Abstract
Background
Persistent high-risk human papillomavirus (hrHPV) infection after hysterectomy or residual cervix resection for incompletely excised cervical intraepithelial neoplasia grade 3 (CIN3) remains a clinical concern. However, the factors associated with postoperative hrHPV positivity in this setting are not well characterized.
Methods
This retrospective study included 288 patients who were treated between 2014 and 2024. We evaluated factors associated with postoperative hrHPV positivity after hysterectomy or residual cervix resection for incompletely excised CIN3. Patients were grouped according to their hrHPV status at the first postoperative follow-up, and associated factors were identified by using logistic regression.
Results
At the first postoperative follow-up, 50 patients (17.4%) were hrHPV positive. According to the univariate analysis, postoperative hrHPV positivity was associated with ectocervical margin involvement, older age, and lower gravidity (all p < 0.05). Multivariate analysis revealed that ectocervical margin involvement remained independently associated with postoperative hrHPV positivity (OR 5.273, 95% CI 1.491–18.640; p = 0.010). For the patients who were hrHPV positive at the first postoperative follow-up, subsequent clearance of infection mostly occurred within 2 years after surgery.
Conclusions
Ectocervical margin involvement was associated with a higher likelihood hrHPV positivity at the first follow-up after hysterectomy or residual cervix resection for incompletely excised CIN3. This observation warrants confirmation in future prospective studies.
Supplementary Information
The online version contains supplementary material available at https://doi.org/10.1186/s12905-026-04667-w.
Keywords: CIN3, Hysterectomy, Ectocervical margin involvement, HPV clearance
Introduction
Cervical intraepithelial neoplasia grade 3 (CIN3) is a high-grade precancerous lesion that is primarily attributable to persistent infection with high-risk human papillomavirus (hrHPV) [1–3]. Without timely and effective treatment, CIN3 may progress to invasive cervical cancer, which remains a major cause of morbidity and mortality among women worldwide [4]. Therefore, early detection and appropriate management of CIN3 are essential components of cervical cancer prevention programmes.
Excisional procedures, including the loop electrosurgical excision procedure (LEEP) and cold-knife conization (CKC), are well-established treatments for CIN3 and substantially reduce the risk of its progression to cancer [5, 6]. However, incomplete excision, defined by positive surgical margins, is reported in approximately 20% of conization cases [7]. Positive margins, particularly at the edge of the endocervical resection site, have been associated with an increased risk of residual or recurrent disease [8]. In such cases, the optimal management remains debated, especially for postmenopausal women, patients without fertility concerns, and those who are not suitable candidates for repeat conservative procedures [7, 9–11]. Hysterectomy or residual cervix resection may be considered in selected patients with recurrent CIN, coexisting uterine conditions, or anatomical limitations that preclude repeat conization [12]. A recent large cohort study revealed that women aged 50 years or older were less likely to achieve negative margins and negative hrHPV status after conization [13], which may partly explain the higher rate of hysterectomy in this population. Nevertheless, despite its greater surgical extent, hysterectomy does not necessarily ensure the clearance of hrHPV infection or eliminate the risk of lower genital tract neoplasia [14, 15]. Persistent hrHPV positivity after cervix removal has been documented in several studies, suggesting the possibility of multifocal or latent infection [14, 16–18].
Data on early postoperative hrHPV outcomes after hysterectomy for incompletely excised CIN3 remain limited. In particular, the impact of the margin involvement, especially ectocervical margin positivity, on postoperative hrHPV persistence has not been clearly defined. Moreover, the interplay among patient characteristics, the surgical approach, the hrHPV type, and viral clearance remains underexplored in this context. Identifying patients at higher risk of persistent hrHPV infection after surgery may support earlier intervention and more intensive follow-up, potentially reducing the long-term risk of subsequent lower genital tract neoplasia.
In this retrospective study, we assessed postoperative hrHPV outcomes after hysterectomy or residual cervix resection for incompletely excised CIN3. We aimed to determine the hrHPV status at the first postoperative follow-up and to identify factors associated with hrHPV positivity at this time point. These findings may inform postoperative risk stratification and support clinical decision-making in a patient population for which current guidance remains limited.
