Hysterectomy or removal of the uterus is a fairly common gynaecological operation done for a variety of conditions such as fibroid uterus ,AUB ,adenomyosis and gynaecological malignancies⁴. Hysterectomy is the most frequently performed major surgical procedure in females worldwide next to cesarean section ¹³ .

Removal of the body of uterus with cervix is called Total hysterectomy,if only body of the uterus is removed and cervix is retained it is called Subtotal hysterectomy (supracervical hysterectomy). Removal of the uterus with cervix and both tubes and ovaries is called Total Abdominal Hysterectomy with bilateral salpingo oophorectomy.In cases of malignancies where besides removal of the uterus, cervix, tubes and ovaries,other structures such as upper vagina,paramedial tissue and lymph nodes from pelvis and para aortic area are removed are labelled as Radical hysterectomy.⁴

Lesions in the cervix and fallopian tubes which are removed as a part of hysterectomy are often less emphasized. In Cervical Intraepithelial Neoplasia ,if hysterectomy is performed ,a vaginal vault sample may be required at 6 months if  CIN was incompletely excised  or the excision is uncertain.² In pathogenesis of high grade serous carcinomas,fallopian tubes has a critical role. Fallopian tubes can be the primary site for a subset of pelvic high grade carcinomas.⁷

USG is an important ,simple and easily accessible investigation to evaluate various causes of acute uterine bleeding. Preoperative diagnosis on the basis of clinical and USG findings may not always tally with histopathology which is ultimate diagnosis.³

Histopathological study help in confirmation of diagnosis and improving the post operative management .Detection of unexpected findings in these specimens will alter the management and thus aids in completion of the treatment along with prevention of complications.

AIM

To determine the prevalence of various histopathological lesions in hysterectomy specimens emphasizing cervix and fallopian tubes and to determine it’s correlation with clinical symptoms and USG reports

Objectives

• Primary

To determine the prevalence of various histopathological lesions in hysterectomy specimens emphasizing cervix and fallopian tubes in a tertiary care hospital of central Kerala

• Secondary

To determine the correlation of clinical symptoms and radiological diagnosis with histopathological diagnosis

1.Histopathological Analysis of Hysterectomy Specimens in a Tertiary Care Centre: A Retrospective Study-Rashmi Wankhade ^,Pratibha Dawande 

Among 110 cases of hysterectomy ,major type was abdominal hysterectomy 71.82 %(79 cases) and major age range was 42.72 %(35-45 years). Most common endometrial lesion was leiomyoma  47.28 %(52 cases) followed by adenomyosis 20.19 %(23 cases). Proliferative phase of endometrium was the most common endometrial pathology accounting for 39.09 %(43 cases) followed by 3.82 % ,35 cases of atrophic endometrium . In cervix,chronic cervicitis was the major incidental finding 77.28 %(85 cases). Ovarian lesions consisted of 20 % (22 cases)of follicular cysts and 6.37 %(7 cases) of serous cystadenoma.2 cases of malignant tumors –one carcinoma endometrium and one mucinous cystadenocarcinoma of ovary was identified.70 % to 100 % of final histopathological diagnosis supported the preoperative clinical diagnosis.

2.Histopathological Audit of 373 Nononcological Hysterectomies in a Teaching Hospital-Kanwardeep Kaur Tiwana , Sarita Nibhoria , Tanvi Monga , Richa Phutela -Patholog Res Int

Major age group was 45+9.2 years. Most common endometrial lesion was leiomyoma 43.7 %(163 cases),then adenomyosis 19.3 %(72 cases) .Also study showed 8.3% (31 cases) of rolapse,4 5 (15 cases) of simple endometrial hyperplasia,3.2 %(12 cases) of obstetrical causes,0.5%(2 cases) of endometriosis, 0.5%(2 cases) of CIN 1 and 0.26 % (1 case) of endometritis.Half of the cases of leiomyoma were identified preoperatively in the study and adenomyosis was totally missed out preoperatively.

