Cervical cancer is a malignancy that poses a significant risk to the health of women. It ranks fourth worldwide in terms of both incidence and mortality, with a higher incidence in developing countries than in developed countries [1]. Persistent cervical infection with high-risk human papillomavirus (HR-HPV) leads to the development of precancerous lesions known as high-grade squamous intraepithelial lesions (HSIL) and adenocarcinoma in situ (AIS), which may ultimately lead to cervical cancer [2].

Individuals diagnosed with early-stage cervical carcinoma and precancerous lesions often undergo conization treatment, predominantly cold knife conization (CKC) and the loop electrosurgical excision procedure (LEEP) [3]. A small number of patients with persistent HR-HPV infection or low-grade squamous intraepithelial lesions (LSIL) require diagnostic conization. For patients with HPV-associated lesions who undergo cervical conization, regular postoperative monitoring of HR-HPV infection and cytology is essential for early detection of persistent HR-HPV infection and diagnosis of residual or recurrent disease [4, 5, 6]. Persistent HPV infection plays a critical role in the recurrence risk following CKC and LEEP. Studies indicate that postoperative HPV persistence is closely associated with the recurrence risk of cervical intraepithelial neoplasia (CIN), particularly with persistent infection by HPV16 being recognized as a significant predictor of CIN2+ recurrence [7, 8]. In postoperative follow-up studies of LEEP procedures, early HPV testing has been proven to be an effective predictor of residual or recurrent lesions. Research indicates that HPV testing conducted 3 months after surgery can accurately identify all residual or recurrent cases, achieving 100% sensitivity and negative predictive value [9]. Furthermore, the relationship between persistent postoperative HPV infection and surgical margins has been extensively investigated. Even when surgical margins were negative, persistent HPV infection significantly increased the risk of CIN recurrence [10]. A meta-analysis revealed that 22.7% of patients had residual HPV after surgery, with CIN recurrence rates remaining substantially elevated even in cases of negative margins [10]. These findings underscore the critical importance of addressing persistent postoperative HPV infections.

Post-conization surveillance relies on HR-HPV and cytology to detect residual or recurrent disease. However, whether the excisional modality itself influences genotype-specific HR-HPV clearance or persistence remains uncertain. As CKC and LEEP differ in thermal artifact, specimen integrity, and typical cone dimensions, they may differentially affect viral reservoirs and, consequently, clearance dynamics. To date, only a few studies have compared the effects of CKC and LEEP on HR-HPV regression and the influencing factors in patients after conization [11]. Therefore, we aimed to investigate the factors associated with clearance of HR-HPV in patients with cervical HPV-associated lesions following conization and to provide insights that can guide the implementation of more targeted treatment action plans in the future.

Cervical cancer is the most prevalent malignant tumor. Since the 1990s, a research study has demonstrated a strong association between HR-HPV infections and cervical cancer [12]. Nonetheless, HR-HPV infections in the epithelial cells of the female reproductive system are quite prevalent, with the majority being temporary, symptomless, and typically eliminated by the immune system within 6–24 months. Only a small number of persistent cases result in cervical abnormalities [13]. Disease progression occurs in a specific sequence, starting with an initial HPV infection and moving through various stages of cervical lesion formation, before culminating in cervical cancer. This progression takes approximately 8–12 years [14]. The molecular mechanisms underlying HPV treatment and persistent infection remain an active area of research. A recent study has indicated that post-translational modifications (PTMs), such as lysine succinylation, play a significant role in regulating antiviral immunity, which may help explain the persistence of HR-HPV infections [15]. Timely intervention during the precancerous phase is crucial for lowering the incidence and death rates associated with cervical cancer. In 2015, Joste and colleagues [16] observed a notable reduction in HPV infection rates within 3 months post-surgery among patients with HSIL who underwent CKC. In this study, the postoperative disappearance rates of HPV16/18 were 92.2% in the CKC group and 85.7% in the LEEP group. This decline could be attributed to lesion removal, enhanced local immune response, and improved self-clearance of the virus, leading to a significant decrease in HPV levels in the reproductive tract. Notably, our HPV clearance rate is higher than that reported in previous studies. For example, a retrospective study demonstrated that 64.5% of patients undergoing conization achieved complete HPV clearance [17]. Additionally, another study reported HPV clearance rates of 24.5% at 6 months and 67.9% at 12 months post-treatment [18]. This may be attributable to regional differences and variations in healthcare resources. Furthermore, the findings of this study indicate a notable statistical disparity in the regression duration of HR-HPV between the CKC and LEEP procedures, with patients undergoing LEEP experiencing a longer regression period than patients undergoing CKC, suggesting potential differences in the therapeutic outcomes of CKC and LEEP for patients with cervical lesions. A possible reason for this is that CKC has a wider scope for cervical resection, and the resection effect is more reliable. At the same time, we observed similar postoperative cumulative positive rates of HR-HPV and RMST between the two groups, with no statistically significant differences. This may be due to censoring and follow-up biases.