Methods
Study design and participants
This study was approved by the Human Research Ethics Committee of the Women’s Hospital, Zhejiang University School of Medicine. We conducted a retrospective, single-centre cohort study at the Women’s Hospital, Zhejiang University School of Medicine, China. Eligible patients were women who underwent hysterectomy (total, extrafascial, or radical) or residual cervix resection for positive surgical margins after cervical conization for CIN3 between January 2014 and December 2024. Conization was performed by using either LEEP or CKC. Positive surgical margins are generally defined as the presence of CIN lesions at any excisional margin (endocervical, ectocervical, or stromal). In this study, only patients with CIN3 lesions at any margin were eligible. The decision to proceed with hysterectomy or residual cervix resection was based on insufficient residual cervical tissue for repeat conization. The contributing factors included a large initial excision, cervical atrophy in postmenopausal patients, and a history of multiple prior conization procedures. Residual cervix resection was performed in patients with a cervical stump after prior subtotal hysterectomy. Although hysterectomy and residual cervix resection are technically distinct procedures, they were analysed together because both remove the remaining cervical disease-bearing tissue. In both groups, the final anatomical status was the absence of both the uterus and cervix. All patients had confirmed hrHPV infection before conization.
The inclusion criteria were as follows: (1) pathologically confirmed CIN3 in LEEP or CKC specimens; (2) CIN3 present at any surgical margin of the conization specimen; (3) hysterectomy or residual cervix resection within 12 months after conization; (4) complete clinical and pathological data; and (5) at least one postoperative hrHPV test within 12 months after hysterectomy or residual cervix resection. The exclusion criteria were as follows: (1) histologically confirmed malignancy in organs other than the cervix; (2) coexisting vaginal intraepithelial neoplasia (VaIN 1–3), which was detected by colposcopy, cervical conization, or postsurgical assessment; and (3) a negative hrHPV test before conization.
Sensitivity analyses were performed to examine the robustness of the primary findings. First, we repeated the main analysis after excluding 10 patients who underwent residual cervix resection. Second, we repeated the analysis among patients whose first postoperative hrHPV test was performed within 6 months after surgery. These analyses evaluated the potential influences of procedural heterogeneity and the timing of follow-up.
Data collection
Demographic and clinical data were extracted from the electronic medical record (EMR) system. The variables included age, body mass index (BMI), gravidity, parity, menopausal status, medical and surgical history, immunocompromising conditions, smoking history, preoperative hrHPV type, preconization cytology, surgical indications, pathological findings, surgical approach, intraoperative blood loss, perioperative complications, length of hospital stay, time to postoperative flatus, antibiotic use, readmissions, and follow-up records (hrHPV testing, cytology, and colposcopy). All pathological diagnoses were independently reviewed by at least two experienced gynaecological pathologists.
Outcomes and definitions
The primary outcome was the hrHPV status at the first postoperative follow-up after hysterectomy or residual cervix resection. Secondary outcomes were (1) hrHPV redetection, defined as the first positive test result after initial postoperative negativity, and (2) subsequent hrHPV clearance among patients who tested positive at the first postoperative follow-up.
hrHPV and cytology testing
High-risk HPV testing was performed for all patients within 6 months before conization by using validated assays, including the Hybrid Capture 2 HPV DNA test (Qiagen), the Aptima HPV assay (Hologic), the cobas 4800 test (Roche Molecular Diagnostics), or other clinically approved methods. Postoperative hrHPV testing was performed by using either the Hybrid Capture 2 or the Aptima HPV assay. All hrHPV tests were conducted according to the manufacturers’ instructions.
Cervical and vaginal cytology tests were performed by using the ThinPrep cytology test (TCT) and reported according to the 2001 Bethesda System as follows: negative for intraepithelial lesion or malignancy (NILM); atypical squamous cells of undetermined significance (ASC-US); low-grade squamous intraepithelial lesion (LSIL); high-grade squamous intraepithelial lesion (HSIL); atypical squamous cells, cannot exclude HSIL (ASC-H); squamous cell carcinoma; atypical glandular cells (AGC); adenocarcinoma in situ (AIS); and adenocarcinoma. All the cytology categories other than NILM were considered abnormal.
Follow-up
The first follow-up visit was scheduled 3–12 months after surgery. Patients who tested positive for hrHPV were reevaluated at 6-month intervals, whereas those with negative results were followed up annually. Each follow-up assessment included concurrent hrHPV testing and the TCT. Patients with persistent hrHPV positivity for at least 12 months or any abnormal TCT results were referred for colposcopic examination (Figure S1).
