Hysterectomy, the most common gynecological surgery, provides a definitive cure to various diseases like DUB (dysfunctional uterine bleeding), leiomyoma, adenomyosis, chronic pelvic pain, prolapse, and malignancy. However, with advent of effective medical and conservative treatment modalities for nononcological causes it is now posing question mark on justification of hysterectomy. Therefore, an audit is required to assess the correlation between preoperative diagnosis and histopathological examination of specimen for justification of the procedure. In this study over period of one year (April 2013 to March 2014) 373 hysterectomies specimens were received in the department of pathology for nononcological causes. The age of patients ranged from 22 to 85 years with mean
Hysterectomy means removal of uterus. Since early twentieth century it is considered definite treatment of various pelvic pathologies like leiomyoma, dysfunctional uterine bleeding (DUB), chronic pelvic pain, endometriosis, adenomyosis, prolapse, and malignancies [
However, with emergence of effective medical and conservative treatment for benign conditions it is now posing a question mark regarding the justification of hysterectomy [
The aim of audit is to evaluate criteria based justification of hysterectomy and to analyze correlation of preoperative diagnosis with final histopathology report of all hysterectomies done in a teaching hospital. In India, very few hysterectomy audits have been published recently and this audit may provide baseline comparison with future studies.
This study involved all the patients who underwent hysterectomy for nononcological reasons in teaching hospital over a span of one year during period of April, 2013, to March 31, 2014. All elective as well as emergency hysterectomies (including obstetric hysterectomies) were analyzed excluding oncological hysterectomies.
Abdominal hysterectomies included subtotal hysterectomies, total abdominal hysterectomies (TAH), TAH with unilateral salpingoopherectomy, or TAH with bilateral salpingoopherectomy along with vaginal hysterectomies. In this study all indications were reviewed with special attention given to cases with age less than 30 years and in those cases where there was more than one indication. Preoperative indications were compared with histopathological report. Preoperative indications were recorded from the histopathological requisition form; however, if indication was not mentioned then direct communication was done with the concerned clinician. Hysterectomy was considered justified if pathology report verified the indication for surgery or had significant pathology. Statistical analyses were done using Cohen Kappa scale for calculation of agreement between preoperative and postoperative diagnosis and kappa value was calculated.
Gross evaluation of all specimens received in the department of pathology was done. Following parameters were recorded, that is, weight, measurements from fundus to ectocervix, cornu to cornu, and anterior to posterior. Length and diameter of cervix were measured from side to side and from anterior to posterior lip. Systematic evaluation of each component of uterus was done. Serosa was examined to see any powder burn spots for endometriosis mainly on posterior aspect. Next cervix was evaluated for any lacerations, scars, ulcers, cysts, or any mass. Using probe the uterus was incised into two halves and longitudinal sections were done on cervix at an interval of 0.2-0.3 cm and were fixed in 10% formalin. After which evaluation of transformation zone and stroma was done. Thickness of endometrium was measured, considering the age of patient if it was found to be >2 mm in postmenopausal female then whole slice was processed to rule out hyperplasia and any focus of malignant transformation. Lastly myometrium was examined with serial sections of 0.5 cm then corpus and lower uterine segment, recording maximum myometrial thickness, intramural leiomyomas, and adenomyosis. Posterior wall was specifically examined for adenomyosis as it is the common site for this pathology appearing as trabeculations or small hemorrhagic cysts. Leiomyomatous uterus was the most frequently encountered pathology. Number and size of leiomyomas were recorded with their locations. Representative sampling was done; however, if size of leiomyoma >5 cm then they were extensively sampled, that is, one section each for centimeter of tumour particularly from areas of hemorrhage and necrosis. Adnexa was examined separately particularly for foci of endometriosis or any other lesions. If no lesions were grossly identified then standard sections of uterus from endometrium, myometrium, cervix, serosa, lower uterine segment, and adnexa were examined.
In this study a total number of cases were 373 over the span of one year (during April, 2013, to March 31, 2014). The patient age ranged from 22 to 85 years with mean
Distribution of various pathologies on hysterectomies.
S. number | Histopathological diagnosis | Number and percentage |
---|---|---|
1 | Leiomyoma | 163 (43.7%) |
2 | Adenomyosis | 72 (19.3%) |
3 | Prolapse | 31 (8.3%) |
Simple endometrial hyperplasia | 15 (4%) | |
4 | Obstetrical causes | 12 (3.2%) |
5 | Endometriosis | 2 (0.5%) |
6 | CIN 1 | 2 (0.5%) |
7 | Endometritis | 1 (0.26%) |
8 | No pathology | 75 (20.1%) |
Distribution of hysterectomies.
