PubMed Health⌕ Search

SEARCH · PubMed Health

Results for “Conization”

Explore indexed PubMed citations for clinical trials, systematic reviews and public health research. Read source abstracts and follow each citation to its original PubMed record.

Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.

At least 37 records · Page 2Linked to original sources

Pregnancy complications following conization of the uterine cervix (II).

The effect of conization upon the course of pregnancy and the fertility has been evaluated. 44 women had a total of 66 pregnancies following conization. These 44 women were compared with an age-matched group of non-conized women, as well as with a group of non-conized women matched for both age and parity. There were more smokers among conized than among non-conized women. All other descriptive variables were found to be without significant differences between the groups compared. There was no significant difference in the frequency of spontaneous and induced abortion, prematurity or cesarean section between conized and non-conized women. The second stage of labor was found to be protracted in conized women. Fertility judged by the "latent period"--the time elapsed from the couple started sexual intercourse without use of contraception to the present pregnancy--showed no difference between conized and non-conized women. We conclude that although a greater number of patients is necessary to permit definite conclusions concerning the risk of pregnancy and delivery complications in conized women, it is of special interest that the present study did not demonstrate an increased risk of spontaneous abortion nor of prematurity.

Abortion, Spontaneous↗

Persistent HPV infection after conization in patients with negative margins.

OBJECTIVES: To investigate the rate of clearance of high-risk HPV after conization with negative margins and to identify the factors that may predict high-risk HPV clearance/persistence after conization with negative margins. METHODS: We performed a retrospective review of 69 patients (mean age 39.5 years, range 25-60 years) with histologically verified CIN 2 or CIN 3 who underwent electroknife conization with negative margins between March 2002 and December 2003. High-risk HPV testing was performed on cervical cytology prior to and 6 months after conization. Hybrid Capture II testing was used to detect HPV DNA. RESULTS: High-risk HPVs were detected in the primary cervical lesions of 67 of 69 patients (97.1%) prior to conization. Follow-up at 6 months revealed that high-risk HPVs were eradicated by conization in 82.1%. Univariate analysis showed that persistent HPV infection after conization with negative margins was more likely to occur when the pretreatment viral load was high (RLU/PC > 500) (P = 0.005). HPV infection after conization with negative margins was persistent in 43.8% (7/16) of patients with high viral load (RLU/PC > 500) and in 9.8% (5/51) of patients with low viral load (RLU/PC < or = 500). Multiple regression analysis showed that high viral load (RLU/PC > 500) was the only significant independent predictor of HPV persistence (P = 0.0027). CONCLUSIONS: High-risk HPV infections were effectively eliminated by conization with negative margins in most cases. Because high viral loads are significantly associated with high-risk HPV persistence after conization with negative margins, patients with high viral loads prior to conization should be closely followed.

Adult↗

[Conization with positive margins: what strategy should be adopted?].

OBJECTIVE: To define recommended treatment in cases of positive margins on cone biopsy specimens. PATIENTS AND METHODS: This single-center retrospective study concerned 220 conizations performed between January 1996 and June 1998. The results of 70 conizations (31.8%) with positive margins were analysed. There were 32 cold knife conizations (mean age: 43 years) and 38 conizations by the loop electrosurgical excision procedure (mean age: 33 years). RESULTS: Mean depth of conization was 15.94 mm for cold knife conization and 10.08 mm for loop electrosurgical conization. Fifteen patients were excluded (5 with invasive cancer and 10 were lost to follow-up). This study included 55 patients with a mean 12-month follow-up. Six underwent hysterectomy for mini-invasion on the specimen or advanced age. Eleven underwent a second conization (followed by hysterectomy in 2 cases). The other 38 patients were submitted to simple surveillance with cervico-vaginal cytology and colposcopic examination. The rate of residual lesions (cervical intra-epithelial neoplasia: CIN 3) after conization with positive margin was 14.5% (n = 8). CONCLUSION: Residual persistent dysplasia is not present in all patients after conization with positive margins. Cytology and colposcopy allow detection of dysplasia, indicating the need for a second conization. In women with no desire for further pregnancy, systematic repeat surgery must be recommended.

Adult↗

Risk of residual invasive disease in women with microinvasive squamous cancer in a conization specimen.