Earlier research has indicated that numerous factors, such as age, single or multiple infections, and infection genotyping, are associated with HPV infection and its resolution [19, 20]. A study conducted in Western Kazakhstan reported a prevalence of HR-HPV types at 26%, which was lower than the prevalence found in our study [21]. This difference may be attributed to variations in the popularity and standardization of cervical cancer screening programs. Nevertheless, our findings are consistent with this study, as both indicate a relatively high prevalence of HR-HPV types among women with cervical lesions [21]. Notably, several markers have been identified as indicators of poor prognosis in HPV-related diseases, including squamous cell carcinoma antigen (SCC Ag), which has been shown to predict unfavorable treatment outcomes in patients with cervical cancer [22]. In recent years, with the progress of the research in the field of HR-HPV, the significance of postoperative outcomes in terms of the progression of cervical lesions has become increasingly clear. Some studies have shown that HR-HPV infection is a risk factor for residual lesions and recurrence after conization. This may be because, in patients whose cervical lesions have been removed but the virus persists, HR-HPV can remain hidden and re-infect the stump epithelium, resulting in persistent HR-HPV infection after surgery [4, 5, 20, 23]. An observational study indicated that patients with HPV 16 infection and a high viral DNA load experience slower viral clearance [24], while another study identified age as a prognostic factor for the clearance of HR-HPV infections after surgery [25]. In addition, a study by Venturoli et al. [26] evaluated several clinical and viral factors, including HPV16 infection and a positive cutting edge, but found no factors affecting virus clearance time. Therefore, no conclusion exists on the negative conversion time of HR-HPV, the various types of HR-HPV, and the high-risk factors affecting negative conversion. In our study, we found that patients in the CKC group had a lower risk of postoperative persistent HR-HPV infection than those in the LEEP group. This finding is consistent with a previous study that reported a higher positive rate of postoperative cervical secretion HPV infection in the LEEP group compared to the CKC group. However, Chen et al. [27] and Jiang et al. [28] found there was no difference in these two groups. Galli et al. [29] also found that women undergoing the LEEP procedure showed no statistically significant difference compared to those undergoing CKC in terms of persistent disease and positive margins. Additionally, they had a lower risk of postoperative bleeding within 24 hours [29]. Higher HPV clearance after CKC may reflect a deeper, en bloc excision with clearer margin assessment, which enhances the removal of endocervical crypt reservoirs. In contrast, thermal artifacts and piecemeal excision associated with LEEP can hinder complete clearance. However, when LEEP achieves adequate depth with negative margins, the differences between the two procedures become minimal [30, 31]. These results indicate that, whether CKC or LEEP is performed, oncologic adequacy must be balanced with the preservation of normal tissue to ensure sufficient excision with minimal collateral damage. Recent advancements in intelligent nanomaterials have opened new avenues for targeted therapies, particularly for HPV-related diseases [32]. These nanomaterials can be engineered to specifically target HPV-infected tissues, thereby enhancing therapeutic efficacy while minimizing off-target effects.

This study had several limitations. First, the retrospective, single-center design is susceptible to confounding by indication and unmeasured variables. The clinical decision to perform CKC versus LEEP may be influenced by factors that also affect HPV clearance. Although available covariates were accounted for, residual confounding is likely. Second, selection bias may be present. Excluding patients who did not undergo CKC or LEEP, or those lost to follow-up, could result in a sample enriched with more adherent patients who have better outcomes; this informative censoring could bias clearance estimates. Third, the follow-up duration was relatively short and variable, which may lead to underestimation of late clearance or recurrence and potential misclassification of persistence when testing intervals are prolonged.

In this retrospective cohort study of women treated with cervical conization, CKC resulted in higher genotype-specific clearance of HR-HPV and a shorter time to regression compared to the LEEP. Multivariable analysis revealed that LEEP was independently associated with persistent postoperative HR-HPV positivity, whereas factors such as age, menopausal status, mixed infections, and margin status were not. These findings underscore the importance of achieving oncologically adequate excision by ensuring sufficient cone depth and volume with clear margins, while minimizing damage to uninvolved tissue, regardless of the procedure used. Future prospective studies should focus on determining the factors influencing postoperative HPV clearance to provide even stronger evidence to guide clinical decision-making.

The datasets generated during and analysed during the current study are available from the corresponding author on reasonable request.

YS: Data analysis, drawing figures and tables, writing original draft. FL: Data analysis. PL: Drawing figures and tables. YY: Data analysis and writing original draft. HS: Conceptualization, project administration. ZD: Conceptualization, project administration, supervision. All authors contributed to critical revision of the manuscript for important intellectual content. All authors read and approved the final manuscript. All authors have participated sufficiently in the work and agreed to be accountable for all aspects of the work.

This study adhered to the ethical guidelines of the Declaration of Helsinki and was approved by the Ethics Committee of the Affiliated Hospital of Qingdao University (approval code: QYFYWZLL27495). Written informed consent was obtained from all participants and their guardians.

The authors thank Editage (https://www.editage.cn/) for English language editing.

This research received no external funding.

The authors declare no conflict of interest.