Uterus benign

Background

Hysterectomy is undertaken for the treatment of a number of medical conditions, ranging from prolapse of the uterus to benign or malignant lesions in the body of the uterus, cervix and/or ovaries. 1-5  Obstetric removal of the uterus may be necessary in the event of intractable haemorrhage, rupture or abnormal placental implantation. 5

This protocol includes uterus for benign conditions such as prolapse, adenomyosis and leiomyomas. See separate protocols for cervical invasive tumours and malignancies of the body of the uterus.


Record the patient identifying information and any clinical information supplied together with the specimen description as designated on the container. See overview page for more detail on identification principles.

Fresh tissue received
  • No
    • Non-routine fixation (not formalin), describe.
  • Yes
    • Special studies required, describe.
    • Ensure samples are taken prior to fixation.
Intraoperative consultation
  • Not performed
  • Performed, describe type and result
    • Frozen section
    • Imprints
    • Other, describe

See general information for more detail on specimen handling procedures.

Inspect the specimen and dictate a macroscopic description.

External InspectionBack to top


Orientate and identify the anatomical features of the specimen.

Orientate the specimen by locating the round ligament on the anterior surface and the ovarian ligament on the posterior surface. The peritoneal reflection is lower on the posterior surface where often it is pointed in shape compared to the higher, straight edge anteriorly.3

Orientation markers

Record additional orientation or designation provided by operating clinician:

  • Absent
  • Present
    • Method of designation (e.g. suture, incision)
    • Featured denoted

Photograph the intact specimen if required.

Describe the following features of the specimen:

Procedure

Record as stated by the clinician.

Options
  • Subtotal hysterectomy
  • Myomectomy
  • Simple hysterectomy
  • Total abdominal hysterectomy (TAH)
  • TAH and bilateral salpingo-oophorectomy (TAH/BSO)
  • Other, specify

Specimen integrity

  • Intact
  • Opened, describe
  • Morcellated 4, describe

Laparoscopic specimens may be received in pieces and should be orientated where possible to resemble intact uterus. 2

Anatomical components included (more than one may apply) and specimen size (mm)

Describe and measure the anatomical components present.

Refer to relevant specimen protocol(s) for more detail.

Specimen weight (g)

  • Weight of total specimen

Uterus

  • Measure in three dimensions
    • Mid-line fundal-serosa to ectocervix
    • Maximum intercornual
    • Maximum anterior to posterior

Cervix

  • Measure in two dimensions, anterior-posterior x transverse

Vaginal cuff

  • Absent
  • Present
  • Measure in two dimensions, length x diameter 3

Cervix appearance 2

  • Normal
  • Polyps
  • Other, describe

Serosal surface

  • Normal
  • Nodular
  • Adhesions
  • Perforation present

Ovary

Fallopian tube(s)

DissectionBack to top


Various methods are used for dissection of hysterectomy specimens. 1,2

The method chosen may depend on whether the uterus has been previously opened or partially opened by the surgeon. The uterus should be opened as quickly as possible following receipt in the laboratory to optimally fix the delicate endometrium. Cutting along the lateral walls with scissors from the cervix to corneal recesses divides the specimen into anterior and posterior halves.  This optimally exposes the entire endometrium for fixation and allows for thorough macroscopic assessment of the cavity. Once fixed routine sagittal midline sections of the cervix and endometrium can be taken anteriorly and posteriorly.  The remainder of the uterus should be sagitally sectioned to ensure adequate assessment of the myometrium.

Examine the uterus for abnormalities and sample for microscopic examination. Sections from all areas of abnormalities should be taken such as adenomyosis, adhesions, cysts, lacerations or incisions if present.

