What we mean by surgery is the need to perform a more in-depth examination or treatment that is best performed while someone is anesthetized or very heavily sedated in the operating room. Surgery is usually required for only a small percentage of patients being treated for anal HSIL. These include:
- Lesions that are so extensive that they cannot be treated by any of the other methods described in the treatment section. Patients who have a lot of intra-anal warts or warts that are bulky in size or involve nearly the entire circumference of the anal canal and/or the warts extend out to the perianal skin are probably best treated in the operating room.
- Lesions are so large that they cannot be sufficiently biopsied in the office to establish or exclude a diagnosis of cancer to the satisfaction of the clinician.
- Lesions are so large that extensive excision is required.
The advantage of surgery is that under anesthesia, not only is the patient sedated and relaxed, but the sphincter muscle is also relaxed and dilated, which allows better exposure and provides a better opportunity to visualize any abnormalities. As mentioned above this also provides the ability to take larger specimens if necessary.
The disadvantage of surgery is that it is expensive compared with the other methods. Patients typically experience more post-procedure side effects, including pain, bleeding, and infection after the procedure when compared with less aggressive treatment modalities. Also, the surgeon must either be certified in HRA or guided in the operating room by a clinician certified in HRA to identify the lesions requiring treatment.
Several examples are described below indicating situations where treatment in the operating room would be preferred:
- Patients who are symptomatic from their anal lesions with either itching, irritation, pain, discomfort, painful bowel movements, frequent bleeding after bowel movements or receptive intercourse, or uncomfortable receptive intercourse are often treated for their lesions surgically. If the disease is too extensive to be treated in the office or if there is a high level of concern regarding a possible cancer, then patients are probably best treated in the operating room. In spite of the significant amount of pain and discomfort associated with anal surgery, virtually all patients who were operated on because of symptoms have improvement in their symptoms once they recover from the acute effects of surgery.
- As above, patients with more extensive disease, which means a larger portion of the circumference of the anus involved may be better treated in the operating room. Generally when treating someone for LSIL or HSIL, the goal is to destroy and remove as much of the abnormal tissue as possible. Based on treating cervical dysplasia, when only part of a lesion is removed, the likelihood of a recurrence is very high. So if the disease seems too extensive to be treated at one sitting in the office, then patients are often referred for surgery.
- Patients who have HSIL which has recurred after office-based treatment such as infrared coagulation within a relatively short period of time, are referred for surgery as another way of treating their HSIL. One of the reasons that lesions recur may be because they were incompletely treated and a more comprehensive approach in the operating room guided by HRA may improve outcome. On the other hand, for some patients HSIL seems to recur in spite of whatever we do. However, it is reasonable to try to decrease the burden of HSIL in the operating room at least once. If it recurs quickly and to such a degree that it can't be managed in the office, then it may be more reasonable to follow the patient closely until better treatments become available.
- Patients for whom anal exams are very difficult and uncomfortable and they cannot tolerate having the anoscope inside them for very long. Occasionally patients will have pain or discomfort because of lesions that are tender. If an exam is too painful or uncomfortable, then it is best to examine patients under anesthesia. Pain and focal tenderness are often warning signs that suggest cancer, and it is important to examine patients thoroughly and carefully to determine whether or not cancer is present, or if some other more benign process might be causing the pain, such as a fissure or fistula.
- Patients for whom anal exams aren't physically uncomfortable but produce a great deal of anxiety and emotional distress. Sometimes this emotional distress is due to previous physically traumatic experiences such as examinations or treatment or assault. Some people just don't like medical procedures of any kind including drawing blood. These patients may benefit from mild sedation with drugs such as Ativan (lorazepam, a Valium-like drug), but may require anesthesia in order to be examined properly.
- Women who have coexistent cervical or vulvar HSIL that requires laser treatment, which is performed under general anesthesia in the operating room. If women also have anal HSIL, then we try to do one procedure to treat both areas simultaneously, which facilitates recovery and avoids having two separate operations.