Statistical analysis
All the statistical analyses were conducted by using R (version 4.4.2). Continuous variables are summarized as medians with interquartile ranges and were compared by using the Wilcoxon rank-sum test. Categorical variables are presented as counts and percentages and were compared by using Pearson’s chi-squared test or Fisher’s exact test, as appropriate. Univariate and multivariate logistic regression models were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for associations between candidate variables and hrHPV positivity at the first postoperative follow-up. Variables with p < 0.10 in univariate analysis were included in multivariate models. hrHPV clearance over time was analysed by using Kaplan–Meier survival curves, and groups were compared with the log-rank test. Statistical significance was defined as p < 0.05.
Results
Patient characteristics
A total of 1372 patients with positive surgical margins after cervical excision for CIN3 were initially screened. Among these patients, 1017 were excluded because of cervical cancer that had been diagnosed before hysterectomy or residual cervix resection (n = 281), coexisting VaIN 1–3 (n = 50), observation after excision (n = 442), incomplete medical records (n = 230), or an interval > 12 months between excision and subsequent surgery (n = 14). Among the remaining 355 patients, 67 were further excluded because of preexcision hrHPV negativity (n = 2), the absence of postoperative hrHPV testing (n = 47), or an interval > 12 months between surgery and the first postoperative hrHPV test (n = 18). Ultimately, 288 patients met all the inclusion criteria (Fig. 1).
Fig. 1.
Flow diagram of patient selection. *Surgery refers to hysterectomy or residual cervix resection
Patients were stratified on the basis of their first postoperative hrHPV test results into hrHPV-negative (n = 238) and hrHPV-positive (n = 50) groups (Table 1). The two groups were comparable in terms of the baseline demographic and clinical characteristics, except for the distribution of gravidity (p = 0.022). None of the patients had immunodeficiency or had received long-term immunosuppressive therapy. The first postoperative hrHPV test was performed within 6 months in 94% of the patients. HPV16 was the most frequent type (37.5%), followed by the other high-risk types, excluding the HPV18/45 (34.7%) and unclassified hrHPV types (24.7%).
Table 1.
Baseline clinicopathological characteristics according to hrHPV status at the first postoperative follow-up
| Variable |
Overall N = 288a |
hrHPV negative N = 238a |
hrHPV positive N = 50a |
p-valueb |
|---|---|---|---|---|
| Age (years old) | 56.0 (49.0, 60.0) | 55.0 (49.0, 60.0) | 57.0 (51.0, 64.0) | 0.055 |
| BMI (kg/m2) | 23.1 (21.2, 25.4) | 23.3 (21.3, 25.5) | 22.7 (21.0, 25.0) | 0.206 |
| Menopausal status | 0.170 | |||
| Postmenopausal | 189 (65.6%) | 152 (63.9%) | 37 (74.0%) | |
| Premenopausal | 99 (34.4%) | 86 (36.1%) | 13 (26.0%) | |
| Time since menopause (years) | 9.0 (5.0, 13.0) | 8.0 (5.0, 12.0) | 10.0 (7.0, 15.0) | 0.094 |
| Gravidity | 3.0 (2.0, 4.0) | 3.0 (2.0, 4.0) | 3.0 (2.0, 4.0) | 0.022 |
| Parity | 0.489 | |||
| 0 | 1 (0.3%) | 1 (0.4%) | 0 (0.0%) | |