Age group | Type of hysterectomy | Indications with percent distributions |
---|---|---|
≤30 years | TAH (18) | 11/18 (61.1%) obstetrical causes |
7/18 (38.9%) no pathology | ||
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31–40 years | TAH (25) | 63/116 (54.3%) leiomyoma |
45/116 (38.7%) adenomyosis | ||
TAH with salpingoopherectomy (91) | ||
3/116 (2.6%) simple endometrial hyperplasia | ||
2/116 (1.7%) endometriosis | ||
2/116 (1.7%) no pathology | ||
1/116 (0.8%) obstetrical cause | ||
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41–50 years | TAH (17) | 100/173 (57.8%) leiomyoma |
TAH with salpingoopherectomy (156) | 10/173 (6%) simple endometrial hyperplasia | |
2/173 (1.1%) CIN-1 | ||
61/173 (35.1%) no pathology | ||
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51–60 years | Vaginal hysterectomy (15) | 15/50 (30%) prolapse |
TAH with salpingoopherectomy (35) | 27/50 (54%) adenomyosis | |
2/50 (4%) simple endometrial hyperplasia | ||
1/50 (2%) endometritis | ||
5/50 (10%) no pathology | ||
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>60 years | Vaginal hysterectomy (3) | 3/16 (18.7%) prolapse |
TAH with salpingoopherectomy (13) | 13/16 (81.3%) prolapse |
In the first category of age ≤30 years, a total number of hysterectomies were 18 (4.8%). All were TAH (total abdominal hysterectomies) without removal of adnexa. The preoperative indications in 11/18 (61.1%) were emergency obstetrical causes like placenta previa, placenta increta and placenta accreta (Figure
Sections show chorionic villi embedded in myometrium (H&E ×100).
In second category of age group 31–40 years, a total number of hysterectomies were 116 out of which 25/116 (21.6%) were TAH and 91/116 (78.4%) were TAH with bilateral salpingoopherectomy. In 91 cases of TAH with BSO only 2/91 (2.2%) had endometriosis (Figure
Sections from ovary shows collections of hemosiderin laden macrophages—endometriosis (H&E ×450).
In third category of age group 41–50 years had maximum cases, that is, 173 out of which 17 were TAH and rest TAH with bilateral salpingoopherectomy. The most common histopathological diagnosis was leiomyoma 100/173 (57.8%) (Figure
Section shows leiomyoma (H&E ×100).
Also in 2/173 cases CIN 1 (cervical intraepithelial neoplasia) was seen and it is known that hysterectomy is not the first treatment modality for it and various alternative options as there.
Fourth category of age group 51–60 years had total 50 cases out of which 15/50 (30%) were vaginal hysterectomies and rest TAH with bilateral salpingoopherectomy. All vaginal hysterectomies were done for prolapse which was justified. In three cases of clinical preoperative diagnosis of pyometra turned out to be endometrial hyperplasia (4%) (Figure
Sections show simple endometrial hyperplasia (H&E ×100).
Section shows endometritis (H&E ×450).
In the last category >60 years total number of cases were 16 and 13/16 were TAH with bilateral salpingoopherectomy. All hysterectomies (vaginal and TAH with bilateral salpingoopherectomy) were for prolapse. But in this category almost all hysterectomies were justified and preoperative diagnosis matched with histopathological report.
Cohen kappa statistics were used to measure agreement between preoperative and postoperative histopathological diagnosis which was found to be fair with
Hysterectomy is the most common gynecological surgery in the world [
In the present study over the period of one year 373 hysterectomies were done for nononcological causes. All different types of hysterectomy procedures were followed with most common being TAH with bilateral salpingoopherectomy 295/373 (79%) followed by TAH 60/373 (16%) and vaginal hysterectomy 18/373 (5%). This was in concordance with various studies which had almost same percentages [
The patient age ranged from 22 to 85 years with mean
The most common indication in all four categories, that is, 31–85 years, was leiomyomas which is in agreement with various other studies [
Only few studies have done an audit by comparison of preoperative diagnosis with histopathological examination of specimens. In India no national statistics are available except for few studies where they pointed out 7-8% of rural women and 5% of urban women had undergone hysterectomy at an age of 37 years [
There is a concern regarding misuse of hysterectomy which is highlighted in this study where the most common diagnosis was leiomyoma (43.7%), followed by adenomyosis (19.3%), but only half the cases of leiomyoma were made preoperatively whereas adenomyosis was totally missed out. This is in concordance with study done by Miller where only 50% of preoperative diagnosis was confirmed on histopathology [
This study wants to highlight the fact that reporting of all hysterectomies should be made mandatory and audit results should be used for improvement in quality of health services. As any surgical procedure hysterectomy is also associated with risk factors, thus indications should be carefully evaluated. Thus implementing targeted actions and conservative therapy for benign gynecological conditions should be effective alternatives to hysterectomies.
Hysterectomy is one of the most common gynecological surgeries. In one-year analysis of all cases it was found that preoperative diagnosis and histopathological correlation could reduce the number of hysterectomies as in many cases conservative approach could have been followed. Thus we conclude by saying that regular audit can help improve quality of health care services and provide safe conservative option to patients.
The authors declare that there is no conflict of interests regarding the publication of this paper.