Curettage and Electrosurgery
Curettage is the surgical removal of growths or tissue from the wall of a body cavity or other surface, using a spoon-like instrument with a sharp edge called a curette. Electrosurgery is a procedure that cuts, destroys, or cauterizes tissue using a high-frequency electric current applied locally with a pencil-shaped metal instrument or needle. When the two procedures are combined, the surgery is referred to as curettage and electrosurgery.
The general purpose of curettage is to scrape an area free of undesirable tissue. The purposes of electrosurgery are to destroy benign and malignant lesions, control bleeding, and cut or excise tissue.
Specifically, a curettage and electrosurgery procedure is used to treat the following conditions:
- benign skin lesions, such as angiomas, nevis, and warts
- actinic keratoses (AKs), which are premalignant skin lesions
- skin cancers, chiefly basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (SCC)
- genital warts that result from human papillomavirus (HPV) infection
Curettage—with or without electrosurgery—is the second most commonly used treatment in the United States. (Cryosurgery is the most commonly used treatment in the United States.)
Approximately 15% of actinic keratoses develop into squamous cell carcinoma. Based on current demographics in the United States, the incidence of actinic keratoses is expected to increase. Older individuals are more likely than younger ones to have actinic keratoses, because cumulative sun exposure increases with age. A survey of older Americans found keratoses in more than half of all men and more than a third of women between the ages of 65 and 74 who had a high degree of lifetime sun exposure. Some medical experts believe that the majority of people who live to the age of 80 have AKs.
Basal cell carcinoma is the most common form of skin cancer and the most common of all types of cancer. It affects about 800,000 individuals in the United States each year. BCC is primarily caused by chronic exposure to sunlight and until recently those most often affected were older, especially older men who worked outdoors. In the last several decades, the incidence of BCC among younger people has increased. So has the number of cases in women. However, many more men are still affected by BCC than women.
Squamous cell carcinoma is the second most common form of skin cancer, affecting more than 200,000 Americans each year. It too is most often caused by chronic exposure to sunlight.
Genital human papillomavirus infection is the most common sexually transmitted disease in the United States with about 55 million new cases reported each year. Genital warts are the most easily recognized sign of HPV infection, but many people with HPV infection never develop genital warts. Both drugs and surgery are used to treat genital warts, but the warts often come back after treatment because the treatment only removes the warts and does not cure the underlying infection.
In the case of AK, the procedure is carried out under local anesthesia to reduce discomfort during curettage. First, the surgeon uses a curette to scrape off the undesirable AK cells down to the level of uninvolved tissue. This is followed by electrosurgery to widen the area of AK cell destruction and removal, and to cauterize the wound to limit bleeding.
In the treatment of skin cancers, curettage is used to scrape away the tumor cells and then an extra margin of surrounding tissue is destroyed by electrosurgery. These steps may be repeated several times in the same treatment session. Curettage and electrosurgery are considered suitable for small primary lesions on sun-exposed skin. It is less effective in the case of recurrent lesions that have attendant scar tissue. Tumors that have spread into subcutaneous tissues or subcutaneous fat are less likely to be cured when treated with this procedure.
The major techniques that may be involved in the electrosurgery step include electrodesiccation (removal of water), fulguration (production of a spark to destroy tissue), electrocoagulation (forming blood clots to stop bleeding), and electrosection (cutting). Electrosurgery can be used to incise, to shave, and to remove lesions. The correct output power is determined by starting at low power and increasing the power level until the desired result is achieved (destruction, coagulation, or cutting).
Skin biopsies and histologic examination confirm diagnoses for AKs and skin cancers such as basal cell carcinoma. A recommendation for curettage and electrosurgery is made following patient evaluation.
Injectable lidocaine is administered before most curetttage and electrosurgical procedures. Lidocaine is often used together with epinephrine to further reduce blood loss. Anesthesia may not be necessary when small lesions are being treated. Another alternative is to use a mixture of local anesthetics, containing 2.5% lidocaine and 2.5% prilocaine, in a cream base. The cream is applied to the skin at least one hour before the procedure to achieve topical anesthesia.
After the procedure, the patient is advised to keep the wound clean and dry. The healing process takes at least several weeks or longer, depending on the size of the wound and other factors. Electrosurgery produces two types of skin wounds—partial- and full-thickness wounds. Partial-thickness wounds result from the electrodesiccation of skin lesions and the curettage and desiccation of basal cell carcinomas. These wounds may be cleansed daily and then covered with an antibiotic ointment that provides a moist environment for new tissue growth. The wound may then be covered with common adhesive bandages. Full-thickness wounds require closure with sutures.
