A retrospective clinico-pathological study of hysterectomy cases in a tertiary care hospital in India – a review of 950 cases

Introduction: Hysterectomy is the most commonly performed gynaecological surgery in India as well as in abroad. It is frequently done in myometrial and endometrial pathologies and rarely for other causes. Hysterectomy is definitive management for diseases like fibroid, adenomyosis, dysfunctional bleeding, prolapsed uterus and malignant lesions of uterus and adenexa. We aimed our study to observe incidence of different pathologies of uterus and other reproductive organs in hysterectomy specimens and retrospective correlation between clinical diagnosis and histopathological finding of hysterectomy cases. Materials and Methods: Retrospective data were collected from our routine histopathological laboratory. Detailed history, clinical examination and operative findings and provisional diagnosis of all 950 hysterectomy cases were recorded during study period of 2 years. Histopathological diagnosis was correlated with clinical and preoperative diagnosis. Observations: Abdominal hysterectomy (734 cases, 77.26%) was the most common route of approach during surgery. Common pre-operative diagnoses were fibroid uterus (32%), dysfunctional uterine bleeding (28.95%), uterine prolapsed (22.74%). Other causes included uterine polyps (1.6%), complications of pregnancy (2.74%), ovarian tumours (8.42%), cervical carcinomas (2.97%) etc. Common pathologies on histology were leiomyoma (32%), adenomyosis (20.32%), atrophic endometrium (17.26%) and endometrial pathology (8.95%). Discussion: Our study has been correlated with other studies of India and other south Asian countries. Most common indication of hysterectomy in our study is dysfunctional uterine bleeding (32%) but Gupta et al and Jha R et al found utero-vaginal prolapse as most common indication. Leiomyoma was the most common histology diagnosed in the present series. Clinical diagnosis was possible in 67.57% cases in our study similar to Khan et al (70.51%). Conclusions: Histopathological examination of hysterectomy specimens helps to detect the exact causes and underlined pathology.


Introduction:
Hysterectomy is most common gynaecological operation in India and also in the world 1 .Charles Clay performed first subtotal hysterectomy in 1843 and first total hysterectomy in 1929 in England 1,2 .Hysterectomies are done for definitive treatment of multiple pathologies of female reproductive organs like fibroids, uterine prolapsed, abnormal uterine bleeding, adenomyosis, endometriosis and malignancy of female reproductive organs 3 .Other less common indications are endometrial hyperplasia, malignancy of reproductive organs, post partum haemorrhage etc.It is done in two approachabdominal and vaginal route.Vaginal route is DOI: http://dx.doi.org/10.3329/bjms.v17i1.35287preferred in prolapsed uterus.Abdominal route is used in pathology of endomyometrium and other reproductive organs.It may or may not be associated with unilateral or bilateral salpingo-oophorectomy.

Materials and Methods:
This retrospective study was conducted in department of Pathology, Bankura Sammilani Medical College, Bankura over a period of two years from January, 2011 to Decmember 2012.Ethical clearance was obtained from institutional ethical committee.All the hysterectomy specimens sent to our department during this study period, included in the study as sample.Clinical data about age, reproductive status, history, clinical diagnosis, type of surgical intervention was recorded retrospectively.All the specimens were fixed in 10% formalin and tissue sections were taken for processing and paraffin block preparation.The paraffin blocks were sectioned and stained by H & E stain.Microscopical examination was performed for histopathological diagnosis.Histopathological diagnosis were analysed and compared with clinical diagnosis.

