Patterns of Lesions in Hysterectomy Specimens in a Tertiary Care Hospital

Introduction: Hysterectomy is one of the most common gynaecological procedures performed all over the world. The most frequent indications for hysterectomy are fibroids, abnormal uterine bleeding uterovaginal prolapse and endometriosis. The objective of this study was to present the histopathological patterns of various uterine and adnexal pathologies in the hysterectomy specimens and also to correlate its pre-operative clinical diagnosis with histopathology. Methods: This is a two-year descriptive study of hysterectomy specimens carried out in the Department of Pathology, Patan Academy of Health Sciences (PAHS), Lalitpur, Nepal. Data of all the hysterectomy specimens collected during this period was analyzed. Results: Out of the 533 cases, fibroid was the most common indication for hysterectomy that was seen in 229 (42.94%) cases followed by uterovaginal prolapse in 101 (18.93%) cases. Leiomyoma was the most common pathology reported in 250 (46.90%) hysterectomy specimens, followed by ovarian tumours in 95 (17.82%) cases. In 17.82% (95/533) cases, no pathology was seen. Overall, the pre-operative indications in 533 cases of hysterectomy were histopathologically verifiable in 487 (91.37%) cases. Conclusions: Though the histopathological examination correlates well with the pre-operative clinical diagnosis, a number of lesions were also encountered as pure incidental findings. Hence, it is mandatory that every hysterectomy specimen should be subjected to histopathological examination so as to ensure better post-operative management. _______________________________________________________________________________________


INTRODUCTION
Uterus is a vital reproductive organ is subjected to many benign and malignant diseases. Many treatment options are available including medical and conservative surgical but hysterectomy still remains the most common gynaecological procedure performed worldwide. 1 inflammatory disease and cancer in the reproductive organs. 2 Hysterectomy can be performed by abdominal, vaginal or laparoscopic route and may or may not be accompanied by salpingo-oophorectomy of either one or both sides. Vaginal hysterectomy is performed predominantly for uterine prolapse, whereas abdominal hysterectomy is an indication for mostly menstrual disturbances and fibroids. At present, most of the hysterectomies performed worldwide are though the abdominal route. Even in the USA and UK, 60-80% of hysterectomies are performed via this route. 3 In recent years, hysterectomy with laparoscopic assistance is increasingly being performed in developed and developing nations all over the world.

METHODS
This is a descriptive study of hysterectomy specimens carried out in the Department of Pathology, Patan Academy of Health Sciences (PAHS), Lalitpur, Nepal. All the hysterectomy specimens received by the Department of Pathology over a period of two years from June 2010 to May 2012 were included in the study.
Patient data retrieved from the medical records included age, indication of hysterectomy, type of operation, clinical indications and histopathological diagnosis. Histopathological findings from the cervix, endometrium, myometrium, ovaries and fallopian tubes were noted. Besides the physiological changes in the endometrium (proliferative, secretory and atrophic endometria), chronic cervicitis, functional cysts of ovary (inclusion cysts, cystic follicles, follicular cysts and luteal cysts) and paratubal cysts were considered histologically "unremarkable." Data was analyzed and statistical analysis done using SPSS version 17.

RESULTS
A total of 533 hysterectomies were performed during a two-year study period. The abdominal route (total abdominal hysterectomy or TAH) was taken in 432 (81.05%) cases, while vaginal one (vaginal hysterectomy or VH) in 101 (18.95%) cases (Table 1).
Overall, the mean age of patients undergoing hysterectomy was 46.98 years (age range: 8 -85 years). Likewise, the mean age of patients undergoing total abdominal hysterectomy (TAH) and vaginal hysterectomy (VH) was 46.75 and 48.32 years, respectively.  (Table 2). An eight year old girl had also undergone total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAHBSO) for a malignant ovarian tumour (immature tertoma) involving both the ovaries.
Clinical indications of hysterectomy varied from menstrual abnormalities to suspected pelvic malignancy. The various indications for hysterectomy are depicted in Table 3. Out of the total 533 cases, fibroid was the most common indication for hysterectomy, accounting for 42.94% (229) of the cases followed by uterovaginal prolapse and ovarian tumours in 18.93% (101) and 16.68% (89) cases, respectively.
Histopathological findings: Most of the hysterectomy specimens had one or more pathology on histopathological examination. Leiomyoma was the most common pathology that was reported in 250 (46.90%) hysterectomy specimens, followed by ovarian tumours and adenomyosis in 95 (17.82%) and 74 (13.88%) cases, respectively.  Cervix: The histopathological findings of the cervix are depicted in Table 6. Four cases of cervical intraepithelial neoplasia (CIN) and five cases of cervical cancer were seen.
Incidental findings: In this study, various types of incidental findings were identified in numerous hysterectomy specimens. These findings are depicted in Table 7. Adenomyosis (60 cases) and leiomyoma (29 cases) were the most common incidental findings.
Unremarkable histopathology: Out of the 533 hysterectomy specimens included in this study, 95 (17.82%) cases were histologically unremarkable. The commonest indication in these cases was uterovaginal prolapse which was seen in 82.1% (78/95) of the cases.
Of the 14 cases of pelvic inflammatory disease (PID) that had undergone hysterectomy, eight (57.14%) cases did not show any abnormality. It was the most common indication in the TAH group in which no pathology was seen.
Overall the pre-operative indications in 533 cases were histopathologically verifiable in 487 (91.37%) cases. In the patients who had undergone hysterectomy for fibroids (229 cases), the final histopathology report confirmed the diagnosis in 211 (92.14%) cases. However, in the 37 patients with pre-operative clinical diagnosis of dysfunctional uterine bleeding (DUB), the diagnosis was confirmed by histopathology in only 5 (13.51%) cases.

