without acetic acid
application
• No problems  Return for repeat VIA in 6 months

27. 6 month follow up
• Repeat VIA exam with acetic acid
• VIA-negative  Return in 1 or more years for next VIA
• VIA-positive  Biopsy

28. Cryotherapy Success

29. Cryotherapy Failure

30. CRYOSURGERY
ADVANTAGE DISADVANTAGE
Effective on CIN 1/2 Les effective on CIN 3
Technical ease PA Specimen (-)
Electric source (-) SQJ changes
Anesthesia (-) Vaginal discharge
Treatment Failure Rate :
- One quadrant : 6,8%
-  Two quadrant : 14,1%
Hatch (Clin Obstet & Gynecol 1995)

31. Side Effect and Complication
 Mild cramping
 Profuse watery vaginal discharge for about 1 month
 Spotting, light bleeding for 1-2 weeks
 Long term: PID < 1%, Necrotic plug < 3%
stenosis, colposcopic exam.

32. Conclusion
• Effective
• Cheap
• Acceptable
• Safe

33. Cure rates (%)
• cryotherapeutic cure rates for CIN1, CIN2, and CIN3 or 94%, 92%, and 85%,
respectively.
• cure rates were significantly increased when the double-freeze method was used
and patients had no endocervical involvement

34. Benefits and harms (%)
• Recurrence rate was 5.3% 12 months after cryotherapy or LEEP, and 1.4% after
CKC.
• There seemed to be little or no differences in frequency of complications after LEEP
or cryotherapy, but they occurred more often after CKC.
• Evidence suggests premature delivery is most common with CKC, but it also occurs
after LEEP and cryotherapy

35. Electrocautery

36. Electrocogulation
Electrocautery
 Destruction of tissue 4000 F to 15000 F
Cold Coagulation
 SEMM 1966
 Destruction of tissue 1200 F to 1600 F

37. Electrocoagulation
Electrocoagulation diathermy
 Electric supply by high freq AC
 Generating specific waveform

38. Effectiveness
 93% (Gordon and Duncan, 1628 CIN 3)
 95,4% (Loobuyck and Duncan, 1165 CIN 2)
 98% (ECD, Chanen, 2990, CIN 3)

39. Complication
 Pain during procedure
 Bleeding
 Vaginal discharge
 Infection
 Cervical stenosis

43.  Unsatisfactory colposcopy
 Lesion extend to endocervix
 Lesion size (two quadrant or
more)
 Competency level of the surgeon
Factor Influence Treatment
Failure

44. Conclusion
Destruksi therapy
• Effective
• Cheap
• Acceptable
• Pre cancer lession

45. Take home message
 Full knowledge and understanding of
destruction methode
 Treatment should be done after PA result
 Be a competent