3.Histopathological analysis of hysterectomy specimens in a tertiary care centre: study of 160 cases-Roopali Jandial,Mehnaz Choudhary, Kuldeep Singh

Common age group was at 5^th decade in 57.5 %(92 cases) and most common type of hysterectomy was TAH+BSO in 63.7 %(102 cases). Proliferative phase of endometrium was common finding in 54.3 % cases(87 cases). Among myometrial findings leiomyoma was he commonest 59.3 %(95 cases) followed by adenomyosis and leiomyoma in 13.1%(21 cases). Cervical specimens had chronic cervicitis in 46.8 %(75 cases),UV prolapse in 29.3 %(47 cases) and 6.2 %(10 cases) of papillary endocervicitis.

4.An audit of hysterectomies: indications, complications and clinicoPathological analysis of hysterectomy specimens in a Tertiary care center-Vanithamani Sivapragasam, Chellammal K. Rengasamy, Aruna B. Patil

The study had common age group of 45-50 years. Majority of hysterectomies were abdominal 82%(162 cases). Histopathological examination showed most common finding as leiomyoma 51 %(101 cases) and adenomyosis in 29 cases. Proliferative endometrium was the commonest pattern of endometrium 41 %. Chronic cervicitis was commonest finding in cervix 85 % followed by squamous metaplasia 20 %.91 % of fallopian tubes had unremarkable histology. The study showed 98%(195 cases) correlation of preoperative diagnosis with final histopathology reports.

1. Age group of study population

The most common age group of the patients in the study is 41-50 years.out of 131 patients 73 (55.72%) belonged to this group.

2. Type of hysterectomy

Among 131 hysterectomies done ,99 cases(75.6 %) were abdominal hysterectomies.

3. Presenting complaints of study population

Most of the patients presented with AUB(49.6%). This included heavy menstrual bleeding, intermenstrual bleeding, post menopausal bleeding.40 patients(30.5%) presented with abdominal pain and 38 patients (29 %) complained of mass coming out of vagina. Only 3 cases(2.3 %) had abnormal vaginal discharge.

4.Ultrasound findings

Ultrasonographic finding in most of the cases  were fibroid uterus accounting for 80 cases(61.1 %).24 cases (18.3 %) of benign ovarian cyst and 22 cases(16.8 %) of adenomyosis was found ultrasonographically. In cervix,2 cases of cervicitis(1.5 %) and 8 cases(6.1 %) of nabothian cyst were identified.2 cases of hydrosalpinx(1.5 %) and 1 case of hematosalpinx(0.8 %) was found in fallopian tubes.

5.Histopathology of cervix

In histopathological examination of we found that majority of cases  were having chronic cervicitis,94 cases with 71.8 %.squamous metaplasia was found in 69 cases(52.7 %). Nabothian cyst was present in 38 cases(29 %).14 cases (10.7 %) had prolapse related changes including ulceration, erosion and keratinization.2 cases (1.5 %) of koilocytic change ,1 case of focal reactive atypia and 1 case of CIN 1 was also recognized in the examination.

6.Histopathology of fallopian tubes

Most of the fallopian tubes had unremarkable histology(58 %) with 76 cases. Paratubal cyst was the commonest pathology found with 24 cases(18.3%).8 cases(6.1 %) had hydrosalpinx,4 cases(3.1%) had hematosalpinx and 3 cases(2.3%) had chronic salpingitis. Fimbrial cyst was present in 4 cases(3.1%). Salpingitis isthmica nodosa ,serous cystadenofibroma and serous cystadenoma was identified in 1 case each.

7.Histopathology of ovaries

Histopathological examination of ovaries revealed common findings as benign cystic lesions in 31 cases(23.7%),corpus albicans in 31 cases(23.7%).Benign ovarian tumors such as 1 case(0.8%) of mucinous cystadenoma,4 cases (3.1 %)of serous cystadenoma ,1 case (0.8 %) fibroma,1 case(0.8%) of papillary cystadenofibroma and 2 cases(1.5 %) of serous cystadenofibroma were also found out.