OBJECTIVE: To quantify the risk of residual invasion when cervical conization reveals microinvasive squamous carcinoma and to determine whether any factors affect this risk. METHODS: We reviewed the charts and histopathology slides of 87 women who underwent a conization that contained microinvasive squamous carcinoma, followed by either a repeat conization or hysterectomy. Depth of invasion, number of invasive foci, and status of the internal margin and post-conization endocervical curettage (ECC) were assessed. The findings were correlated with the presence of residual invasion. RESULTS: Significant predictors of residual invasion included status of the internal margin (residual invasion present in 22% of women with an involved margin versus 3% with a negative margin; P < .03) and the combined status of the internal margin and post-conization ECC (residual invasion in 4% of patients if both negative, 13% if one positive, and 33% if both positive; P < .015). Depth of invasion and number of invasive foci in the conization specimen were not significant. The power of this study to detect a 25% difference in the risk of residual invasion was 73% for depth of invasion and 75% for number of invasive foci. CONCLUSION: Women with microinvasive squamous carcinoma in a conization specimen in which both the internal conization margin and post-conization ECC are negative have a low risk of residual invasion and are candidates for follow-up or simple hysterectomy. If either the internal margin or the post-conization ECC contains dysplasia or carcinoma, the risk of residual invasion is high and warrants repeat conization before definitive treatment planning.

Carcinoma, Squamous Cell↗

[Evaluation of cervical conization in diagnosis and management of cervical intraepithelial neoplasia].

OBJECTIVE: To determine whether cervical conization can be instead of colposcopic multiple biopsies and to evaluate the clinical value of cervical conization in diagnosis and management of cervical intraepithelial neoplasia. METHODS: Fifty four patients with cervical intraepithelial neoplasia (CIN) diagnosed and treated at Peking Union Medical College hospital were retrospectively analyzed focusing on the comparative study in pathology between cerical conization and colposcopic multiple biopsies. RESULTS: Of the 54 patients, there was a correlation in pathology between cervical conization and colposcopic multiple biopsies in 22 cases (40.7%), but there was not much correspondence between cervical conization and colposcopic multiple biopsies in 32 cases (59.3%). In 31 cases conization performed for ruling out invasive cancer, there was a correlation in pathology between cervical conization and colposcopic multiple biopsies in only 13 cases (41.9%). After conization radical hysterectomy was performed in 2 cases (3.7%) because of early invasive carcinoma and simple hysterectomy was performed in 13 cases (24.1%) because of CINIII involved the gland and microinvasive carcinoma of the cervix. 39 cases (73.2%) were closely followed-up postoperatively with preservation of fertility. During the mean follow-up time of 18.3 months, no cytology abnormality was detected and 3 patients had pregnancy and delivery. Postoperative hemorrhage was main side effect for conization. CONCLUSIONS: Cervical conization plays a very important role in diagnosis and treatment of CIN and it can not be instead of colposcopic multiple biopsies. Cervical conization is a good choice for patient with CINIII and desired childbearing.

Adult↗

Predictive factors from cold knife conization for residual cervical intraepithelial neoplasia in subsequent hysterectomy.

