Feb 1

Electrosurgery

Overview

During electrosurgery, doctors use an electrical current to heat up your genital warts to get rid of them. It is also called diathermy or a loop electrosurgical excision procedure (LEEP).

One study found that, after six months, warts had cleared up in 8 in 10 people who had electrosurgery.

It isn’t clear whether electrosurgery works better than freezing the warts off (cryotherapy).

Electrosurgery can cause scarring, swelling, pain generally and pain during sex.

It’s safe to have electrosurgery if you’re pregnant.

In Depth

Electrosurgery is another destructive treatment used for the treatment of genital warts. It uses electrical energy to destroy HPV-affected areas and is applied by doctor only. Local anesthesia is needed to perform electrosurgery.

A few types of electrosurgery are available.

Electrocautery consists in burning of the affected site and surrounding tissue by means of a electrocautery (an instrument for directing a high-frequency current through a local area of tissue).
Electrofulguration is another type of electrosurgery. It results in a superficial dessication of tissue with little dermal damage.
Monopolar surgery uses different waveforms, allowing desiccation, cutting, or coagulation. This leads to a cleaner cut and less damage to surrounding tissue.
The loop electrosurgical excision procedure (LEEP) uses a thin, low-voltage electrified wire loop to cut out affected tissue. It removes only a small amount of normal tissue at the edge of the abnormal area.
It is recommended to leave skin bridges between treatment sites to help healing and keeping scarring to minimum. All electrosurgical techniques result in a plume of smoke which has been shown to contain HPV DNA. Because of this infectious potential, mask should be worn by provider during procedure.

Electrosurgery side effects include infection, bleeding, pain, temporary or permanent nerve damage, not healing wound, scarring.

Efficacy and Recurrence

A retrospective 5-year study of 213 patients with extensive anogenital warts treated by day case electrosurgery was undertaken to determine clearance and recurrence rates. One hundred and seventy-six patients underwent single procedures, 35 underwent repeat procedures and two (1%) spontaneously cleared before surgery. Clearance of the warts was found by 3 months in 57% of the single procedure cases, 78% of the repeat procedure patients and 61%, [95% confidence interval [CI] 52.4-68.8%]) of the whole sample. Recurrence rates were 24%, 23% and 24%, [95 CI 16.9-31.2%]) respectively (Challenor R, 2002).

In a 203 patient cohort randomly assigned to intramuscular or subcutaneous recombinant interferon alfa-2b; and no treatment, electrosurgery significantly increased clearance of warts at 6 months after treatment compared with no treatment (82% with electrosurgery v 8% with no treatment; P < 0.001) (Benedetti P, 1989).

Few studies compared electrosurgery against IFN, cryotherapy, and podophyllin resin (Beutner KR, 1999; Beutner K, 1997; Stone K, 1990; Benedetti P, 1989; Simmons PD, 1981). Overall, 61%–94% of electrosurgery-treated patients showed clearance in these comparative trials within 3–6 weeks of treatment. Electrosurgery was found to be 3 times more effective than intramuscular interferon (IFN) and 6 times more effective than subcutaneously injected IFN (Wiley DJ, 2000).

Other study found that systemic recombinant interferon alpha-2b is active in treating patients with primary condyloma lesions and does so as well as cauterization (Benedetti P, 1989).Compared with podophyllin resin, electrotherapy was about twice as effective initially but equally effective 3 months after therapy (Stone KM, 1990). When comparing electrosurgery with cryotherapy, there was slightly greater efficacy for electrotherapy, but only short term, as after 3 months of follow up, results were similar for the 2 methods (Stone KM, 1990; Simmons PD, 1981).

The efficacy of electrodesiccation was compared with that of podophyllin and cryotherapy in a 450 patient trial (Stone KM, 1990). Complete clearance of warts was observed in 41%, 79%, and 94% of patients who received up to six weekly treatments of podophyllin, cryotherapy, and electrodesiccation, respectively. Relapses were found in 25% of all patients, yielding 3 month clearance rates of 17%, 55%, and 71% for podophyllin, cryotherapy, and electrodesiccation, respectively. Wart volume and duration did not influence treatment outcome. Women showed a greater response rate than men. Although electrodesiccation and cryotherapy were more effective than podophyllin, none of these treatments were highly successful for the treatment of GW.
The loop electrosurgical excision procedure (LEEP) has been compared with laser treatment for genital warts (Schoenfeld A, 1995). In a group of 28 women, 86 % of lesions treated with LEEP and 75 % of lesions treated with a laser showed no HPV DNA within a 20-mm circumference of the treated lesion.
Electrosurgery appears to be as effective as continuous wave CO2 laser for treating vaginal and external anogenital warts, especially those limited to a 5 cm2 or less area (Ferenczy A, 1995).
The two methods (electrosurgery and laser therapy) can be used in case of giant warts (Madrigal de la Campa MA, 2000).
Clinical trials reported recurrences in 14-22 % of patients undergoing electrosurgery (Schonefeld A, 1995; Stone KM, 1990). Interferon significantly reduced recurrence rates at 6 months, but not at 12 months, compared with electrosurgery (Benedetti P, 1989).