8.Histopathology of myometrium

We found out that 88 cases(67.2%) were having leiomyoma as the common endometrial lesion. 55 cases (42 %) had adenomyosis.

9.Histopathology of endometrium

Atrophic endometrium is the common endometrial pathology with41 cases( 31.3 % )in this study.27 patients (20.6 %) had proliferative endometrium and 23 patients (17.6 %) had  secretory endometrium.

1 case of Endometrial Adenocarcinoma with >50 % myometrial invasion(FIGO Grade 1) was found in the study.

10.Association of clinical symptoms and histopathological diagnosis

We found out that back pain has statistically significant association with benign ovarian cystic lesions as shown in the table. Association of mass per vagina with atrophic endometrium and AUB with fibroid were also statistically significant.

11.Risk estimate of various symptoms

Risk of patients with mass PV to have atrophic endometrium is 9.255 times. Patients with back pain have 5.449 times more chance of having Benign ovarian cystic lesions. Patients with AUB has 8.044 times risk of having fibroid.

12.Association of radiological diagnosis with histopathological diagnosis

Statistically significant association between USG and histopathological finding was found for fibroid and adenomyosis.

13.Risk estimate of ultrasonographic diagnosis

In patients with fibroid in USG has 19.688 times risk of havig fibroid in histopathological examination.USG finding of adnexal cyst has 8.133 times risk of getting fimbrial cyst in histopathology.USG cervical cyst shows 2.89 times odds of having chronic cervicitis as pathology. Odds of radiological to pathological adenoyosis is 6.353 times.

In India, a large scale survey revealed hysterectomy prevalence of 17 per 1000 ever married women. The number of women undergoing hysterectomy ranged from 2 to 63 per 1000 ever married women across different states of India.⁸

Today ,the number of hysterectomies conducted in India continues to outnumber surgeries performed in other countries.³  number of hysterectomies conducted in 2013 was 23.2 lakh ,while during the same period hysterectomies reported in USA,UK and Russia was 5.9 lakh,1.3 lakh and 3.12 lakh respectively.¹¹

Therefore ,in this situation efforts should be made to analyze clinical indications and pathologies in hysterectomy cases.¹

In this study ,most common age group in which hysterectomies were performed is 41-50 years(55.7%). This is similar to the study by Saha D et al. where the highest incidence of cases was in age group of 41-50 years(58%).³

The most performed hysterectomy is Total Abdominal type in the present study with 99 cases(75.57 %).In a study by Sivapragasm V et al.major type of hysterectomy was abdominal 82%(162 cases).¹²

The major presenting symptom in this study is AUB with 65 cases(49.6%) followed by abdominal pain 30.5 % and mass PV 29%. The least complaint was abnormal vaginal discharge and constipation with 2.3 % cases each.In the study done by Sivapragasm et al.the had similar findings with AUB as the commonest presenting complaint followed by AUB-L ,other common indication was UV prolapse. ¹²

Major USG  finding of the present study is fibroid with 61.1 %cases ,benign ovarian cyst 18.3 % and adenomyosis 16.8 %.2 cases of cervicitis (1.5 %),8 cases (6.1 %) of nabothian cyst,2 hydrosalpinx (1.5 %) and 1 heamatosalpinx (0.8%) case was diagnosed ultrasonographically. In a similar study done by Saha D et al. commonest USG finding was fibroid in 39 % patients,9 % cases had adenomyosis.³

In this study ,the most common histopathological finding in cervix is chronic cervicitis in 94 cases(71.8 %). other major findings are squamous metaplasia 52.7 % and nabothian cyst 29 %. 1 case of focal reactive atypia and 1 case of CIN 1 was identified.The study conducted by Jandial R et al.showed 46.8 % chronic cervicitis in cervical specimens and 6.2 %  cases of papillary endocervicitis .¹⁰Another study by Thomake et al. commonest finding in cervix was chronic cervicitis with or without squamous metaplasia and keratinization of ectocervix present in 96 cases.¹