- Subcutaneous bleeding. If it occurs, subcutaneous bleeding may create a hematoma and require the wound to be reopened and drained.
- Temporary or permanent nerve damage. This may result from excision in an area with extensive nerves.
- Wounds that reopen. If this occurs, the risk of infection and scarring increases.
Curettage and electrosurgery results in the removal of the targeted skin lesion, AK, skin cancer, or genital wart and in the formation of a minor wound that heals rapidly after the procedure.
Alternative treatment for AKs include:
- cryosurgery, the most common method of treating AKs in the United States
- dermabrasion, a procedure performed with an instrument that removes skin with a rapidly rotating brush
- laser removal, a treatment that uses the infrared beam of a carbon dioxide laser to destroy AK cells
- surgical excision, an uncommon treatment for AKs, used only if the lesions are very thick or difficult to remove by other means
Alternative treatment for skin cancers include:
- cryosurgery, a treatment that uses subfreezing temperature to destroy the tumor
- surgical excision, a procedure useful for both primary and recurrent tumors
- Mohs micrographic surgery, a treatment used to deal with some recurrent lesions
- laser surgery, a procedure that uses a laser to excise or destroy the tumor
- radiation therapy, a treatment that is useful for definitive treatment of primary tumors and some recurrent cancers
- interferon therapy, a drug therapy that prevents the growth of cancerous cells
- photodynamic therapy, a treatment in which the patient is given a photoactive compound followed by photoirradiation
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Gonzalez, D. I., C. M. Zahn, M. G. Retzloff, W. F. Moore, E. R. Kost, and R. R. Snyder. "Recurrence of Dysplasia After Loop Electrosurgical Excision Procedures With Long-term Follow-up." American Journal of Obstetrics and Gynecology 184 (February 2001): 315–321.
Moniak, C. W., S. Kutzner, E. Adam, J. Harden, and R. H. Kaufman. "Endocervical Curettage in Evaluating Abnormal Cervical Cytology." Journal of Reproductive Medicine 45 (April 2000): 285–292.
Sheridan, A. T., and R. P. Dawber. "Curettage, Electrosurgery and Skin Cancer." Australasian Journal of Dermatology 41 (February 2000): 19–30.
Werlinger, K. D., G. Upton, and A. Y. Moore. "Recurrence Rates of Primary Nonmelanoma Skin Cancers Treated by Surgical Excision Compared to Electrodesiccation-curettage in a Private Dermatological Practice." Dermatology and Surgery 28 (December 2002): 1138–1142.
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American Academy of Dermatology Association. 1350 I Street NW, Suite 880, Washington, DC 20005. (202) 842-3555. <http://www.aadassociation.org/>.
American College of Obstetricians and Gynecologists. 409 12th St., S.W., PO Box 96920 Washington, D.C. 20090-6920. (312) 786-1468. <http://www.acog.com/>.
American Society for Dermatologic Surgery (ASDS). 5550 Meadowbrook Dr., Suite 120, Rolling Meadows, IL 60008. (847) 956-0900. <http://www.asds-net.org>.
National Association for Women's Health. 300 W. Adams Street, Suite 328, Chicago, IL 60606-5101. (312) 786-1468. <http://www.nawh.org/>.
CANCERLIT: NIH Cancer Information Center. [cited May 14, 2003]. <http://www.cancer.gov/CancerInformation/cancerliterature>.
National Women's Health Information Center. [cited May 14, 2003]. <http://www.4woman,org/>.
The Skin Cancer Foundation. [cited May 14, 2003]. <http://www.skincancer.org/>.
Monique Laberge, Ph.D.
WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?
Curettage and electrosurgery is done in a hospital or clinic, although most physicians have small electrosurgical units in their offices to treat benign lesions. The procedure is usually performed by a dermatologist or dermatologic surgeon. The American Academy of Family Physicians and several private organizations offer basic training sessions in electrosurgery.
QUESTIONS TO ASK THE DOCTOR
- How is the procedure performed?
- Why is curettage and electrosurgery required?
- What are the risks of the procedure?
- Is curettage painful?
- What are the alternative treatments?
- How long will it take to recover from the surgery?
- What are the after-effects of the surgery?
- How many curettage and electrosurgery procedures do you perform each year?