Many of these grossing templates were made with generous help from Dr. Zarrin Hossein-Zadeh. Others are based on templates from institutions I’ve practiced at. For some, you’ll see that there are different versions/options. As with all templates, these must be customized for each case–no two cases are the same!
Prostate
Received: In formalin labeled ” ” is a radical prostatectomy with attached bilateral seminal vesicles and bilateral vasa deferentia
Weight: [ ]g
Dimensions
Apex to Base: [ ]cm
Anterior to Posterior: [ ]cm
Transversely: [ ]cm
Right Seminal Vesicle: [ x x ]cm
Left Seminal Vesicle: [ x x ]cm
Right Vas Deferens: [ x ]cm
Left Vas Deferens: [ x ] cm
Inking
Right Lobe: Blue
Left Lobe: Black
Posterior: Overinked orange
External Surface: Pink-red and roughened
Peripheral Zone: Noted in the region of the [left/right] [anterior/posterior] prostate is a [ x x ] cm area of white-tan tissue with ill-defined borders, located [ ]cm below the capsule and [ ]cm from the distal prostatic urethral margin. An additional similar-appearing lesion is found in the region of the [right/left] [anterior/posterior] prostate, measuring [ x x ] cm. This lesion is located [ ]cm from the capsule and [ ]cm from the distal prostatic urethral margin.
Periurethral/Transitional Zone: Tan parenchyma with no identifiable lesions or nodules.
Additional Comments: Specimen photographs are obtained.
The prostate parenchyma is entirely submitted for examination. Representative sections of the vas deferens and seminal vesicles are submitted.
Submitted: Representative tissue in [ ] cassettes:
3A: Right distal urethral margin, radial sections
3B: Left distal urethral margin, radial sections
3C: Right proximal urethral (bladder neck) margin, radial sections
3D: Left proximal urethral (bladder neck) margin, radial sections
3E: Right vas deferens margin, seminal vesicle
3F: Left vas deferens margin, seminal vesicle
3G-3Q: Serial section of left anterior prostate (apex to base)
3R-3AC: Serial section of left posterior prostate (apex to base)
3AD-3AN: Serial section of right anterior prostate (apex to base)
3AO-3AZ: Serial section of right posterior prostate (apex to base)
Partial nephrectomy
Received: In formalin labeled ” “, consisting of a partial nephrectomy specimen
Weight: [ ]g Total Size: [ x x ]cm
Inking:
Margin of Resection: Blue
Capsule/Overlying Fat: Black
Area of Interest:
Lesion: A [ x x ]cm, lesion with a [well-circumscribed/ill-defined] [tan/hemorrhagic/cystic/solid/papillary/necrotic/friable] surface [with/without] papillary excresences is identified. The lesion is located at [ ]cm from the perinephric fat margin and [ ]cm from the parenchymal margin.
Additional Comments: Additionally in the container is a [ ] g aggregate of tan-yellow and friable soft tissue fragments that measures [ ]cm in aggregate.
Specimen photographs are obtained and submitted: Representative sections in [ ] cassettes:
1A-1B: lesion with resection margin
1C-1E: lesion with capsule
Radical nephrectomy:
Received: [Fresh/in formalin] labeled ” “, consisting of a radical nephrectomy
Laterality: [right/left]
Integrity: [Intact/disrupted]
Weight: [ ] g Total specimen size: [ x x ]cm
Ureter: [ x ]cm, [patent/occluded]
Renal Artery: [ x ] cm, [patent/occluded]
Renal Vein: [ ]cm in length and [ ]cm in diameter, [patent/occluded]
Kidney: [ x x ]cm, [intact/focally disrupted/ adhesed] kidney. The capsular surface is [tan/red/lobulated/cystic/granular]
Inking
Perinephric Fat: Black
Area of Interest:
Mass: [ x x ]cm well-circumscribed, tan-brown to golden yellow, focally hemorrhagic and cystic soft mass, comprising approximately [ ]% of the kidney
Location: [Superior/middle/inferior] pole
Distance to Perinephric Fat Margin: [ ] cm
Distance to Ureteral Margin: [ ] cm
Involves: The mass abuts the renal capsule and appears to [involve/not involve] the renal sinus, the renal pelvis, or the renal hilum.
Additional Comments: [#] simple cysts are identified in the [superior/middle/inferior] pole ranging from [ ]cm to [ ]cm. The nearest cyst is located [ ] cm from the mass. The cysts are filled with translucent serous fluid and shows smooth inner lining.
Remaining Parenchyma: The uninvolved renal parenchyma is tan-brown, rubbery and unremarkable.
Hilar Lymph Node(s): Not identified
Notes
Photographs are taken.
