Histopathological audit of hysterectomies for analysis of indication and respective pathology at tertiary care teaching hospital

Introduction

The uterus comprises the endometrium and the myometrium, stimulated throughout by hormones, denuded monthly of its endometrial mucosa, and once a while inhabited by fetuses. The lesions of the uterus and cervix account for most patient visits to gynecologists.1, 2 Even though many medical and conservative surgical treatment options are existing, hysterectomy still is the most commonly performed major gynecological procedure worldwide.

The most common benign conditions in hysterectomy specimens are uterine fibroid and adenomyosis with the peak incidence in the 5th decade i.e 41-50 years. The other causes are abnormal heavy bleeding, chronic pelvic pain, uterine prolapse, pelvic inflammatory disease, cervical intraepithelial neoplasia (CIN), prophylaxis against uterine cancer, and endometrial carcinoma. Most vaginal hysterectomies are done for uterine prolapse and patients are older than those undergoing abdominal hysterectomies.3

Histopathological examination is mandatory for the uterine specimen after hysterectomy Correlation between clinical and histological patterns is important in the general management of the patients. The studies were done in India, Bangladesh, and Nigeria respectively showed a correlation between pre- operative clinical and histopathological diagnoses as 74, 77, and 95.6%.4, 5 The present study aims to audit indications and to rationalize the surgery by relating preoperative diagnosis with histopathology reports in tertiary care hospitals. This type of evaluation might be supportive in the endowment of quality reassurance and correctness of hysterectomy.

Materials and Methods

Present study was retrospective study of histopathological reports of the hysterectomy specimens with uterine and cervical indications received at The Department of Pathology, D Y Patil Medical College, Kolhapur, India. Study duration was between June 2019 to May 2021. Study approval was obtained from institutional ethical committee.

Results

Among 150 cases of hysterectomy, we noted that peak incidence was at 5th decade of life i.e 41-50 years age group with 76 cases (50.67%). The most common route of hysterectomy was abdominal hysterectomy in 124 cases (82.67%).(Table 1)

The most common clinical indication was fibroid uterus in 68 cases (45.33%) followed by abnormal uterine bleeding and uterine prolapse, seen in 38 cases (25.33%) and 26 cases (17.33%) respectively.(Table 2)

Endometrial Adenocarcinoma was seen in 1 case, Atypical endometrial hyperplasia in 4 cases while Endometrial hyperplasia without atypia in 11 cases. The proliferative phase of endometrium was the commonest finding seen in 68 cases (45.33%).(Table 3)

Leiomyoma was the most common lesion noted in myometrium, in 78 cases (52%), followed by Adenomyosis in 34 cases (22.67%) and Adenomyosis and Leiomyoma together in 18 cases (12%).(Table 4)

In present study commonest finding in the cervix was chronic cervicitis with or without squamous metaplasia and keratinization of ectocervix is present in 96 cases (64%).(Table 5)

In this study, total out of 150 cases, 68 cases of fibroid were clinically diagnosed, histologically 51 cases were diagnosed as leiomyoma, 9 cases as adenomyosis with leiomyoma and 7 cases with adenomyosis while none were unremarkable.

Uterine prolapse was clinically diagnosed in 26 cases. Out of which 22 cases showed features of atrophic endometrium, a finding consistent with uterine prolapse. Incidental findings of leiomyoma and adenomyosis was seen in 15 cases out of these.

Single case was histopathological diagnosed as endometrial carcinoma which presented clinically as mass in the abdomen.

Therefore, total of 150 cases, 128 were concordant with the histopathological diagnosis and 22 cases were non-concordant. P value was calculated and it shows high significance (P <0.0001) with association of clinical diagnosis with histopathological findings.(Table 6)

Figure 1

A: Endometrial carcinoma; B: endometrial carcinoma(10X)

Figure 2

A: Submucosal leiomyoma; B: Leiomyoma (H&E 40X)

Figure 3

A: Adenomyosis; B: Adenomyosis (H & E 10X)

Discussion

Hysterectomy is still a majorly performed surgery in women all over the world. The patient often presents with menorrhagia, white discharge per vagina, mass per vagina, abdominal pain or in rare cases mass in abdomen. These patients are evaluated further with radiological or with Pap smear examination, cervical and endometrial biopsy and upon clinical diagnosis are posted for hysterectomy. The common clinical indications are fibroid, abnormal uterine bleeding, uterine prolapse, adenomyosis and carcinoma.