OBJECTIVE: The optimal management of cervical intraepithelial neoplasia after cold knife conization remains controversial. Reliable predictors of residual dysplasia in the cervix after cold knife conization have not been consistently identified. This study was initiated to examine the accuracy of the traditional factors used to predict residual dysplasia in hysterectomy specimens after cold knife conization. STUDY DESIGN: A retrospective 10-year chart review identified a cohort of 1272 patients who underwent cold knife conization, of whom 311 had a subsequent hysterectomy within 1 year of conization. Residual disease was defined as cervical intraepithelial neoplasia or cancer in the hysterectomy specimen. All cone specimens were completely submitted for pathologic examination, and the following factors were analyzed for their predictive value: degree of dysplasia, margin involvement, endocervical gland involvement, and status of the endocervical curettage. The predictive value of age, race, gravidity, parity, socioeconomic status, cigarette smoking, and marital status were also examined. The chi 2 test, t test, and logistic regression were used for statistical analysis. RESULTS: Dysplasia or cancer were identified in 1066 (84%) of the 1272 patients who underwent cold knife conization. Of the 311 patients having a subsequent hysterectomy, 106 (34%) had residual disease in their hysterectomy specimen. By multivariate analysis only increasing age and degree of dysplasia were predictive of residual disease. The odds ratio of residual disease in the hysterectomy specimen for a 25-year-old woman was 2.7 (95% confidence interval 1.6 to 4.4) compared with a 40-year-old woman whose odds ratio was 4.9 (95% confidence interval 2.2 to 10.8). The presence of dysplasia in the cold knife conization specimen conferred an odds ratio of 12.1 (95% confidence interval 2.7 to 54.5) of identifying residual disease. Dysplasia involving the ectocervical margin, endocervical margin, and endocervical glands was not predictive of disease in the hysterectomy specimens. Endocervical curettage was not performed in 44% of the patients, preventing reliable statistical evaluation. Further analysis indicated that residual disease was found in 32% of the hysterectomy specimens with negative margins, in 31% with no endocervical gland involvement, and in 23% with a negative endocervical curettage sample. CONCLUSIONS: The presence or absence of dysplasia in the cold knife conization ectocervical margin, endocervical margin, and endocervical glands was not predictive of residual dysplasia in post-cold knife conization hysterectomy specimens. Increasing age and severity of disease in the cone specimen were the only factors that accurately predicted residual dysplasia. The traditional factors used to justify hysterectomy after cold knife conization may not be valid on the basis of these results.

Adolescent↗

Delivery outcome after cold-knife conization of the uterine cervix.

OBJECTIVE: To estimate the risk for preterm delivery and obstetric complications in women with prior cold-knife conization. METHODS: In a retrospective study, we compared 76 deliveries of 65 women with prior cold-knife conization with the remaining 29,711 singleton deliveries at our institution between 1992 and 2002. RESULTS: We found significant shorter duration of pregnancies in the conization group. Delivery prior to 37 weeks was found in 22.4% (n = 17) of the conization group and in 6.6% (n = 1961) of the controls (OR = 4.07 [2.22-7.10], P < 0.001). Preterm premature rupture of the membranes was found in 17.1% (n = 13) of the conization group and in 2.6% (n = 775) of the controls (OR = 7.70 [3.87-14.21], P < 0.001). Birth weight less than 2500 g was found in 18.4% (n = 14) of the conization group and in 7.7% (n = 2280) of the controls (OR = 2.72 [1.40-4.92], P = 0.002). Overall, birth weight in the conization group was not significantly lower (median 3147 g vs. 3287 g, P = 0.115). Cervical tears were found more frequently in the conization group (8.8% [n = 6] vs. 1.3% [n = 236], OR = 7.53 [2.63-17.57], P < 0.001). There was no difference in mode of delivery, duration of labor, head circumference, chorioamnionitis and use of oxytocin. CONCLUSION: Cold-knife conization is a risk factor for preterm birth and preterm premature rupture of the membranes and seems to be a risk factor for cervical tears.

Adolescent↗

Conization of the cervix using harmonic scalpel.

Conization, as a surgical treatment for cervical intraepithelial neoplasm (CIN), is a good method that preserves reproductive functions. Technological developments have introduced a wide variety of energy sources for surgical procedures. Traditional cold knife conization has been replaced by laser conization and by the loop electrosurgical excisional procedure (LEEP). However, laser conization and LEEP have some disadvantages. Laser conization requires expensive equipment. LEEP induces electrocautery artifacts and cannot excise the cervical tissue as a single-piece, because of the various extensions and depths of lesion, so that evaluation of the margins is sometimes not possible. Laser conization and LEEP both generate smoke. The presence of smoke is not only inconvenient, but also dangerous. Harmonic Scalpel (HS), ultrasonic cutting and coagulation system, is a new surgical tool that cuts and coagulates using ultrasonic mechanical vibrations. Eleven women with CIN III underwent conization using HS. HS eliminated the major disadvantages of electrosurgery and laser surgery. No complications during conization were observed. Postoperative hemorrhage was noted in only one patient. Histological diagnosis was not affected by heat or ultrasound. This surgical method using HS is characterized by negligible bleeding, a good visual field not obscured by smoke and resection of an ideal shape that fits the size of the lesion. It is concluded that this method overcomes most problems associated with conization using conventional methods.

Adult↗

Loop diathermy and cold-knife conization in patients with cervical intraepithelial neoplasia: a comparative study.

