Original Title: Avis - Pertinence et indications de transmission des prélèvements chirurgicaux au laboratoire d’anatomopathologie : la chirurgie en obstétrique-gynécologie et urologie

Authors' objectives: Since the publication of the Organization and Management of Institutions Regulation (C.Q.L.R., chapter S-5, r. 5)1 in 1984, section 59 has generally been interpreted in clinical circles to mean that all surgical specimens must be sent to the anatomic pathology laboratory for analysis. This regulatory provision has, for many years, resulted in a large volume of specimens being submitted and analyzed. It is estimated that a significant proportion of these submissions may not be necessary. To promote optimal utilization of anatomic pathology resources and ensure consistency between institutions, the Ministère de la Santé et des Services sociaux asked the Institut national d’excellence en santé et en services sociaux (INESSS) to make recommendations to guide clinicians in their decision to submit or not submit certain surgical specimens to the anatomic pathology laboratory, based on the anatomical region, the domain of surgical expertise concerned, and the relevance of an anatomopathological examination. To this end, the project has been divided into six parts: orthopedic surgery and neurosurgery, general surgery, plastic surgery and dermatology (part A); the general surgery subspecialities (part B); obstetrics/gynecology and urology; cardiovascular and thoracic surgery; otolaryngology and maxillofacial and cervicofacial surgery; and ophthalmology. The present report deals with obstetric/gynecologic and urologic surgical specimens.

Authors' results and conclusions: RESULTS: Based on the scientific literature, there is a low risk of missing a clinically significant abnormality (i.e., a fortuitous finding that could have an impact on the patient’s management) in omitting an anatomopathological examination of tissue from a voluntary termination of pregnancy, a salpingectomy for a benign indication, a circumcision, or an inguinal hernia repair. For tissues from a voluntary termination of pregnancy, the sensitivity of an anatomopathological examination is low for the identification of an abnormal outcome, including procedural failure, an incomplete procedure or an ectopic pregnancy. The effectiveness of the surgeon’s examination in predicting an abnormal outcome is, in fact, greater than that of an examination by the pathologist. One study found that a histological analysis failed to identify chorionic villi in 4.2% of ectopic pregnancies confirmed by ultrasound and surgery. In the case of fallopian tubes, a fortuitous cancer discovery rate of less than 1% is reported for salpingectomies performed during surgery for benign indications in a population at low risk for ovarian cancer. For the purpose of this report, consultations with experts on the advisory committee allowed for the drawing up of a list of obstetric/gynecologic and urologic surgical specimens for which the level of risk to the patient is considered low. In these cases, an anatomopathological examination is unlikely to provide useful information for managing the patient, and the specimens could be submitted to the anatomic pathology laboratory on a selective basis at the clinician’s discretion. This selective submission list includes: 1) tissues of conception from a normal voluntary termination of pregnancy; 2) rectocele and cystocele repair tissue; 3) tissues from a labiaplasty; 4) normal-appearing foreskins from neonates and boys; 5) hydroceles; 6) spermatoceles; 7) varicoceles; 8) urinary calculi; 9) prostheses, devices, and foreign bodies from the genitourinary sphere; and 10) normal-appearing scars. CONCLUSIONS: The analysis and integration of the data from the scientific literature, the learned society guidelines and positions, and the perspectives of various stakeholders have enabled INESSS to make recommendations concerning the selective submission of certain surgical specimens to the anatomic pathology laboratory. These recommendations should contribute to more judicious utilization of anatomic pathology resources. However, the changes to practice that might result from them will depend on the dissemination and implementation of the recommendations in Québec’s health-care facilities. A gradual implementation with the councils of physicians, the directors of professional services, the OPTILAB co-directors and other bodies responsible for the quality of care acting in concert will be needed to facilitate the changes and ensure optimal management of risk and of the quality of medical acts.

Authors' methods: To fulfill the mandate, a systematic review was carried out in the scientific literature and using publications presenting or containing positions, recommendations or guidance on the subject. In addition, contextual information and the perspectives of various stakeholders were gathered to document perceptions of and level of acceptability associated with the selective submission of certain surgical specimens and materials to the anatomic pathology laboratory, and to determine the potential organizational, clinical, ethical and legal issues. To gather different perspectives, INESSS created an advisory committee consisting of obstetricians/gynecologists, urologists and anatomic pathologists. In addition, electronic surveys were sent to the directors of professional services and OPTILAB co-directors (a clinical laboratory reorganization project) to obtain information on surgical specimen submission practices and anatomic pathology resource utilization in Québec’s healthcare facilities. The Canadian Medical Protective Association was consulted to validate certain medicolegal issues potentially associated with a change in the procedures for submitting surgical specimens. Information on the impact of selective submission of certain surgical specimens on billing and auditing processes was obtained from the Régie de l’assurance maladie du Québec. The recommendations concerning obstetric/gynecologic and urologic surgical specimens that could be submitted to the anatomic pathology laboratory according to a selective approach are based on a simplified Delphi consultation process with 4 rounds. This process was carried out with the advisory committee in the light of the data and information from the systematic literature review and from consultations with informants and stakeholders, including the aforementioned Canadian Medical Protective Association and RAMQ

Project Status: Completed

URL for project: https://www.inesss.qc.ca/en/publications/publications/publication/pertinence-et-indications-de-transmission-des-prelevements-chirurgicaux-au-laboratoire-danatomopathologie-la-chirurgie-en-obstetrique-gynecologie-et-urologie.html

Year Published: 2021

URL for published report: https://www.inesss.qc.ca/en/publications/publications/publication/pertinence-et-indications-de-transmission-des-prelevements-chirurgicaux-au-laboratoire-danatomopathologie-la-chirurgie-en-obstetrique-gynecologie-et-urologie.html

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: Gouvernement du Québec