| 1 | 128 (44.4%) | 109 (45.8%) | 19 (38.0%) | |
| 2 | 118 (41.0%) | 98 (41.2%) | 20 (40.0%) | |
| 3 | 32 (11.1%) | 22 (9.2%) | 10 (20.0%) | |
| 4 | 6 (2.1%) | 5 (2.1%) | 1 (2.0%) | |
| 5 | 1 (0.3%) | 1 (0.4%) | 0 (0.0%) | |
| 6 | 1 (0.3%) | 1 (0.4%) | 0 (0.0%) | |
| 9 | 1 (0.3%) | 1 (0.4%) | 0 (0.0%) | |
| hrHPV results prior to conization | 0.168 | |||
| HPV16 | 108 (37.5%) | 85 (35.7%) | 23 (46.0%) | |
| HPV18 or HPV45 | 9 (3.1%) | 7 (2.9%) | 2 (4.0%) | |
| Other hrHPV | 100 (34.7%) | 89 (37.4%) | 11 (22.0%) | |
| Unclassified | 71 (24.7%) | 57 (23.9%) | 14 (28.0%) | |
| TCT results prior to conization | 0.464 | |||
| NILM | 33 (11.5%) | 31 (13.0%) | 2 (4.0%) | |
| LSIL | 15 (5.2%) | 11 (4.6%) | 4 (8.0%) | |
| AGC-N | 1 (0.3%) | 1 (0.4%) | 0 (0.0%) | |
| ASC-H | 65 (22.6%) | 55 (23.1%) | 10 (20.0%) | |
| ASC-US | 46 (16.0%) | 40 (16.8%) | 6 (12.0%) | |
| HSIL | 99 (34.4%) | 79 (33.2%) | 20 (40.0%) | |
| SCC | 1 (0.3%) | 1 (0.4%) | 0 (0.0%) | |
| Missing | 28 (9.7%) | 20 (8.4%) | 8 (16.0%) | |
| Conization approach | 0.055 | |||
| Cold knife conization (CKC) | 71 (24.7%) | 64 (26.9%) | 7 (14.0%) | |
| Loop electrosurgical excision procedure (LEEP) | 217 (75.3%) | 174 (73.1%) | 43 (86.0%) | |
| Margin involvement of conization tissue | 0.234 | |||
| Stromal margin | 24 (8.3%) | 21 (8.8%) | 3 (6.0%) | |
| Ectocervical margin | 25 (8.7%) | 17 (7.1%) | 8 (16.0%) | |
| Endocervical margin | 166 (57.6%) | 141 (59.2%) | 25 (50.0%) | |
| Multiple margins | 39 (13.5%) | 33 (13.9%) | 6 (12.0%) | |
| Uncertain | 34 (11.8%) | 26 (10.9%) | 8 (16.0%) | |
| Surgicalc approach | 0.683 | |||
| Da Vinci robotic-assisted | 15 (5.2%) | 12 (5.0%) | 3 (6.0%) | |
| Laparoscopy | 187 (64.9%) | 157 (66.0%) | 30 (60.0%) | |
| Open abdominal | 82 (28.5%) | 65 (27.3%) | 17 (34.0%) | |
| Vaginal | 4 (1.4%) | 4 (1.7%) | 0 (0.0%) | |
| Postoperatived pathology | 0.746 | |||
| Cervical squamous cell carcinoma (SCC) | 13 (4.5%) | 11 (4.6%) | 2 (4.0%) | |
| Chronic mucosal inflammation | 149 (51.7%) | 125 (52.5%) | 24 (48.0%) | |
| CIN2 | 6 (2.1%) | 4 (1.7%) | 2 (4.0%) | |
| CIN3 | 110 (38.2%) | 89 (37.4%) | 21 (42.0%) | |
| LSIL/CIN1 | 10 (3.5%) | 9 (3.8%) | 1 (2.0%) | |
| Ovarian preservation, yes | 68 (23.6%) | 60 (25.2%) | 8 (16.0%) | 0.163 |
| Blood loss (ml) | 50.0 (50.0, 100.0) | 50.0 (50.0, 100.0) | 50.0 (50.0, 100.0) | 0.410 |
| Hospital stay (days) | 7.0 (6.0, 8.0) | 7.0 (6.0, 8.0) | 7.0 (6.0, 7.0) | 0.656 |
| Complications | 0.755 | |||
| Catheter-related infection | 1 (0.3%) | 1 (0.4%) | 0 (0.0%) | |
| Incisional infection | 1 (0.3%) | 1 (0.4%) | 0 (0.0%) | |
| Pelvic lymphocele with infection | 1 (0.3%) | 1 (0.4%) | 0 (0.0%) | |
| Septicemia | 1 (0.3%) | 1 (0.4%) | 0 (0.0%) | |
| Other postoperative infections | 3 (1.0%) | 2 (0.8%) | 1 (2.0%) | |
| Incisional omental incarceration | 1 (0.3%) | 1 (0.4%) | 0 (0.0%) | |
| Intestinal obstruction | 2 (0.7%) | 2 (0.8%) | 0 (0.0%) | |
| Left ureteral stent placement | 1 (0.3%) | 0 (0.0%) | 1 (2.0%) | |
| Urinary retention | 3 (1.0%) | 3 (1.3%) | 0 (0.0%) | |
| Ureteral fistula | 1 (0.3%) | 1 (0.4%) | 0 (0.0%) | |
| No complications | 273 (94.8%) | 225 (94.5%) | 48 (96.0%) | |