One hundred and sixty-eight cases of cervical conization were performed for cervical intraepithelial neoplasia (CIN) in a 32-month study. The indications for conization were unsatisfactory colposcopic finding, abnormal epithelium that extended into the endocervical canal, a microinvasive cervical cancer, and significant discrepancy among cytology, colposcopy, and/or punch biopsy histology. In the early period of the study, conization was done by the cold-knife method (N = 107), whereas loop diathermy was used in the latter part of the study (N = 61). Both groups were similar in terms of age, indications for conization, and size of cervical cone specimens. Loop diathermy conization was done in a significantly shorter time (5.7 +/- 1.8 minute vs 15.2 +/- 6.1 minute)(P < 0.05) than cold-knife conization. However, the difference in the postoperative complications between loop diathermy(3.0%) and cold-knife conization(4.7%) was not significant. The incidence rate of residual CIN III lesions in the subsequent hysterectomy specimens, found by histological documentation on these specimens was 25.0 and 26.1 percent after loop diathermy and cold-knife conization respectively. These results suggest that loop diathermy is much easier to perform and a more time-conserving treatment modality than cold-knife conization in the management of patients with cervical intraepithelial neoplasia.

Adult↗

Is therapeutic conization sufficient to eliminate a high-risk HPV infection of the uterine cervix? A clinicopathological analysis.

BACKGROUND: High-risk human papillomavirus infection plays a predominant role in the pathogenesis of preinvasive and invasive cervical cancer. One of the recognized treatments of cervical intraepithelial neoplasia is conization. The aim of this study was to evaluate if cold-knife conization is sufficient to eliminate cervical intraepithelial neoplasia and the associated high-risk HPV infection. PATIENTS AND METHODS: Thirty-seven high-risk HPV-positive women who underwent cold-knife conization entered this study. The cervical sampling for HPV DNA was performed using the Digene cervical sampler. Smears were taken immediately before and 3 months after conization and the patients were followed-up for 2 years. RESULTS: High-risk HPV was identified in all 37 patients before conization. In 4 out of 37 patients a coincidence of low/intermediate and high-risk HPV types was present. A CIN II was detected in 5 out of 37, a CIN III in 25 out of 37 and a carcinoma in situ in 7 out of 37 cases. Follow-up at three months revealed that HPV was eradicated by conization in 73%. Patients with persistent HPV infection tended to be older compared to patients with eliminated HPV infection (mean: 34 vs. 36 years; p = 0.25) and showed a higher rate of severe dysplasia (p = 0.07). A high HPV prevalence among patients with positive resection margins and/or recurrence disease was detected (83% and 100%, respectively). A statistically significant higher rate of positive margins and recurrences was observed in patients with persistent compared to patients with eliminated HPV infection (50% vs. 4%. p = 0.001 and 30% vs. 0%, p = 0.003). CONCLUSION: The data of the present study demonstrated that a high-risk HPV infection is successfully eliminated by conization in most cases. A high HPV prevalence in patients who had positive cone margins and/or disease recurrence was observed. Patients with persisting HPV infection after conization show statistically significant higher rates of positive resection margins and are at increased risk of disease recurrence. HPV testing seems to be, therefore, a valuable tool to monitor the therapeutic results of conization and to discriminate patients who have a higher risk of disease recurrence.

Adult↗

Influence of diagnostic conization on surgical morbidity and survival in patients undergoing radical hysterectomy for stage IB and IIA cervical carcinoma.

The purpose of this retrospective study was to investigate whether diagnostic conization influenced surgical morbidity of a subsequent radical hysterectomy in patients with early cervical carcinoma. Furthermore, the impact of an irradical conization on nodal metastases and prognosis was analysed. Included were 271 patients with stage IB and IIA cervical carcinoma who underwent an Okabayashi radical hysterectomy between 1982 and 1991. There were 68 patients who underwent conization prior to radical hysterectomy. The conization-radical hysterectomy interval was approximately six weeks. Surgical morbidity in patients with a previous conization was not significantly different from that in patients without a previous conization. Survival was also not significantly different between these groups (95% vs. 91%, p = 0.23). Multivariate analysis showed that an irradical conization was not associated with an increased risk for nodal metastases or a poorer prognosis. We suggest that in early cervical carcinoma, a diagnostic conization does not adversely affect early morbidity of a following radical hysterectomy. An irradical conization does not seem to influence prognosis.