Previously used terms like menorrhagia, metrorrhagia, dysfunctional uterine bleeding, polymenorrhea, oligomenorrhea are not recommended. The PALM-COEIN system has standardized the nomenclature to describe the etiology and severity of abnormal uterine bleeding (AUB).6, 7

Hysterectomy recommended in women with AUB only after all the relevant investigations have been done and conservative treatment options have failed or are refused by the patient.8, 9

In Western countries, a decreasing trend is being reported for hysterectomy over time, in contrast to increasing trends observed in developing countries like India. Therefore, it is an alarming situation and efforts should be made to analyze and evaluate the clinical indications and pathologies in hysterectomies performed in women of reproductive age, by conducting timely audits that can help in the proper allocation of resources for primary health care and conservative management.10

In the present study age range of the patient were between 31 to 80 years with majority of patients in age group of 41-50 years (50.67%), which was similar to studies done by Pandey et al.,11 study the age range was seen between 21-90 years, Kaur Tiwana et al.,12 the age range was 22-85 years, Sivapragasam et al.,13 study the age range was 32-75years. And the peak age prevalence in present study and all others study was in between 41- 50 years of age.

In the present study the most common route of hysterectomies performed were abdominal route constituting 82.67%. When compared with other studies as shown in table, Sivaprasagam et al.,13 98.54%, Sujatha et al.,[2] had 87.74% and Pandey et al.,11 with 74.7% also showed similarity with this study.

On our study most common indication for hysterectomy was fibroid with 68 cases (45.34%) followed by abnormal uterine bleeding 38 cases (25.33%) and uterine prolapse 26 cases (17.34%) which was in concordance with study of Gupta et al.,14 with indication of fibroid uterus as 164 cases (41%), abnormal uterine bleeding 142 cases (35.5%) and prolapse uterus 42 cases (10.5%). While indication of fibroid uterus was in concordance with Pandey et al.,11 in 210 cases (39.9%) and Patil et al.,15 in 56 cases (37.3%) it was discordant with study of Sivaprasagam et al.,13 where most common indication was abnormal uterine bleeding (28%) followed by fibroid (21%).

In present study, proliferative and secretory endometrium were most common findings constituting 68 cases (45.33%) and 24 cases (16%) which is in concordance with other studies. Endometrial carcinoma was seen in 1 case (0.67%) which was similar to seen in Patil et al.,15 with 2 cases (1.3%). Patient was diagnosed as postmenopausal bleeding in concordance with other studies. Atypical endometrial hyperplasia was seen in 4 cases (2.7%) which is concordant with Patil et al.,15 4 cases (2.7%), Medhi et al.,16 3 cases (2%) and Sujatha et al.,2 with 3 cases (1.93%).

Among myometrial lesions, majority of lesions comprise of leiomyoma as in this study seen in 78 cases (52%) which is comparable with Sivapragasam et al.,13 with 101 cases (51%) and Sujatha et al.2 with 66 cases (42.58%). Second most common is adenomyosis in concordance with other studies. Adenomyosis is a lesion which is diagnosed on histopathological examination as incidental finding as it does not have any specific clinical presentation of its own. Our study has one case in which myometrium showed involvement by endometrioid adenocarcinoma which is similar to finding in Patil et al.,15

The most common cervical pathology in hysterectomy specimen is Chronic cervicitis as seen in present study with 96 cases (63.99%) which is consistent with Sujatha et al.[2], Medhi et al.,16 and Patil et al.,15 Endocervical polyp was seen in 4 cases (2.67%) in this study which is in concordance with Sujatha et al.,2 and Medhi et al.,16 Our study had 4 cases (2.67%) of cervical dysplasia and 45 cases (30%) of papillary cervicitis which is discordant with other studies like Sujatha et al.,2 and Patil et al.,11 who has higher cases of cervical dysplasia and less cases of papillary cervicitis as compare to this study.

In the present study the correlation between clinical diagnosis and histological diagnosis was 85.33% which was comparable to study of Khan et al.,17 and Sharma et al.,18 The study of Sivaprasagam et al.,13 had correlation of 98.47%. This analysis can be helpful for exploring less invasive options like myomectomy and further non-surgical options like uterine artery embolization and newly discovered medical treatment especially for women of reproductive age group who do not wish for surgery or want to retain the fertility. Hence has a role in reducing the number of hysterectomy.

Conclusion

It was established that most patients undergoing hysterectomy were present in 5th decade of life. The most common clinical indications for which hysterectomy was performed was fibroid, which in majority of cases correlated with its histological finding of leiomyoma.

There was wide spectrum of histopathological lesions in uterus and cervix in hysterectomy specimens along with incidental findings of adenomyosis and intraepithelial neoplasia of cervix emphasizing the importance of histopathological examination in this specimen. This analysis can be helpful for exploring less invasive options and newly discovered medical treatment especially for women of reproductive age group reducing the number of hysterectomy. Therefore, hysterectomy should only be performed when other treatment options are not available. The regular audits of such a kind should be conducted for improvement of health care services.

Conflict of Interest

None to declare.

Source of Funding

None.