| Antibiotics day (days) | 5.0 (3.0, 7.0) | 5.0 (3.0, 7.0) | 5.0 (4.0, 6.0) | 0.611 |
| Time to first flatus (days) | 0.372 | |||
| 0 | 1 (0.3%) | 1 (0.4%) | 0 (0.0%) | |
| 1 | 159 (55.2%) | 132 (55.5%) | 27 (54.0%) | |
| 2 | 100 (34.7%) | 85 (35.7%) | 15 (30.0%) | |
| 3 | 28 (9.7%) | 20 (8.4%) | 8 (16.0%) | |
| First follow-up intervale (months) | 3.0 (3.0, 4.0) | 3.0 (3.0, 4.0) | 3.0 (3.0, 3.0) | 0.251 |
BMI Body mass index, SCC Cervical squamous cell carcinoma, hrHPV high-risk human papillomavirus, CIN Cervical intraepithelial neoplasia, NILM Negative for intraepithelial lesion or malignancy, LSIL Low-grade squamous intraepithelial lesion, HSIL High-grade squamous intraepithelial lesion, ASC-H Atypical squamous cells–cannot exclude HSIL, ASC-US Atypical squamous cells of undetermined significance, AGC-N Atypical glandular cells–not otherwise specified, TCT ThinPrep cytologic test
aMedian (Q1, Q3) for continuous variables; n (%) for categorical variables
bStatistical tests: Wilcoxon rank sum test for continuous variables; Fisher’s exact test or Pearson’s Chi-squared test for categorical variables
cSurgery includes hysterectomy or residual cervix resection
dPostoperative pathology refers to pathological findings from hysterectomy or residual cervix resection
eIt refers to the time from hysterectomy or residual cervix resection to the first hrHPV testing
At the first follow-up, 82.6% (238/288) of the patients were hrHPV negative, whereas 17.4% (50/288) remained positive. Postoperative complications were infrequent (5.2%), and infection was the most common complication (2.4%; 7/288). Histopathology revealed residual CIN3 in 38.2% of the patients, CIN2 in 2.1%, and invasive squamous cell carcinoma in 4.5%.
Among the 278 patients who underwent hysterectomy, first postoperative hrHPV positivity was observed in 48 patients (17.3%), compared with 2 of 10 patients (20.0%) in the residual cervix resection group. The difference was not statistically significant (p = 1.000), although the comparison was limited by the small number of patients in the residual cervix resection group.
Factors associated with hrHPV positivity at the first postoperative follow-up
Univariate logistic regression analysis indicated that ectocervical margin involvement (OR 2.723, 95% CI 1.073–6.909; p = 0.035) and older age (OR 1.044, 95% CI 1.004–1.086; p = 0.030) were associated with hrHPV positivity at the first follow-up. High gravidity was inversely associated with this outcome (OR 0.740, 95% CI 0.575–0.954; p = 0.020) (Table 2). Other factors, including BMI, parity, menopausal status, surgical approach, and ovarian preservation, were not significant. Multivariate analysis (Table 2) revealed that ectocervical margin involvement remained independently associated with hrHPV positivity at the first postoperative follow-up (OR 5.273, 95% CI 1.491–18.640; p = 0.010). The other variables were no longer significant. The multivariate logistic regression model showed acceptable calibration (Hosmer–Lemeshow chi-squared statistic = 5.296, df = 8, p = 0.726) and discrimination (AUC = 0.781, 95% CI 0.679–0.882), with a Nagelkerke R-squared of 0.248, suggesting adequate model performance.
Table 2.