Submitted: Representative sections in [ ] cassettes:
1A: En face ureteral margin, renal artery margin, renal vein margin
1B: Renal hilum
1C-1D: Mass with the nearest inked perinephric fat, bisected contiguous section
1E: Mass with capsule
1F-1G: Mass with renal pelvis (G = bisected contiguous section)
1H-1J: Mass with renal sinus (H = bisected contiguous section)
1K: Mass with uninvolved renal parenchyma
1L: Simple renal cysts from [ ] pole
1M: Disrupted renal parenchyma from [ ] pole
1N: Uninvolved renal parenchyma from [ ] pole
Testis/Orchiectomy:
Received: [Fresh/in formalin] labeled ” “ and consists of a radical orchiectomy specimen
Weight: [ ]g
Size: Testis: [ x x ]cm
Spermatic Cord: [ ]cm length, [ ]cm diameter; The epididymis measures [ x x ] cm
Outer Surface Inked: Black
Cut Surface: Bivalving reveals a [ x x ] cm well-circumscribed mass located in the testicular parenchyma. The mass shows tan-yellow to brown-gray, focally hemorrhagic and somewhat mottled firm cut surface. The mass appears to be abutting the epididymis and tunica albuginea. The mass is located [ ] cm from the nearest inked spermatic cord margin (inked blue). The remaining testicular parenchyma is tan-brown, homogeneous, stringy and soft.
Tunica Vaginalis: The tunica vaginalis is pink-purple, dull, wrinkled with adhesion. Bivalving reveals approximately 10 cc translucent serous fluid in the cavity of the tunica vaginalis.
Tunica Albuginea: Pink-white, smooth, glistening and dense.
Notes
Photographs are taken.
Submitted: Representative sections in [ ] cassettes:
1A: En face inked spermatic cord margin
1B: Mass with epididymis
1C: Mass with epididymis and rete testes
1D: Mass with tunica albuginea and tunica vaginalis
1E-1F: Additional sections of mass
1G: Mass with uninvolved testicular parenchyma
1H: Uninvolved testicular parenchyma
Bladder, partial cystectomy
Received: [Fresh/in formalin] labeled ” “, consisting of a portion of bladder wall and attached soft tissue. The overall dimensions of the specimen are [ ] x [ ] x [ ] cm. The portion of bladder measures [ ] x [ ] x [ ] cm. The mucosa is [tan/pink/red/hemorrhagic] with a [flat/sessile/ulcerated/papillary] lesion which measures [ ] x [ ] x [ ] cm which is located [ ]cm from the closest margin of resection (inked black). The bladder wall appears to be [involved/uninvolved/indurated]. The adjacent urothelium is [tan-pink/ homogenous/ denuded/ vesicular/trabecular]. The perivesicle soft tissue is [tan-pink] and appears to be [involved/uninvolved/indurated]. The bladder walls margins of resection appear grossly [unremarkable]; The perivesicle soft tissue margin appears grossly [unremarkable]. The medial umbilical ligament and umbilicus are [present/not present], measuring [ ] x [ ] x [ ]cm. Specimen photographs are obtained. Representative sections submitted in[ ] cassettes:
Summary of sections:
[1A]: Margin of resection, perpendicular section [1B]: Soft tissue margin, perpendicular section [1C]: Full-face of the lesion with deepest invasion [1D-1E]: Additional sections of the lesion [1F]: Representative section of uninvolved mucosa [1G]: Medial umbilical ligament [1H]: Umbilicus
Bladder, radical cystectomy
The specimen is received [in formalin/fresh/fresh for intraoperative consultation] labeled “ ” and consists of bladder and attached soft tissue, ureters, [and uterus, cervix, vaginal wall, ovaries, fallopian tubes]. The overall dimensions of the specimen are [ ] x [ ] x [ ] cm. The bladder measures [ ] x [ ] x [ ] cm. The ureters are identified and are [probe patent/obstructed]. The right ureter measures [ ] cm in length and [ ] cm in diameter and the left ureter measures [ ] cm in length and [ ] cm in diameter. [additional description if obstructed.]. The right half of the specimen is inked red, the left half is inked blue and the posterior surface is over inked black. The specimen is opened anteriorly in a Y shaped.
Upon opening the bladder, the mucosa is [tan-pink/red/hemorrhagic/denuded/ trabecular/ vesicular] and there is [ulcerated/flat/sessile/exophytic/papillary/polypoid] lesion measuring [ x x ] cm on the [left/right][lateral/posterior/anterior] [superior/inferior] surface of the bladder. On sectioning, the lesion appears to be [non-invasive/invades into lamina propria/invades into inner half of the muscularis propria / invades into the outer half of the muscularis propria / invades into the perivesical fat] with a maximum depth of invasion of [ ]cm. The bladder wall thickness is [ ]cm. The tumor is [ ]cm from the right ureteral orifice and [ ]cm from the left ureteral orifice. There [is/is no] gross involvement of the ureteral luminal surface by the tumor.The perivesicle soft tissue appears to be [involved or uninvolved or indurated].