Adult↗

[Increased risk of preterm delivery in women with earlier conization].

The object of the study was to determine the relation between cervical conization and preterm birth. All Danish women with singleton pregnancies who gave birth to their first infant in 1982 and second infant in 1982-1987 were included in a register-based cohort study. Information on pregnancy outcome and cervical conization in 1977-1987 was obtained from the Medical Birth Register and the National Register of Hospital Discharges. It was found that in a cohort of 14.233 women, 170 had had cervical conization. Thirty-four had had cervical conization before the first delivery, 62 between the first and the second, and 74 after the second delivery. Women with cervical conization had a significantly higher risk of preterm birth. Also, women with subsequent cervical conization had a higher risk of preterm birth in previous pregnancies. However, the risk of preterm birth was higher in women with previous than with subsequent cervical conization. It is concluded that cervical conization is correlated with preterm birth. Since women with subsequent cervical conization are at increased risk of preterm birth in preceding pregnancies, other factors than the surgical intervention may contribute to the significantly increased risk of preterm birth.

Adult↗

Diagnostic and therapeutic conization using loop radiothermal cautery.

A group of 173 patients with abnormal cervical cytology underwent diagnostic or therapeutic conization following colposcopic examination. The series includes 23 patients with cold knife conization in the hospital under general anesthesia, 12 patients with an outpatient KTP laser procedure under local anesthesia, 53 patients with an outpatient CO2 laser procedure under local anesthesia, 10 patients with hospital-based loop radiothermal cautery conization and 75 patients with loop radiothermal cautery conization in the office under local anesthesia. Loop radiothermal cautery conization was advantageous, with a shorter duration of surgery, lower cost, reduced operative bleeding, less of a need for pain-relieving medication and shorter duration of postoperative disability. Cold knife conization patients had the most intraoperative bleeding and the longest hospitalization. KTP laser conization produced specimens of inferior quality, resulting in the least satisfactory histologic diagnosis. Office-based loop radiothermal cautery conization may be preferable to other methods of conization in the diagnosis and management of squamous intraepithelial lesions.

Colposcopy↗

Increased risk of preterm birth in women with cervical conization.

OBJECTIVE: To determine the relation between cervical conization and preterm birth. METHODS: All Danish women with singleton pregnancies who gave birth to their first infant in 1982 and second infant during the time period 1982-1987 were included in a register-based cohort study. Information on pregnancy outcome and cervical conization in 1977-1987 was obtained from the Medical Birth Register and the National Register of Hospital Discharges. RESULTS: In a cohort of 14,233 women, 170 had cervical conization. Thirty-four had cervical conization before the first delivery, 62 between the first and the second, and 74 after the second delivery. Women with cervical conization had a significantly higher risk of preterm birth. In addition, women with subsequent cervical conization had a higher risk of preterm birth in previous pregnancies. However, the risk of preterm birth was higher in women with previous than with subsequent cervical conization. CONCLUSIONS: Cervical conization is correlated with preterm birth. Because women with subsequent cervical conization have an increased risk of preterm birth in preceding pregnancies, factors other than the surgical intervention may contribute to the significantly increased risk of preterm birth.

Adult↗

[Conization of the uterine cervix in prevention and diagnosis of cancer (author's transl)].

The result of conization of the uterine cervix in 446 cases was reviewd regarding the diagnostic and preventive therapeutic value of the procedure with special attention to post-operative complications. Conizations for benign lesions of the cervix in 33 patients resulted in a well formed cervix with squamous epithelium covering of the ectocervix in 32 patients. There was only 1 failure. In 413 diagnostic conizations with extensive microscopic work-up the lesion was only completely removed in 62% of the cases. In spite of careful colposcopy and Schiller iodine marking the external margin of the cone biopsy material went through the atypical lesion in 51% of the cases. It is therefore necessary to extend the limits of the cone biopsy specimen in all cases as far to the periphery and upwards into the canal as feasible. The incidence of early and late complications was 10.9%. In 133 conizations with hemostasis by cauterization the complication rate was 22.6%. This rate was reduced to a complication rate of 5.2% in 261 cases with hemostasis by suture. The commonest early complication was cervical bleeding. The only late complication was stenosis of the cervical canal. After conization of the cervix 18 of 22 pregnancies were uncomplicated. The increased incidence of cervical dystocia following conization of the cervix is significant and was the indication for Caesarean Section in 6 cases. For the prevention of cancer, the indication for conization of the cervix should be diminished in favor of an increase of the indication for hysterectomy because of the high failure rate of conization to prevent cancer (37%) and because of the relatively high incidence of complications of conization.

