In daily surgical practice, clinicians and pathologists may encounter the temptation of assuming that tissue excised for purely anatomical, aesthetic, or functional reconstructive reasons lacks significant underlying pathology. While gross examination or clinical impression often suggests benignity, submitting surgical specimens for formal anatomical pathology evaluation represents an essential component of clinical thoroughness, objective verification, and risk management.

This discussion is illustrated by the routine histopathological examination of a surgical specimen from acolpoplasty and vaginal repair performed on a 70-year-old postmenopausal woman presenting with symptomatic stage III pelvic organ prolapse (POP; cystocele and rectocele). Preoperative cervical/vaginal cytology showed no intraepithelial lesions or malignancy. Following informed patientconsent, tissue was excised and submitted in 10% neutral buffered formalin. Gross evaluation showed atissue fragment measuring 2.2 × 2.0 × 1.3 cm in maximum dimensions, presenting a grayish-white outersurface and a soft-elastic consistency on sectioning.

Specimens were routinely processed, embedded in paraffin, sectioned at 4 µm, and stained with Hematoxylin and Eosin (H&E). Microscopic examination revealed a physiological tissue architecture, fully congruent with the patient postmenopausal hormonal status (Figures 1 to 5). A stratified squamous epithelium exhibiting marked senile atrophic changes was observed, characterized by epithelial thinning,loss of intermediate and superficial cell maturation, and focal areas of reactive superficial hyperkeratosis/orthokeratosis (Figures 2 and 4). The underlying subepithelial stroma displayed marked,paucicellular, hyalinized collagenous fibrosis with thin-walled blood vessels. In the deeper strata, mature adipose tissue intermingled with the surrounding fibrous tissue. There was a strict absence of cellularatypia, atypical mitoses, dysplastic epithelial proliferation (squamous intraepithelial lesions [SIL] /vaginal intraepithelial neoplasia [VAIN]), or specific inflammatory infiltrates (Figures 1,3,and 5).

In summary, the findings yielded the histopathological confirmation of benign stromal remodeling and involutive epithelial atrophy. Despite the absolute benignity of this case, a fundamental clinical question arises: to what extent is the systematic histopathological analysis of specimens obtained during reconstructive pelvic floor procedures (e.g., colpoplasties and POP repairs) or aesthetic gynecological surgeries (e.g., labioplasties) justified?

In recent decades, the debate regarding the cost-effectiveness of routine histological examination inbenign gynecological surgery has received attention in the medical literature. Several authors argue that the rate of unexpected malignant findings in such specimens is low, questioning the financial expenditureand clinical workload involved [1,2]. However, scientific literature documents clinically silent, unexpected histological findings in vaginal remodeling and prolapse resections. These range from incidental high-grade vaginal intraepithelial neoplasia (VAIN 3) and early-stage squamous cellcarcinomas [3], to insidious mesenchymal entities such as angiomyofibroblastoma, reactive fibroepithelialstromal tumors, or sarcoma botryoides /rhabdomyosarcoma presenting at atypical ages [4,5], as well asunrecognized deep infiltrative endometriosis, granulomatous infections (e.g., tuberculosis, deep fungal infections), or stromal amyloidosis deposits [6].

Comparing our specimen with these literature-reported findings illustrates how the histological spectrum of the vaginal wall spans from benign senile fibrous atrophy—such as the one presented here—to subclinical diagnostic traps. Without systematic microscopic examination, such conditions would pass unnoticed, potentially compromising patient management and long-term outcomes.

From a clinical and methodological perspective, foregoing microscopic evaluation converts visual Clinical judgment into an unverified assumption. Histopathological evaluation provides four distinct Clinical benefits: (1) diagnostic confirmation by excluding occult dysplasia or malignancy; (2) quality assurance of surgical care through objective tissue verification; (3) medico-legal protection documenting tissue benignity; and (4) patient safety mitigation against subclinical neoplastic or inflammatory processes.

Furthermore, distinguishing between functional reconstructive operations (colpoplasties/POP repair) and aesthetic procedures (labioplasties) is essential when assessing risk profiles across different patient demographics.

In conclusion, the case of our 70-year-old patient offers confirmation of tissue benignity. Nevertheless, it reinforces the pathological principle that patient safety should rely on objective microscopic evidence rather than visual impression alone. We advocate for maintaining the systematic histopathological evaluation of all vaginal plastic and reconstructive surgical specimens as an indispensable pillar ofdiagnostic accuracy and clinical safety in gynecology.

Ethics and patient consent

Written informed consent was obtained from the patient for publication of this case and accompanying images. In accordance with institutional guidelines, single retrospective case reviews of routine pathological specimens are exempt from formal institutional review board approval.

1. Radaelli F, et al. Is routine pathological examination of vaginal wall tissue excised during pelvic organ prolapse surgery necessary? Int Urogynecol J. 2019;30(8):1321-1326.
2. Dellas A, et al. Histopathological findings in vaginal wall resections during vaginal repair operations: a routine procedure under debate. Arch Gynecol Obstet. 2014;290(3):485-489.
3. Boreham MK, et al. Incidental histological findings during pelvic organ prolapse surgery. Am J Obstet Gynecol. 2002;187(4):911-915.
4. McCluggage WG. Mesenchymal tumors of the female genital tract: an update on selected benign andmalignant entities. Int J Gynecol Pathol. 2012;31(1):21-35.
5. Loverro G, et al. Unexpected histological findings after vaginal prolapse repair: clinical implicationsand management. Eur J Obstet Gynecol Reprod Biol. 2018;221:112-116.
6. Teresi M, et al. Unsuspected pathology in vaginal tissue excised during pelvic reconstructive surgery: asystematic review. Gynecol Surg. 2021;18(1):14.