Feb 3

SURGICAL EXCISION

Surgery is a destructive treatment for Genital Warts. It can be performed with scissors, a scalpel or by electrocautery (electrosurgery, detailed here). Surgical removal is the preferred method especially for large lesions causing obstruction, i.e., involving the urethral meatus, although it can be applied to any wart. It is particularly useful when there is a suspicion of malignancy, and in this case, the material harvested by surgery can be examined histopathologically.

Surgical excision usually requires adequate anesthesia (local, regional, or general) and surgical instruments for hemostasis, because large genital warts are very vascular and can heavily bleed.
The side effects of procedure include pain, bleeding/ hematoma, infection, scarring.
Efficacy and Recurrence

 

Two trials comprising 97 patients found no significant difference between surgical excision and podophyllin in terms of wart clearance (16/18 [89%] with surgical excision v 15/19 [79%] with podophyllin; RR 1.13, 95% CI 0.85 to 1.50 (Khawaja HT, 1989); and 28/30 [93%] with surgical excision v 23/30 [77%] with podophyllin; P = 0.20 (Jensen SL, 1985). However, the recurrence rates over 6–12 months were significantly reduced by surgery compared with podophyllin (19% with surgical excision v 60% with podophyllin, P = 0.05 (Khawaja HT, 1989), and 29% with excision v 65% with podophyllin, P < 0.01 (Jensen SL, 1985). More patients receiving surgical excision than receiving podophyllin had pain (11/18 [61%] with excision v 5/19 [26%] with podophyllin (Khawaja HT, 1989); 25/30 [83%] with excision v 7/30 [23%] with podophyllin (Jensen SL, 1985). More people receiving surgical excision than receiving podophyllin had bleeding (13/30 [43%] with excision v 11/30 [37%] with podophyllin) (Jensen SL, 1985). The statistical significance of the differences was not assessed by these trials.

Overview research to medicine:


Another trial compared surgical excision versus carbon dioxide laser (Duus BR, 1985). The two treatment had similar outcomes, with no significant difference in wart clearance (43 people; RR 1.2, 95% CI 0.6 to 2.4), and no significant difference in recurrence rates. The trial also found no significant difference in postoperative pain, healing time, and rate of scar formation (p > 0.1-0.2), although fewer people having surgical excision developed scars (9% had scars with surgical excision v 28% with laser surgery; P > 0.2).

Excision of extensive anal warts has a high probability of recurrences. However, the risk of developing anal stenosis was low in a study of 41 patients undergoing excision of large anal warts with an average follow-up of 6 months. Recurrent warts developed in 19 patients (46.3%). Bleeding was a complication in 22% of the cases. None of the patients developed postoperative stricturing or anal stenosis at follow-up (Klaristenfeld D, 2008).
A randomized controlled study was carried out in 261 patients with anal warts allocated to surgical excision alone (control group; n = 122) and surgical excision plus postoperative immunostimulation for 30 days with a natural product (STET; study group; n = 139). Six months after surgery, recurrence occurred in 7.2% (10/139) in the study group and in 27.1% (33/122) in the control group (P < 0.0001), suggesting that immunostimulation using a natural product may be used to reduce the incidence of recurrence of anal warts in patients undergoing surgical excision Mistrangelo M, 2010).
Surgical excision was safely and successfully used in a pregnant woman to remove an obstructive urethral wart causing difficulty in urine voiding. (Parnell BA, 2010).

In conclusion, surgical excision is as effective as laser surgery at clearing and preventing recurrence of genital warts, and is more effective than podophyllin at preventing recurrence after 6–12 months. Surgical excision of external GW may cause pain, bleeding and scaring.

References

Duus BR, Philipsen T, Christensen JD, Lundvall F, Søndergaard J. Refractory condylomata acuminata: a controlled clinical trial of carbon dioxide laser versus conventional surgical treatment. Genitourin Med. 1985 Feb;61(1):59-61.

Jensen SL. Comparison of podophyllin application with simple surgical excision in clearance and recurrence of perianal condylomata acuminata. Lancet. 1985 Nov 23;2(8465):1146-8.

Khawaja HT. Podophyllin versus scissor excision in the treatment of perianal condylomata acuminata: a prospective study. Br J Surg. 1989 Oct;76(10):1067-8.

Klaristenfeld D, Israelit S, Beart RW, Ault G, Kaiser AM. Surgical excision of extensive anal condylomata not associated with risk of anal stenosis. Int J Colorectal Dis. 2008 Sep;23(9):853-6.

Mistrangelo M, Cornaglia S, Pizzio M, Rimonda R, Gavello G, Dal Conte I, Mussa A. Immunostimulation to reduce recurrence after surgery for anal condyloma acuminata: a prospective randomized controlled trial. Colorectal Dis. 2010 Aug;12(8):799-803.
Parnell BA, Geller EJ, Jannelli ML. Urethral condyloma accuminata causing bladder outlet obstruction in pregnancy: a case report. J Reprod Med. 2010 Nov-Dec;55(11-12):514-6.

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