THE USE OF LARGE-LOOP EXCISION OF THE TRANSFORMATION ZONE IN AN INNER-CITY POPULATION

Objective. To determine whether large-loop excision of the transformat ion zone (LLETZ) can be used in our population to treat patients in a routine colposcopy clinic without diminishing the capability to see th e large number of patients who require care, and to compare these resu lts to our previous experience with laser surgery. Methods: Patients f ound to have squamous intraepithelial lesions on colposcopically direc ted biopsies were offered treatment with LLETZ during counseling regar ding their biopsy findings. Procedures included ''ablation equivalents '' and ''cone biopsy equivalents'' using local anesthesia. Follow-up e xaminations were used to determine cure and included cytology, colposc opy, and directed biopsies when indicated. The cure rate was compared to our previous experience with laser surgery. Results: Two hundred th irty-six patients were treated in the colposcopy clinic without dimini shing the capability to see all patients requiring care. Complications were few. The mean (+/- standard deviation) follow-up period was 50.7 +/- 25.3 weeks. The overall cure rate of 91.3% (95% confidence interv al [CI] 87.1-95.5) was not influenced by the severity of the disease, but positive endocervical margins significantly lowered the cure rate to 69.2% compared with those who had negative margins. Before this ser ies, only 73.1% of our patients scheduled for laser surgery returned f or treatment. Assuming a 90% cure rate among those who returned, this means that the actual cure rate was only 65.8%. The likelihood of cure was 1.37 times greater (95% CI 1.27-1.52, P < .0001) using LLETZ in t he clinic at the time the patient was counseled regarding her biopsy f indings than using laser at a later date. In 33 patients, the LLETZ sp ecimen showed no evidence of disease. The relative risk of negative hi stology was 3.31 (95% CI 1.78-6.13; P <.001) when LLETZ was done for a discrepancy between cytology and histology as opposed to any other in dication. Cancer was found on the LLETZ specimen in four patients (two microinvasive, two frankly invasive), but was not suspected preoperat ively in any of the patients. Conclusion: In our inner-city clinic, tr eatment with LLETZ at the time the patient was counseled regarding her biopsy finding improved the actual cure rate. The LLETZ procedure can be done safely in a clinic setting without diminishing the capability to care for a large number of patients.