The most common adverse effect after electrosurgery was slow cicatrisation, found in 9/51(18 %) people, and lasting for 30–50 days (Benedetti P, 1989). Other adverse effects after electrosurgery included moderate local edema and pain (17/51 [33%]), and dyspareunia (2/51 [4%]), which persisted from 1–8 weeks (median 2 weeks).
Below is a summary of trials involving electrosurgery, cryotherapy and combination therapy of GW (Scheinfeld N, 2006). These studies were detailed in previous sections.

Reference
Patients
Design
Clearance
Recurrence/side effects
Stone KM, 1990
450
Randomized Control
Surgical excision showed complete clearance of warts in 94% and 71% after 6 weeks and 3 months
Recurrence
Simmons, PD 1981
42
Randomized Control
No significant difference over 3 months follow-up comparing cryotherapy versus electrocautery
No data
Eron et al, 1993
97
Randomized control, double blind
Interferon alpha-2a had no benefit as an adjuvant to cryotherapy.
28% of interferon recipients and 43% of placebo recipients experienced recurrences. At six months follow-up, 69% interferon and 73% placebo recipients experienced recurrences.
Handley et al,1991
91
Randomized control
At eight weeks subcutaneous IFN alpha 2a combined with cryotherapy showed 60.7% clearance versus 67.9% clearance with cryotherapy alone.
Recurrence at three months was 50% and 37.5% of patients in the IFN and placebo groups respectively
Abdullah et al, 1993
86
Randomized controlled
86% clearance of warts in patients who received cryotherapy vs 70% of patients who received TCAA.
No data on recurrences. Ulcerations at the site of application developed in 30% of the TCAA treated patients
Damstra et al, 1991
134
Clinical trial
Showed clearance in 83% within 4 weeks and 96% after 6 weeks with cryotherapy versus 13% and 45% after 4 weeks and 6 weeks, respectively in the control
No data
Godley et al, 1987
130
Randomized Control
Showed clearance in 88% of patients treated with cryotherapy versus 81% of those treated with TCAA
Recurrence found in 36% of patients treated with TCAA and in 39% of those treated with cryotherapy.

TCAA= tricholoroacetic acid

In conclusion, in terms of clearance of genital warts, electrosurgery is superior to sham treatment. It is as effective as laser ablation and cryotherapy after 3 months and may be as effective as intramuscular or subcutaneous interferon after 6 months. Overall, the clearance rates were up to 94% at the end of treatment and 78-91% 3 month after therapy.
As for the wart recurrence, electrosurgery may be more effective than intramuscular or subcutaneous interferon at preventing recurrence of warts after 6 months, but the benefit may be limited to this period of time. The recurrence rate reported in studies was as high as 24%.

References
Benedetti Panici P, Scambia G, Baiocchi G, Perrone L, Pintus C,Mancuso S. Randomized clinical trial comparing systemic interferon with diathermocoagulation in primary multiple and widespread anogenital condyloma. Obstet Gynecol 1989;74:393-7.
Beutner KR, Wiley DJ, Douglas JM. Genital warts and their treatment. Clin Infect Dis 1999;28(Suppl 1):S37-56.
Beutner K, Wiley D. Recurrent external genital warts: a literature review. Papillomavirus Report 1997;8:69-74.
Challenor R, Alexander I. A five-year audit of the treatment of extensive anogenital warts by day case electrosurgery under general anaesthesia. Int J STD AIDS. 2002 Nov;13(11):786-9.
Ferenczy A, Behelak Y, Haber G, Wright TC Jr, Richart RM. Treating vaginal and external anogenital condylomas with electrosurgery vs CO2 laser ablation. J Gynecol Surg. 1995 Spring;11(1):41-50.
Madrigal de la Campa MA, Ruiz Moreno JA, Palacios Ochoa J. Treatment of giant vulvar condylomata acuminata combining CO2 laser and electrosurgery. Ginecol Obstet Mex. 2000 Jan;68:27-30.
Simmons PD, Langlet F, Thin RN. Cryotherapy versus electrocautery in the treatment of genital warts. Br J Vener Dis 1981;57:273-4.
Scheinfeld N, Lehman DS. An evidence-based review of medical and surgical treatments of genital warts. Dermatol Online J. 2006 Mar 30;12(3):5. Review.
Schoenfeld A, Ziv E, Levavi H, Samra Z, Ovadia J. Laser versus loop electrosurgical excision in vulvar condyloma for eradication of subclinical reservoir demonstrated by assay for 2′5′ oligosynthetase human papillomavirus. Gynecol Obstet Invest 1995;40:46-51.
Stone KM, Becker TM, Hadgu A, Kraus SJ. Treatment of external genital warts: a randomised clinical trial comparing podophyllin, cryotherapy, and electrodesiccation. Genitourin Med 1990;66:16-9
Wiley DJ, Beutner KR. Genital warts. Clin Evidence 2000;3:764-74.

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