Hypothesis / aims of study
This large-scale study takes a critical perspective on the routine use of histopathological examination after hysterectomy for pelvic organ prolapse (POP). Although this practice is widely adopted, its clinical value remains uncertain. We hypothesized that clinically relevant incidental findings, particularly malignancies requiring additional treatment, are rare and may not justify routine histopathological examination.
The aim of this study was to determine the prevalence and clinical relevance of incidental uterine and cervical pathology in women undergoing vaginal hysterectomy for POP without prior indication for histopathological examination.
Study design, materials and methods
A cross-sectional study was performed using a nationwide pathology databank (January 1991 to January 2025). Patients who underwent vaginal hysterectomy for POP were included. Patients without pre-existing indication for histopathology were classified as low risk. Those with abnormal cytology, bleeding, macroscopic or imaging findings, or other risk factors (e.g. genetic mutations) stated on the clinical application form, were analyzed as high risk.
Outcomes included prevalences of cervical intraepithelial neoplasia (CIN) I to III, adenocarcinoma in situ (AIS), endometrial intraepithelial neoplasia (EIN) and cervical and endometrial carcinomas. Prevalences were presented for all CIN II+ incidental findings, and cervical and uterine carcinoma separately.
Results
A total of 30.692 patients were included (mean age of 61 years, Stand Deviation=11.9), of whom 28.937 were classified as low risk and 1.755 a high risk.
In the low-risk group, CIN II+ lesions were found in 1.4% (n=395) and malignancies in 0.3% (n=86), predominantly early-stage disease.[1,2] Cervical carcinoma were found in 0.02% (n=6) and uterine carcinoma in 0.3% (n=80).
In the high-risk group, CIN II+ lesions occurred in 26.6% (n=86) of patients with abnormal cyto- or histology before surgery, in 5.1% (n=12) of patients with macroscopic or ultrasonic abnormalities, in 2.1% (n=3) of patients with other and in 0.8% (n=8) of with abnormal vaginal blood loss. Malignancy rates were 4.1% in the abnormal cyto- or histology group, 2.1% in both the macroscopic and ultrasonic abnormalities group and other indications group.
Interpretation of results
Incidental clinically relevant pathology is uncommon in women without preoperative risk factors, and most findings are premalignant or early stage with limited impact after hysterectomy. In contrast, substantially higher prevalences in high-risk groups support targeted rather than routine histopathological examination.