Hysterectomy for Nonmalignant Disease
zpThe category of hysterectomy of nonmalig-nant disease includes hysterectomies for uterine prolapse, persistent abnormal bleeding, intracta-ble pelvic pain, leiomyomas, and endometrial hy-perplasia. The procedure can be performed either vaginally or abdominally. The fallopian tubes and ovaries may also be present.
Orient the uterus by identifying the stubs of the round ligaments that insert anterior to the fallopian tubes. The ovaries should lie posteri-orly. In addition, because the anterior peritoneum reflects onto the bladder, the anterior perito-neum does not extend as far inferiorly along the uterus as does the posterior peritoneum. Vaginal and abdominal hysterectomies may be distin-guished by examining the peritoneal surface in the region of the posterior cul-de-sac. The peri-toneum appears V-shaped in a vaginal and U-shaped in an abdominal hysterectomy specimen.
If the adnexa are present, remove them from the right and left cornual regions, and examine them separately. Weigh the uterus, and record the following measurements: fundus to ectocervix, cornu to cornu, and anterior to posterior. Measure the length of the cervix from the level of the internal os to the ectocer-vix and the diameter of the cervix from side to side and from anterior to posterior.
The uterus can now be evaluated with a sys-tematic examination of each of its main compo-nents. Begin by examining the uterine serosa. Look for and describe any adhesions or small ‘‘powder burn’’ spots, which may signify endo-metriosis. These may be seen more frequently on the posterior aspect.
Next, evaluate the cervix. Note the shape of the external os, which is usually circular in nul-liparous women and slit-like in parous women. Examine the ectocervix for any lacerations, scars, masses, ulcers, or cysts. Place a probe through the cervical canal and into the endometrial cavity. Beginning at the cervix, incise the uterus with a large blade using the probe as a guide to divide it into anterior and posterior halves. Another method for bivalving the uterus is to use a pair of scissors to cut along the lateral margins from the ectocervix to the cornu. Gently remove the excess mucus from the endocervical canal, and examine it for the presence of polyps. At this point, the uterus may be photographed and then pinned to a wax tablet for fixation. Be sure to avoid placing pins through the mucosal surfaces. After fixation, longitudinally section the cervix at 0.2- to 0.3-cm intervals, and evaluate the transformation zone and stroma.
Now, measure the thickness of the endome-trium, and look for any unusual thickenings or polyps. Keep in mind the age and reproductive status of the patient. If the woman is postmeno-pausal, an endometrial thickness greater than 2 mm may signify a hyperplastic process. Con-versely, a thick endometrium in a premenopausal woman may reflect only the normal secretory phase.
The myometrium is examined last. Make serial 0.5-cm-thick transverse cuts through the uterine corpus and lower uterine segment, and record the maximum myometrial thickness. Look for intramural leiomyomas or evidence of adeno-myosis. Adenomyosis is usually more extensive in the posterior wall and may be recognized by a thickened wall with trabeculations and small hemorrhagic or cystic foci.
If no lesions are identified, standard sections of the uterus include longitudinal sections of the anterior and posterior cervix (including the transformation zone) and full-thickness sec-tions of the anterior and posterior walls of the uterus to include endometrium, myometrium, and serosa. At our institution, sections of the anterior and posterior lower uterine segment regions are routinely submitted as well.
Additional sampling may also be required if the standard sections reveal either endometrial hyperplasia or a cervical intraepithelial lesion. In the case of endometrial hyperplasia, the en-tire endometrium may need to be evaluated to rule out an invasive process. Multiple thin strips of endometrium with only a small amount of underlying myometrium can be submitted in a limited number of tissue cassettes. If a high-grade squamous intraepithelial lesion is iden-tified, the cervix should be processed and submitted as described for cone biopsies. For low-grade squamous intraepithelial lesions, a section from each quadrant may suffice.
The evaluation of a uterus with multiple leio-myomas deserves special mention. A leiomyo-matous uterus is one of the most frequently encountered specimens, and the gross exam-ination of these specimens is the key to their proper handling. Orient, weigh, measure, and section the uterus as described above. Record the number of nodules present and their size. Specifically state whether they are submucosal, intramural, or subserosal in location. All nodules should be sectioned at 1- to 2-cm intervals and examined grossly but not necessarily microscopi-cally. Benign leiomyomas are firm and white with a whorled cut surface. Their border with the surrounding myometrium is smooth and well-circumscribed. If these criteria are met, representative sampling of each leiomyoma is sufficient. Always include sections demonstrat-ing the border between the leiomyoma and the surrounding myometrium or overlying endome-trium. Any leiomyomas with areas of hemor-rhage, necrosis, or softening need to be sampled more extensively. In these cases, the general rule of one section per 1 cm of tumor diameter should be followed. Smooth muscle tumors less than 5 cm do not need to be sampled, as they rarely metastasize, regardless of their micro-scopic appearance.
· What procedure was performed, and what structures/organs are present?
· Cervix: Are any preinvasive or invasive lesions identified?
· Endometrium: Is the endometrium hyper-plastic, atrophic, or functional? If functional, specify whether it is in the proliferative or secretory phase. Are any polyps present?
· Myometrium: Are any leiomyomas or regions of adenomyosis identified? Specify whether the leiomyomas are submucosal, intramural, or subserosal.
· Serosa: Are any adhesions or regions of endo-metriosis identified?