DISCUSSION
Hysterectomy is one the common surgical procedures in the peri and post menopausal women; it is the second most common surgical procedure in the USA. 4 According to the center of disease control and prevention, about five per 1000 women undergo hysterectomy annually year in USA and one in four women will have hysterectomy by the age of 60 years. 5 It is an effective treatment option for many diseases, including benign and malignant tumours involving the uterus and its adnexae. It provides symptomatic relief, patient satisfaction and definitive cure in many of these diseases. Preference of the vaginal route over abdominal one in some of the studies from Nepal is probably due to a higher prevalence of uterovaginal prolapse in Nepal. 11 The predisposing factors are early age of marriage, lack of post-natal rest, heavy workload and smoking habits of the rural women. 12 Poverty stricken hardship, multiparity are other responsible factors.
The mean age of all patients undergoing hysterectomy was 46.98 years. Most of the hysterectomies were performed in the age group of 41-50 years (45.63%). These findings were similar to that observed by Rather et al, 13 (47.27%) and Pradhanang et al, 11 (34.1%).
In this study, the most common clinical indication for hysterectomy was uterine leiomyoma in 42.96% (229/533) cases followed by uterovaginal prolapse in 18.95% (101/533) cases which was consistent with the data reported by Nisa et al, 14 (33% and 19%, respectively) and Siwatch et al, 15 (39% and 22.6%, respectively). Menorrhagia was the most common indication in similar studies by Rather et al, 13 (35.43%) and Saleh et al, 16 (39%) whereas uterovaginal prolapse was the commonest indication in a study by Jha et al, 9 (37.1%).
Leiomyomas of the uterus are extremely common neoplasms. The overall incidence is between 4% and 11%, but it rises to nearly 40% in women over the age of 50 years. These tumours occur subserosally, intramurally, or submucosally and produce symptoms referable to their size and location. 17 In our study, leiomyoma was the most common pathology seen in the hysterectomy specimens (46.91%). Similar observation was made in the studies by Abdullah 18  Endometrial adenocarcinoma is the most common malignant tumour of the uterine corpus and is divided into endometrioid (usual) and special variant types. 21 In this study there were 6 cases of endometrial carcinomas which were seen 1.13% (6/533) hysterectomy specimens which was comparable to other studies by Jha et al, 9 and Gupta et al, 22 were 0.9% and 1%, respectively. However in other studies, a lower incidence was observed by Rather et al, 13 and Nisa et al, 14 (0.52% and 0.69%, respectively) while a higher incidence was reported by Saleh et al, 16 (2.92%).
In this study, ovarian tumor was diagnosed in 17.82% (95/533) hysterectomy specimens. This data was similar to that observed by Ranabhat et al, 8 (17.26%) and Jha et al, 9 (18.55%). However, a lower incidence (8.02%) was noted in a study by Rather et al. 13 In our study, histopathological examination of 17.82% (95/533) hysterectomy specimens showed no pathology. In other studies by Jha et al,, 9 Saleh et al, 16 and Siwatch et al, 15  Adenomyosis is rarely diagnosed preoperatively and is still largely under diagnosed as it has no specific symptoms of its own. 23 It is usually diagnosed after hysterectomy by histopathological examination. 24 In our study, it was the most common incidental finding on histopathological examination and was seen in 11.26% (60/533) cases.

CONCLUSIONS
A wide range of lesions was encountered on histopathological examination. Though the histopathological examination correlates well with the pre-operative clinical diagnosis, a number of lesions were also encountered as pure incidental findings. Hence, it is mandatory that every hysterectomy specimen should be subjected to histopathological examination so as to ensure better post-operative management.