Biopsy-confirmed CIN2-3 lesions are usually treated with LEEP or cold knife conzation. Hysterectomy is denied for most CIN2 + patients and only is considered when repeat diagnostic excision is not feasible for treatment of recurrent or persistent biopsy-confirmed CIN2-3 or it is depicted as a definitive solution [11, 12]. Nevertheless, in many developing countries, due to the access of medical souses and following-up, many histology-confirmed CIN2 + lesions are treated with hysterectomy [10, 13]. However, the most serious late-complication brought by this is vaginal recurrence [14–16]. In Schockaert retrospective analysis of 3030 women with CIN2 + without history of VAIN in the University Hospital Gasthuisberg, Leuven, Belgium from1989 to 2003, he found that incidence rate of subsequent VAIN2 + is as high as 7.4% and hysterectomy may not be considered as a definitive therapy for CIN2 + because the the high incidence rate of subsequent vaginal intraepithelial neoplasia .
To address this problem, we modified the standard extrafascial hysterectomy to improve locoregional control for CIN3 patients who choose have hysterectomy. The efficacy of replacing the method in terms of reducing postoperative vaginal intraepithelial neoplasia was assessed. Compared with the conventional uterus removing method, the most important finding in our study is that the postoperative vaginal recurrence rate was significant reduced due to the use of this modified method. The DFS was greatly extended with this modification than the previously defined simple hysterectomy group (P = 0.026). Significant reduction at vaginal recurrence in the modified group suggest that this modification per se is a definitive favorable and decisive factor that determine the prognosis of patients.
Despite the similarities of the patient populations and the surgical factors, this modified hysterectomy is not associated with an increase in operative complications, including blood loss, and hospital stay compared to a simple hysterectomy. Although the operative time was higher in patients undergoing modified hysterectomy, this difference did not reach statistical significance. Furthermore, this modified procedure was well tolerated as reflected by the not prolonged bladder catheter retention and hospital stay times. The incidence of surgical complication between the group, such as fistulas, or other serious complications were not significantly increased. The extra procedure, therefore, has shown some benefit without any harmful effect.
By Piver-Rutledge-Smith or by Querleu and Morrows classification of hysterectomies [18, 19], as for the class I or type A hysterectomy, no vaginal portion is excised or as small as possible (less than 10mm). But narrow cut margins just near the vaginal portion cannot provide assurance that the disease has been completely excised as cervical intraepithelial neoplasia can be multifocal and discontinuous. the benefits observed in the group demonstrate that this technique is an effective means of reducing vaginal liaison after hysterectomy in patients who choose to remove their uterus, and treatment strategies, such as hysterectomy for histopathologically confirmed CIN3 liaison should be tailored [20, 21]. This modification might be recommended to clinical practitioners and hospitals where patients with CIN3 are treated sometimes to remove the uterus [22, 23].
Colposcopy, as indicated by other authors, directed vaginal multipoint biopsy should be conducted to exclude vaginal disease and patients of CIN should routinely undergo vaginal multipoint biopsy upper vagina . Colposcopy is also essential for the evaluation of abnormal cytology/hrHPV tests after hysterectomy and the early detection of vaginal . However, as vaginal cancer is an uncommon gynecologic malignancy and regular screening is not performed, this finding may not attribute to hysterectomy alone [26, 27]. Due to the low positive predictive value of vaginal cuff cytology for detection of vaginal cancer and the mean length of time from hysterectomy to abnormal cytology result may take many years, the final may not see yet. Our study is that several gynecologic oncologists working in our unit during the studied period performed hysterectomy, which likely resulted in variations in surgical practice. Specialized treatment centers should be acquired with this knowledge that ensures the value of this strategy for patients with CIN2+. Vaginal neoplasm is also associated with high-risk human papillomavirus, the persistence of HPV is a prognostic factor associated to the failure or recurrence after hysterectomy.