Fibroids

Large fibroids must be incised by cutting from the serosal surface to enable full macroscopic assessment. If macroscopically unremarkable, the three largest should be sampled. Macroscopically atypical fibroids must be widely sampled and areas of necrosis, softening, haemorrhage or calcification must be described. The interface between lesion and myometrium should also be sampled. 2

Obstetric hysterectomies

Obstetric hysterectomies may require sections in composite blocks to demonstrate the full thickness of the wall including placenta and decidua if present. 2

Ovaries and fallopian tubes

Serially section the ovary sagitally through its full thickness at 3-4mm mm intervals. 2 Examine the cut surface for abnormalities and heterogeneous areas. Post-menopausal ovaries may be bisected longitudinally.1 Transversely section the fallopian tube at 3-4mm intervals with longitudinal sections of the fimbrial end. For more detail see separate protocols for ovary and fallopian tube.

Internal InspectionBack to top


Describe the cut surface appearance of the uterus including the following items:

Tumour

  • Absent
  • Present, see separate protocols for malignancies of the cervix and body of the uterus.

Endometrium

  • Thickness (mm)
  • Abnormalities
    • Absent
    • Present, describe
      • Polyp(s), size in three dimensions (mm) and location

Myometrium

  • Depth (mm)
    • Anteriorly
    • Posteriorly
  • Appearance
  • Leiomyoma
    • No
    • Yes
      • Number
      • Location
      • Size of largest leiomyoma in three dimensions (mm)
      • Maximum dimension (mm) of other leiomyomas
      • Macroscopic evidence of necrosis, haemorrhage or softening
  • Adenomyosis present
  • Caesarean scar present

Other abnormalities e.g. cysts

  • Absent
  • Present, describe
    • Number (if relevant)
    • Location

Note any photographs taken, diagrams recorded and markings used for identification.

ProcessingBack to top


Dissect the specimen further and submit sections for processing according to the ilustrations provided.

Full thickness sections along the mid-line of the cervix from both the anterior and posterior lips including the transformation zone should be taken to exclude any cervical neoplasia. 2

Sample the entire transformation zone if there is a recent past history of intraepithelial neoplasia and if the most recent cervical smear was abnormal.

The number of blocks taken will be dependent on the cervical anatomy. It is better to have fewer blocks with good representation of the zone than more blocks with poorer representation. See protocol for uterus for cervical neoplasia for more detail.

A thin shave section from the posterior peritoneal reflection may be valuable to exclude the presence of endometriosis at this site.

Uterus, normal or with benign abnormalities

Submit representative sections of:

  • Midline cervix, to include transformation zone from anterior and posterior lip
  • Body of uterus, sections demonstrating endometrium, anterior and posterior wall, myometrium and serosa
  • Representative sections of ovaries and fallopian tubes
  • Representative sections of any abnormalities:
    • Fibroids, one block per 10mm up to four blocks from each, demonstrating relationship with adjacent normal tissue
    • Polyps, all tissue including the base
    • Cysts, representative sections of wall of each
    • Other abnormalities, representative sections of each e.g. posterior peritoneal reflection
Obstetric hysterectomy

Submit representative sections as applicable of:

  • Cervix, including transformation zone from anterior and posterior lip
  • Caesarean scar
  • Retained placental tissue
  • Junction of placenta and myometrium
  • Edge of traumatic rupture
  • Composite blocks to demonstrating the full thickness of wall may be required

Record details of each cassette.

An illustrated block key similar to those provided below may be useful.

Block allocation key

Uterus, normal or with benign abnormalities

Cassette id
Site
No. of pieces
A-B
Cervix, anterior and posterior
 
C-D
Endomyometrium, anterior
 
E
Endomyometrium, posterior with serosa
 
F-G
Ovaries with fallopian tubes, left and right 
 
H-K
Abnormalities (e.g. fibroids etc), representative sections
 

Acknowledgements

Drs Kerryn Ireland-Jenkin and Marsali Newman for their contribution in reviewing and editing this protocol.

ReferencesBack to top


  1. Brown L, Andrew A, Hirschowitz L and Millan D. Tissue pathways for gynaecological pathology, The Royal College of Pathologists, London, 2008.
  2. Heatley MK. Dissection and reporting of the organs of the female genital tract. J Clin Pathol 2008;61(3):241-257.
  3. Lester SC. Manual of Surgical Pathology. Philadelphia: Saunders Elsevier; 2010.