Biopsy↗

Adequacy of conization margins in adenocarcinoma in situ of the cervix as a predictor of residual disease.

In this retrospective analysis, 18 patients with adenocarcinoma in situ (AIS) of the cervix diagnosed on cervical conization between April 1988 and June 1994 were identified. The margins of all specimens were assessed for disease involvement. If hysterectomy or repeat conization was performed, the presence of AIS in the specimen was ascertained. Eleven of 18 conizations (61%) had AIS with negative margins of resection. Two of these 11 patients (18%) were followed conservatively and have had negative Pap smears for a mean of 1.7 years. The remaining 9 patients (82%) were treated by hysterectomy, with 4 (44%) showing residual AIS in the final surgical specimen. Six of the 18 conizations (33%) had positive margins for AIS. Five of these patients (83%) were treated with hysterectomy and one patient was treated with a repeat conization. Three of the five hysterectomy specimens as well as the repeat conization specimen (67%) contained residual AIS. One conization (6%) had margins that could not be assessed. The absence of residual AIS in the final surgical specimen was not predicted by the negative margin status on the conization.

Adenocarcinoma↗

A study of diagnostic failure of loop conization in microinvasive carcinoma of the cervix.

OBJECTIVE: The aim of this study was to evaluate the specimen adequacy and the histological interpretation of loop conization for microinvasive cervical carcinoma. METHODS: We retrospectively reviewed the histopathological findings of the original cone specimens together with the final hysterectomy specimens in patients with microinvasive carcinoma of the cervix. From 1990 to 1995, 63 consecutive patients with microinvasive carcinoma of the cervix were included in the study, of which 35 patients underwent loop conization and 28 underwent cold-knife conization. All patients had a hysterectomy. RESULTS: The mean width, depth, and cone volume of the conization specimens were 2.44 cm, 2.15 cm, and 3.96 cm3, respectively, in the loop group versus 2.3 cm, 2.35 cm, and 4.38 cm3 in the cold-knife group. No significant differences were seen between the two groups. The application of loop conization was completed in a single slice in 27 patients (77.1%) and multiple slices by the loop in 8 (22.9%), in spite of the attempt to perform conization in a one-pass application when possible. In assessing these cone specimens microscopically, the rate of transection of tissue was significantly higher in the loop cone than in the cold-knife cone (17.1% versus 0%, P = 0.02). Because of transection of tissue and misorientation, pathologic determination of the depth and width of stromal invasion was undetermined in two loop cone specimens compared with none in the cold-knife cones. CONCLUSION: Our study suggests that cold-knife conization is a preferred method in assessing microinvasive carcinoma of the cervix if multiple applications of loop conization are inevitable.

Adult↗

Transvaginal sonographic evaluation of cervix length after cervical conization.

OBJECTIVE: The purpose of this study was to evaluate transvaginal sonographic cervical length before and after cervical conization for squamous intraepithelial lesions. METHODS: Between November 2002 and October 2004, all women undergoing conization by either cold-knife conization or a loop electrosurgical excision procedure for squamous intraepithelial lesions were prospectively enrolled in this study. Cervical length was measured by transvaginal sonography (TVS) before and after conization. RESULTS: A total of 48 women were studied before and after a mean of 7 days after conization. Complete excision was achieved in 41 patients, and endocervical margins were involved in 7 patients. Mean TVS cervical length was significantly shorter after than before conization (mean +/- SD, 22.7 +/- 6.9 versus 26.7 +/- 8.1 mm; P < .001). The correlation coefficient between cone specimen length and postoperative length was r = 0.75 (P < .001). Mean TVS cervical lengths were 24.3 +/- 6.7 mm in the group of women who underwent a loop electrosurgical excision procedure and 20.7 +/- 9.4 mm in the group of women who underwent cold-knife conization (P = .13). CONCLUSIONS: Transvaginal sonographic measurement of cervical length after conization is well correlated with cone specimen length.

Adult↗