Results:
We have studied 950 hysterectomy cases in our study period of two years (Jan 2011-Dec 2012).Among 950 cases 734 cases (77.26%) were undergone abdominal hysterectomy and vaginal hysterectomy were done in 216 cases (22.74%).Laparoscopic method has been used in 64 cases (6.74%).26 cases were subtotal hysterectomy and all were either at peripurtum or postpartum period.In histopathological diagnosis leiomyoma was the most common pathology identified comprising of 304cases (32%).Adenomyosis was encountered in193 cases (20.32%).Histological evidence of atrophic uterus was found in 164 cases (17.26%).Most of the prolapsed uterus had atrophic endometrium and hyperkeratinisation of cervical squamous epithelium.But in 54 cases (5.68%) we found normal secretary or proliferative endometrium.We diagnosed 85 cases (8.95%) of endometrial hyperplasia in our study period.Among this spectrum disordered proliferative endometrium was encountered in 22 cases (25.88%).48 patients (55.29%) had simple endometrial hyperplasia without atypia.Simple endometrial hyperplasia with atypia was found in 8 cases (9.41%).Among 8 cases of complex endometrial hyperplasia, 6 cases (7.05%) were complex hyperplasia without atypia (Figure2) and 2 cases (2.35%) were of complex hyperplasia with atypia.Uterine polyps (figure 3) had been diagnosed in 47 cases (4.95%).Leiomyomatous polyp is most common subtype found in 24 cases (51.06% of all uterine polyps).Endometrial polyp was diagnosed in 16 cases (34.04%).3 cases (6.38%) of adenomatous polyp and 4 cases (8.51%) of cervical polyp were diagnosed in histopathological examination.
In our study 26 cases of peripartum or postpartum hysterectomy were listed.16 cases were clinically diagnosed as postpartum haemorrhage due to atonic uterus.In histology all the cases show decidual change of endometrium and myometrial hyperplasia.Four cases of ruptured uterus were diagnosed clinically and also proved in gross and microscopy.Adherent placenta was found in 6 cases among which 3 cases were diagnosed as placenta acreta, 2 cases were placenta increta (figure 4) and one case was placenta percreta.
We diagnosed only 13 cases (1.37%) of malignant lesions in uterine corpus in this study.Among these 11 cases (84.61%) were primary uterine lesions and two secondary involvement were noted, one from serous adenocarcinoma of ovary and another by squamous cell carcinoma of cervix.Of 11 primary malignant lesions of corpus, 6 cases (46.16%) were endometrial carcinoma, two were gestational choriocarcinoma (15.38%) and leiomyosarcoma, carcinosarcoma, and adenosarcoma were comprised one case each.80 cases of diagnosed ovarian tumour were undergone hysterectomy with sulphingo-oophorectomy.Histophathological examination revealed 50 cases were benign lesions (62.5%).26 cases (32.5%) were malignant ovarian tumours and 4 cases (5%) were diagnosed as borderline ovarian tumours.Among 28 cases (2.95%) of cervical carcinoma most common was squamous cell carcinoma (25cases) and three cases (10.71%) were of adenocarcinoma.Endometritis was diagnosed in 7 cases (0.74%) and granulomatous endometritis (tubercular) was reported in one case.Endometritis was diagnosed in 7 cases (0.74%).One case of granulomatous endometritis of tubercular origin was diagnosed.Endometriosis was found in 3 cases (0.31%).Two cases of ovarian and one case of tubal endometriosis were diagnosed.In 56 cases (5.89%) combined pathology were detected.Leiomyoma with adenomyosis is most common type encountered in 32 cases (3.36%).All histopathological findings were correlated with clinical diagnosis.Among 304 histopathologically proven leiomyoma clinical diagnosis was possible in 275cases (90.46%).Other 29 cases (9.54%) were clinically diagnosed as DUB.All cases of clinically diagnosed prolapsed uterus, carcinoma cervix and hysterectomy of gestational causes are concordant with histopathological findings.Among 47 cases of uterine polyp (figure3), only 16 cases (34%) were clinically diagnosed.Rest 31 cases were presented as DUB (66%).All isolated cases of adenomyosis, endometrial hyperplasia, endometritis, and endometrial carcinoma were presented with abnormal uterine bleeding.Among 80 cases of ovarian tumour, 4 clinically diagnosed benign ovarian tumours appear as borderline lesion and two clinically malignant solid ovarian mass proved benign in histopathology.

: Distribution of cases according to type of hysterectomy performed Type of hysterectomy No of Cases Percentage
. Dysfunctional uterine bleeding was diagnosed in 275 cases (28.95%) and prolapsed uterus was the indication of hysterectomy in 216 cases (22.74%).All the 26 subtotal hysterectomy (2.74%) were done due to complications of pregnancy such as post partum haemorrhage, ruptured uterus and adherent placenta.Clinical diagnosis of polyp was encountered in 16 cases (1.6%).Ovarian tumor was the indication of hysterectomy in 80 patients (8.42%).Clinical diagnosis of cervical carcinoma was done in 28 cases (2.95%).Other rare indications like chronic pelvic pain and malignancy of non-gynaecological malignancy were found in three (0.31%) and two (0.21%) cases consequtively.Pre operative clinical diagnosis has been shown in table no2.Table2: Pre-operative clinical diagnosis of hysterectomy cases.
131terectomy is most common gynaecological surgery in India as well as in world2.Hysterectomy can be either done through abdominal route or through vaginal route.Laparoscopic approach is also being used progressively in recent times.Abdominal hysterectomy is still favoured all over the world due to training habits, practice and performance of gynaecologist 2 .Abdominal hysterectomy leads to longer hospital stay and also have greater complication rate.Vaginal hysterectomy commonly done in prolapsed uterus and pathology where weight of the uterus is less than 280gm 4 .Abdominal route is favourable in large fibroid, bulky uterus, suspected malignancy, emergency hysterectomy for obstretic reason.In the present study, vaginal route have been used in 216 cases (22.74%)where in previous study by Charyssiopoulos et al and Abdullah et al it were 13.4% and 14.67% respectively5,6.Large trials showed that hysterectomy is definitive management for diseases like fibroid, adenomyosis, DUB, prolapsed uterus and malignant lesions of uterus and adenexa3,7.Mean age of patients in our study was 45.78 years, similar to study by Ranabhat et al (45.6years) 1 and Gupta et al (45.6 years)2.clinicaldiagnosisalwaysmaynot be possible because in many cases histopathological examination of endometrium is the key for pathological evaluation.Clinical examination and radiological evaluation may diagnose fibroid uterus, polyps, prolapsed uterus, cervical and ovarian pathology, pregnancy related complications.But abnormal uterine bleeding due to adenomyosis, endometritis, hyperplasia, early stage malignant uterine lesions are quite difficult to diagnosis clinically.Cinical diagnosis was possible in 67.57% cases in our study.Khan et al showed clinicopathological concordance in70.51% cases 8 .Lee NC reported 80% of pre-operative diagnosis was confirmed by histopathological examination13.After all most of the lesions are benign and only 7.68% are malignant lesions among large number of hysterectomy cases.In other studies by Gupta et al and Ranabhat et al reported 4% and 6% malignant lesions in their study2,1.In other study by Ojeda et al reported malignant lesions were 12.33% in hysterectomy cases.
Conflicting Interest: None