Univariate and multivariate logistic regression analyses of factors associated with first postoperative hrHPV positivity
| Variable | Level | Univariate analysis | Multivariate analysis | ||
|---|---|---|---|---|---|
| OR (95% CI) | p-value | OR (95% CI) | p-value | ||
| Age | — | 1.044 (1.004–1.086) | 0.030 | 1.048 (0.977–1.125) | 0.189 |
| BMI (kg/m2) | — | 0.924 (0.834–1.024) | 0.134 | — | — |
| Gravidity | — | 0.740 (0.575–0.954) | 0.020 | 0.646 (0.410–1.018) | 0.060 |
| Parity | — | 1.153 (0.852–1.561) | 0.357 | — | — |
| Margin involvement of conization tissue | Ectocervical margin | 2.723 (1.073–6.909) | 0.035 | 5.273 (1.491–18.640) | 0.010 |
| Endocervical/Stromal margin | 1 | — | 1 | — | |
| Postoperativea pathology | Non-CIN3 or SCC | 0.851 (0.461–1.570) | 0.605 | — | — |
| CIN3 or SCC | 1 | — | — | — | |
| Menopausal status | Premenopausal | 0.621 (0.313–1.232) | 0.173 | — | — |
| Postmenopausal | 1 | — | — | — | |
| hrHPV results prior to conization | Non-HPV16 | 0.500 (0.239–1.049) | 0.067 | 0.450 (0.169–1.197) | 0.110 |
| HPV16 | 1 | — | 1 | — | |
| TCT results prior to conization | LSIL or higher | 2.067 (0.910–4.696) | 0.083 | 2.235 (0.712–7.017) | 0.168 |
| ASC-US or lower | 1 | — | 1 | — | |
| Conization approach | LEEP | 2.259 (0.967–5.279) | 0.060 | 4.572 (0.890–23.499) | 0.069 |
| CKC | 1 | — | 1 | — | |
| Surgicalb approach | Open abdominal | 1.339 (0.698–2.569) | 0.379 | — | — |
| Minimally invasive | 1 | — | — | — | |
| Ovarian preservation | Yes | 0.565 (0.251–1.271) | 0.168 | — | — |
| No | 1 | — | — | — | |
Variables with p < 0.10 in univariate analysis were included in multivariate logistic regression
BMI Body mass index, SCC Cervical squamous cell carcinoma, hrHPV high-risk human papillomavirus, CIN Cervical intraepithelial neoplasia, LSIL Low-grade squamous intraepithelial lesion, ASC-US Atypical squamous cells of undetermined significance, LEEP Loop electrosurgical excision procedure, CKC Cold knife conization, TCT ThinPrep cytologic test, OR Odds ratio, CI Confidence interval
aPostoperative pathology refers to pathological findings from hysterectomy or residual cervix resection
bSurgery includes hysterectomy or residual cervix resection
Sensitivity analyses supported the robustness of the primary findings. After the 10 patients who underwent residual cervix resection were excluded, ectocervical margin involvement remained independently associated with hrHPV positivity at the first postoperative follow-up (OR 4.217, 95% CI 1.144–15.536; p = 0.031; Table S1). Similarly, among patients whose first postoperative hrHPV test was performed within 6 months after surgery, ectocervical margin involvement remained significantly associated with the outcome (OR 4.029, 95% CI 1.193–13.610; p = 0.025). In this subgroup, each additional pregnancy was associated with lower odds of hrHPV positivity at the first postoperative follow-up (OR 0.629, 95% CI 0.401–0.988; p = 0.044; Table S2).
hrHPV clearance dynamics
Beyond the primary endpoint at the first postoperative follow-up, we also examined long-term hrHPV clearance and hrHPV redetection patterns. Among the 238 patients who were hrHPV negative at the first follow-up, hrHPV was redetected in 19 patients (8.0%) during the subsequent follow-up. Patients without documented hrHPV redetection were censored at their last available hrHPV-negative test. Kaplan–Meier estimates revealed that 95.5% (95% CI 91.7–99.5%) of patients remained free from hrHPV at 12 months, 84.7% (95% CI 77.1–93.1%) remained free from hrHPV at 36 months, and 73.3% (95% CI 62.5–86.0%) remained free from hrHPV at 60 months (Fig. 2B). The median time to hrHPV redetection was not reached, indicating largely durable viral negativity.
Fig. 2.
Kaplan–Meier curves of postoperative hrHPV clearance and redetection according to hrHPV status at the first postoperative follow-up
Among the 50 patients who were hrHPV positive at the first follow-up, 14 (28.0%) subsequently achieved hrHPV clearance. Patients without documented clearance were censored at their last available hrHPV-positive test. The estimated probability of persistent hrHPV infection decreased from 61.9% (95% CI 44.6–86.0%) at 12 months to 31.4% (95% CI 14.8–67.0%) at 60 months (Fig. 2A). Most conversions to hrHPV negativity occurred within the first 2 years.