Most of the fallopian tubes had unremarkable histology in  58 %.Paratubal cyst is the major histopathological finding of current study in fallopian tubes (18.3 %).6.1 %  specimens showed hydrosalpinx,3.1 % showed hematoslpinx,3.9 % had cyst like fimbrial cyst and mesothelial cyst and 2.3 % chronic salpingitis.In histopathological study of surgically resected specimens of fallopian tubes by Nanigopal Bhattacharya et al. 31.5 % specimens had unremarkable histology. Most common finding was paratubal cyst and 3 % hydrosalpinx and 2 % hematosalpinx . Walthard cell nest and ectopic gestation was also a common finding.⁶

Our study has benign ovarian cystic lesions as major pathology 23.7 % in ovaries.Benign ovarian tumors are 3.8 % cystadenoma(mucinous and serous),2.3 % cystadenofibroma (serous and papillary) and 1.5 % fibroma. In a study conducted by Wankhade et al. common ovarian lesions consisted of 20 % of follicular cysts and 6.37 % of serous cystadenoma.⁹

In our study ,leiomyoma is the most common histopathological lesion in myometrium ,67.2 % followed by adenomyosis 42 %. Common endometrial findings are atrophic endometrium accounting 31.3 % and proliferative phase 20.6 %. 1 case of Endometrial Adenocarcinoma with >50 % myometrial invasion(FIGO Grade 1)was identified histopathologically .USG finding of the same case was right adnexal cyst which was found as right serous cystadenoma ovary post operatively and the clinical presentation was mass coming out of vagina associated with difficult micturition. In similar study of non oncological hysterectomies by Kanwardeep Kaur Tiwana et al. most common endometrial lesion was leiomyoma ,43.7 % followed by adenomyosis 19.3 %.⁵Another study by Wankhade et al. showed proliferative phase of endometrium as common endometrial pathology 39.09 % followed by atrophic endometrium 31.82 %. 1 case of Carcinoma Endometrium was identified in this study.⁹

Our study showed that statistically significant association exit between back pain and benign ovarian cystic lesion,mass PV and atrophic endometrium and AUB and fibroid. Similar statistical significant association for uterine prolapse and atrophic endometrium was present in study by Thomake et al .¹

In this study of 131 cases ,80 cases (61.1 %) of fibroid was diagnosed clinically while histopathology identified 88 cases(67.2 %). Thus,90.92 %  histological diagnosis is in concordance with preoperative diagnosis. In study by Thomake et al. out of 150 cases,128 (85.33 %) were concordant with histopathological diagnosis and 22 were non concordant.¹The study by Sivapragasam et al. was also comparable to our study with correlation of 98.47 % between clinical and histological diagnosis.

The present study established majority of patients had hysterectomy at 41-50 years  and the main indication for hysterectomy is AUB. The common diagnosis is fibroid uterus.

Clinical and radiological diagnosis was done for all cases but these methods were not adequate to identify the lesions in cervix and fallopian tubes. Most of the histopathological findings in cervix as well as fallopian tubes were incidental.

Major preoperative (clinical and ultrasonographic) diagnosis was confirmed postoperatively by histopathological examination.

Cases having non malignant cytology reports were included in the study,still histopathological examination revealed 1 case of CIN I and 1 case of Endometrial Adenocarinoma . The study also showed that many of findings in ovaries as well as endometrium were also missed out preoperatively.This emphasizes the need for careful histopathological examination especially on domains like cervix and fallopian tubes.

RECOMMENDATION

All patients should undergo all relevant investigations including clinical and radiological examination preoperatively. Hysterectomy should be considered as a last resort when all the medical management fail. All hysterectomy specimens should be subjected for histopathological examination irrespective of preoperative diagnosis. Cervix and fallopian tubes which are removed as a part of hysterectomy should be evaluated thoroughly histopathologically as lesions in these specimens are often incidental not recognized priorly and are less emphasized . Identification of such findings aids in reaching a comprehensive diagnosis ,thus alter the post operative management and improves the patient care.

CONFLICT OF INTEREST

Nil

BUDGETING

All expenses were borne by the investigator

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