Pathologic Evaluation of the Morcellated Uterus: A Quality Assurance Study
IS Hagemann, AR Hagemann, VA LiVolsi, KT Montone. University of Pennsylvania, Philadelphia, PA
Background: Uterine morcellation is performed to allow extraction of the uterus through a small incision. The laparoscopic morcellator processes the tissue into unoriented cores, making it impossible for the pathologist to thoroughly evaluate the specimen. It is generally accepted that morcellation should be performed only in cases where significant histopathology is not anticipated. The standard of care includes a preoperative workup to exclude malignancy in the organs being removed. Careful quality assurance practices are important in ensuring that morcellation is performed only under appropriate circumstances and after appropriate workup.
Design: We performed a retrospective clinicopathologic study of morcellated hysterectomies at our institution between 2006 and 2009.
Results: Of 70 cases meeting inclusion criteria, the majority were performed for meno/metrorrhagia (57%) or pelvic organ prolapse (27%). Preoperative sampling of the endometrium was documented in 41% of all cases and in 57% of cases performed for bleeding. Preoperative Pap smear was documented in 54% of all cases and in 65% of cases performed for bleeding. Only 35% of patients with bleeding had both endometrial sampling and Pap smear in the year prior to hysterectomy, although this is the workup recommended by OB/GYN departmental policy for most morcellations. No workup revealed significant concern for hyperplasia, dysplasia or malignancy in the organs to be morcellated, although one endometrial biopsy showed atypical trophoblastic tissue favored to represent a placental site nodule and another showed simple hyperplasia without atypia. Endometrium was detected histologically in 69/70=99% of all morcellated hysterectomies, as was cervix in 8/15=53% of cases that included cervical resection. No significant endometrial or cervical pathology was identified on resection, but the case with atypical trophoblastic tissue could not be adequately classified. Institution of a departmental policy on morcellation did not improve the completeness of the preoperative workup.
Conclusions: Morcellated specimens are not amenable to full pathologic evaluation, yet a minority of patients in our series underwent the recommended anticipatory workup. In this series, there was no evidence that neoplasia was underdiagnosed in the resulting hysterectomies.
Category: Quality Assurance
Monday, March 22, 2010 9:30 AM
Poster Session I Stowell-Orbison/Surgical Pathology/Autopsy Awards Poster Session # 247, Monday Morning