Among patients with at least 24 months of follow-up, 13.5% (14/104) remained hrHPV positive. The corresponding proportions were 11.9% (7/59) among patients with at least 48 months of follow-up and 9.1% (4/44) among those with at least 60 months of follow-up (Table S3), indicating that the proportion of hrHPV-positive patients decreased over time.
Gravidity was not consistently associated with persistent infection (Figure S2), although lower gravidity (< 3) suggested a possible trend towards higher hrHPV redetection after initial clearance (Figure S3). No clear associations were observed for age, hrHPV type, conization method, ovarian preservation, or surgical approach. These findings should be interpreted with caution because the subgroup sizes were small.
Discussion
In this retrospective cohort study, we evaluated the postoperative hrHPV status after hysterectomy or residual cervix resection for incompletely excised CIN3. Ectocervical margin involvement was associated with a higher likelihood hrHPV positivity at the first postoperative follow-up, suggesting that the margin status may have value for postoperative risk stratification.
Studies on hrHPV persistence after conization have reported rates of 5–25% [19–22] and a nonlinear decline in positivity, with a rapid decrease within the first 24 months [19]. A meta-analysis identified positive margins, residual disease, postmenopausal status, and HPV16 infection as factors associated with post-conization hrHPV persistence [23]. Fewer studies have examined hrHPV clearance after hysterectomy. Cao et al. reported a post-hysterectomy hrHPV positivity rate of 18.8% in women with prior CIN [14], and Liu et al. reported 76.5% clearance at 12 months after hysterectomy for HSIL [18]. In our cohort, 17.4% of patients were hrHPV positive at the first postoperative follow-up. Liu et al. also found similar hrHPV clearance after conization and hysterectomy [18]. Given that persistent post-hysterectomy hrHPV infection is associated with an increased risk of VaIN [14, 17], identifying factors associated with hrHPV persistence in high-risk patients remains clinically relevant. After conization, positive endocervical margins may indicate residual endocervical disease or infection and have been linked to recurrence. By contrast, after hysterectomy or residual cervix resection, the cervix and transformation zone have been removed, and postoperative hrHPV positivity may be more likely to reflect viral persistence or redetection in the vaginal vault or broader lower genital tract. This anatomical difference may partly explain the association with ectocervical rather than endocervical margin involvement, although this interpretation remains speculative and requires validation using site-specific postoperative HPV sampling.
Residual cervix resection removes the retained cervical stump after prior subtotal hysterectomy, and cervical dysplasia has been reported as one indication [24, 25]. Although hysterectomy and residual cervix resection are technically distinct surgical procedures, they were analysed together because the grouping was predefined according to the postoperative anatomical and biological context relevant to the study endpoint, rather than surgical equivalence. Specifically, both procedures remove the remaining cervical disease-bearing tissue, including the cervical transformation zone, which is the principal site of HPV-associated CIN [26]. This shared post-cervical-removal context allowed postoperative hrHPV status to be assessed within a comparable biological framework. Excluding the residual cervix resection cases did not materially change the main findings, suggesting that this small subgroup did not drive the observed association.
Kaplan–Meier analysis indicated that most patients who were initially hrHPV positive cleared the virus within 2 years, whereas a minority remained positive at 60 months. In contrast, subsequent hrHPV redetection occurred in a minority of patients who were hrHPV negative at the first follow-up. These findings suggest that early postoperative hrHPV negativity may be associated with durable viral clearance. An exploratory analysis suggested a possible trend towards higher hrHPV redetection among patients with lower gravidity (< 3 pregnancies), but the number of events was limited. Potential contributors, such as the hormonal status, the vaginal microbiota, and sexual behaviour, were not captured in this study and warrant further investigation. Previous studies have generally reported no significant association between gravidity and persistent hrHPV infection [27–29], indicating that our findings may reflect cohort-specific factors.
Taken together, these findings add to the limited literature on postoperative hrHPV outcomes after definitive cervix removal for incompletely excised CIN3. Unlike most previous studies, which have focused on hrHPV persistence after conization or on VaIN risk after hysterectomy, the present study specifically evaluated early postoperative hrHPV positivity and its associated factors after hysterectomy or residual cervix resection. The relatively large sample size in this specific postoperative setting, together with long-term follow-up data, allowed assessment of subsequent hrHPV clearance and redetection over time. Because a subset of patients continued to show hrHPV positivity after surgery, extended and individualized follow-ups may be warranted, particularly in patients with additional clinicopathological risk factors, such as ectocervical margin involvement.