The uterus measures [ ] x [ ] x [ ] cm. The right ovary measures [ ] x [ ] x [ ] cm. The right fallopian tube measures [] x [] x [] cm. The left ovary measures [ ] x [ ] x [ ] cm. The left fallopian tube measures [] x [] x [] cm. The vagina measures [] cm.
[No/#] lymph nodes are identified in the perivesical fat.Specimen photographs are obtained. Representative sections submitted [ ] cassettes:
Summary of sections:
[1A]: Left ureteral margin [1B]: Right ureteral margin [1C]: Urethral margin [1D]: Soft tissue margin [1E]: Full-face of tumor with deepest invasion [1F-1H]: Additional sections of the tumor [1I-1K]: Bladder mucosa – trigone, dome, left and right lateral wall, anterior, posterior wall [Sections of Uterus, ovaries, fallopian tubes, cervix and Vagina if present] [ ]: lymph node candidates
Bladder, cystoprostatectomy:
The specimen is received [in formalin/fresh/fresh for intraoperative consultation] labeled “ ” and consists of bladder and attached soft tissue, ureters, prostate, and seminal vesicles. The overall dimensions of the specimen are [ ] x [ ] x [ ] cm. The prostate measures [ ] cm apex to base, [ ] cm anterior to posterior and [ ] cm left to right. The ureters are identified and are [probe patent/obstructed]. The right ureter measures [ ] cm in length and [ ] cm in diameter and the left ureter measures [ ] cm in length and [ ] cm in diameter. [additional description if obstructed.]. The right half of the specimen is inked red, the left half is inked blue and the posterior surface is over inked black. The specimen is opened anteriorly in a Y shaped.
Upon opening the bladder, the mucosa is pink-red and there is [ulcerated/flat/sessile/exophytic/papillary/polypoid] lesion measuring [ x x ] cm on the [left/right][lateral/posterior/anterior] [superior/inferior] surface of the bladder. On sectioning, the lesion appears to be [non-invasive/invades into lamina propria / invades into inner half of the muscularis propria/invades into the outer half of the muscularis propria/invades into the perivesical fat] with a maximum depth of invasion of [ ]cm. The bladder wall thickness is [ ] cm. The tumor is [ ] cm from the right ureteral orifice and [ ] cm from the left ureteral orifice. There [is/is no] gross involvement of the ureteral luminal surface by the tumor.
The prostatic urethra measures [ ] cm and [is/is not] grossly involved by the tumor. The cut surface of the prostate shows nodular, tan, solid tissue. The right and left seminal vesicles and vas deferentia are unremarkable and measure [ ]cm respectively.
[No/#] lymph nodes are identified in the perivesical fat.Specimen photographs are taken. Representative sections are submitted in [ ]cassettes:
[1A]: Left ureteral margin [1B]: Right ureteral margin [1C]: Urethral margin [1D]: Soft tissue margin [1E]: Full-face of tumor with deepest invasion [1F-1H]: Additional sections of the tumor [1I-1K]: Bladder mucosa – trigone, dome, left and right lateral wall, anterior, posterior wall [1L]: (LVDSV) Left vas and seminal vesicle [1M]: (RVDSV): Right vas and seminal vesicle [1N-1Y]: Prostate submitted every other slice from apex to base [1Z]: Lymph node candidates
Bladder (+/- Prostate) (Option 2)
Received [fresh/in formalin], labeled with patient’s name, medical record number and designated as “***”, is a [cystoprostatectomy or cystectomy] specimen.
Size
– Overall: *** cm, *** gm
– Bladder: *** cm
– Ureters: *** cm length x *** cm diameter right, *** cm length x *** cm diameter left with [patent, obstructed] lumina
– [Prostate: *** cm
– Seminal vesicles: *** cm right, *** cm left
– Vasa deferentia: *** cm length x *** cm diameter right, *** cm length x *** cm diameter left]
Ink: Right half = blue, left half = black, serosa = orange, urethral opening = purple
Bladder lesion [#1]:
– *** cm [ulcerated, fungating, friable] [dome, trigone, etc.]
– Lesion involves [submucosa/bladder wall/adipose tissue] to a depth of *** cm, coming to within *** of the [ink color] margin
Uninvolved bladder mucosa: [Color, edematous, smooth, wrinkled, congested, etc.], wall thickness *** cm
Ureteral orifices: [Probe patent, not probe patent]
[Prostate: [No definitive indurations are identified] ___ cm lesion, ___ color, [location in prostate], ___ cm from inked margin]
Gross photographs: [Yes or remove line]
Cassette Summary
***: Distal urethral margin
***: Prostatic apical margin, shaved and sectioned
***: Right ureteral margin
***: Left ureteral margin
***: Tumor sections, including deepest extension in ***
***: Ulceration, entirely submitted
***: Uninvolved dome
***: Uninvolved anterior wall
***: Uninvolved posterior wall
***: Uninvolved right lateral wall
***: Uninvolved left lateral wall
***: Uninvolved trigone
***: Representative prostate