Several limitations of this study should be noted. First, as a retrospective single-center study based on a tertiary hospital, its generalizability is limited. The findings remain hypothesis-generating and require further multicenter prospective validation. Second, potential selection bias exists due to the exclusion of patients without postoperative hrHPV testing. Included patients had better follow-up adherence, whereas excluded cases may differ in socioeconomic background, healthcare access and disease severity. Although baseline differences were compared, residual confounding cannot be excluded. In addition, the limited number of positive events may reduce statistical precision, indicating that our results mainly apply to patients with complete postoperative surveillance.Third, the use of different hrHPV detection platforms (HC2 and PCR-based assays) introduced methodological heterogeneity [30–32]. Variable assay targets, cut-off values and genotype coverage may cause misclassification of low-viral-load results [33]. Such non-differential misclassification typically biases effect estimates toward the null [34]]. Residual detection variability remains owing to incomplete assay recording and imperfect inter-test concordance [30, 35, 36], and stratified analysis was infeasible due to limited events. Fourth, postoperative hrHPV testing varied from 3 to 12 months. Early testing may overestimate transient HPV infection, while delayed testing may miss persistent cases. However, sensitivity analysis restricted to 6-month testing yielded consistent results, supporting the robustness of our main finding. Fifth, unmeasured confounding factors, including postoperative sexual behavior, partner exposure, immune status and vaginal microbiota, were unavailable in this retrospective cohort. Therefore, only statistical associations rather than causal relationships can be concluded. Sixth, the combined analysis of hysterectomy and residual cervix resection should be interpreted cautiously, given their different surgical characteristics and the relatively small subgroup size of residual cervix cases. Prolonged surveillance may cause psychological burden on patients, emphasizing the need for patient-centered follow-up strategies [37]. The observed associations should not be interpreted as evidence of a causal relationship but rather as a basis for generating hypotheses to be tested in future prospective studies.
In conclusion, ectocervical margin involvement was associated with a higher likelihood of postoperative hrHPV positivity at the first follow-up after hysterectomy or residual cervix resection for incompletely excised CIN3. Within the constraints of our observational design, these findings provide preliminary evidence for factors associated with postoperative hrHPV persistence, although causal inferences cannot be drawn. Further prospective studies with standardized postoperative HPV testing and follow-up are warranted to confirm these results and explore the underlying mechanisms. Given the observational design of this study, these results should be interpreted as hypothesis-generating and require confirmation in prospective, multicenter cohorts before any clinical recommendations can be made.
Supplementary Information
Acknowledgements
None.
Abbreviations
- hrHPV
High-risk human papillomavirus
- CIN3
Cervical intraepithelial neoplasia grade 3
- LEEP
Loop electrosurgical excision procedure
- CKC
Cold-knife conization
- EMR
Electronic medical record
- BMI
Body mass index
- TCT
ThinPrep cytology test
- NILM
Negative for intraepithelial lesion or malignancy
- ASC-US
Atypical squamous cells of undetermined significance
- LSIL
Low-grade squamous intraepithelial lesion
- HSIL
High-grade squamous intraepithelial lesion
- ASC-H
Atypical squamous cells, cannot exclude HSIL
- AGC
Atypical glandular cells
- AIS
Adenocarcinoma in situ
- VaIN
Vaginal intraepithelial neoplasia
- OR
Odds ratio
- CI
Confidence interval
Authors’ contributions
Conceptualization, writing—review and editing: J.X.; data curation, methodology, formal analysis, writing—original draft: Y.R.; data curation, visualization: X.Z. All authors have read and agreed to the published version of the manuscript.
Funding
No external funding was received for this study.
Data availability
The datasets used during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
This study was approved by the Human Research Ethics Committee of Women’s Hospital, Zhejiang University School of Medicine (approval no. IRB-20250108-R). The requirement for individual informed consent to participate was waived by the Ethics Committee owing to the retrospective nature of the study, which used anonymized patient data. The study was conducted in accordance with the ethical standards of the institutional and national research committees and with the Declaration of Helsinki and its subsequent amendments.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Yedan Ren and Xiuli Zhang contributed equally to the work.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets used during the current study are available from the corresponding author on reasonable request.