- C William Helm, MD
C William Helm, MD
- Consultant Gynaecological Oncologist
- Northern Gynaecological Oncology Centre
- Queen Elizabeth Hospital
Historically, the standard operation for the treatment of even a small invasive carcinoma of the vulva was radical vulvectomy with removal of the primary tumor, including a wide area of skin extending onto the medial thigh, groins, and lower abdomen, together with an en bloc resection of the inguinal and often the pelvic lymph nodes . This operation had a high morbidity rate with approximately 50 percent of the wounds experiencing breakdown.
Surgical procedures for the treatment of carcinoma of the vulva have become more conservative and individualized to each patient. The fundamental basis of surgery for the primary tumor is now complete excision with a minimum 2 cm margin and dissection down to the deep fascia and to the periosteum of the pubic symphysis. Although adenocarcinoma of the vulva is treated in much the same fashion as squamous cell carcinoma, involvement of Bartholin gland is still thought to require total radical vulvectomy. The management of malignant melanoma remains controversial. (See "Bartholin gland masses: Diagnosis and management" and "Initial surgical management of melanoma of the skin and unusual sites".)
The exact procedure used depends upon the site, size, and histologic features of the tumor (picture 1). The clitoris may be preserved if the tumor is situated posteriorly on the vulva or lies 2 cm or more from the clitoris or closer in selected cases [2-4].
When a groin node dissection is planned it is usually performed first, unless the patient's medical condition is uncertain, in such patients it is best to excise the vulva tumor first in case the anesthetic has to be abandoned.
The extensive nature of some of the procedures, the unavoidable distortion of the appearance of the perineal area, and stoma formation can lead to major psychosexual problems for the patient. Preoperative counseling and postoperative support are vital parts of patient management.
- WAY S. The anatomy of the lymphatic drainage of the vulva and its influence on the radical operation for carcinoma. Ann R Coll Surg Engl 1948; 3:187.
- Heaps JM, Fu YS, Montz FJ, et al. Surgical-pathologic variables predictive of local recurrence in squamous cell carcinoma of the vulva. Gynecol Oncol 1990; 38:309.
- Preti M, Ronco G, Ghiringhello B, Micheletti L. Recurrent squamous cell carcinoma of the vulva: clinicopathologic determinants identifying low risk patients. Cancer 2000; 88:1869.
- Chan JK, Sugiyama V, Tajalli TR, et al. Conservative clitoral preservation surgery in the treatment of vulvar squamous cell carcinoma. Gynecol Oncol 2004; 95:152.
- Helm CW, Hatch KD, Partridge EE, Shingleton HM. The rhomboid transposition flap for repair of the perineal defect after radical vulvar surgery. Gynecol Oncol 1993; 50:164.
- O'Dey DM, Bozkurt A, Pallua N. The anterior Obturator Artery Perforator (aOAP) flap: surgical anatomy and application of a method for vulvar reconstruction. Gynecol Oncol 2010; 119:526.
- Wheeless CR Jr, McGibbon B, Dorsey JH, Maxwell GP. Gracilis myocutaneous flap in reconstruction of the vulva and female perineum. Obstet Gynecol 1979; 54:97.
- Chafe W, Fowler WC, Walton LA, Currie JL. Radical vulvectomy with use of tensor fascia lata myocutaneous flap. Am J Obstet Gynecol 1983; 145:207.
- Horta R, Filipe R, Costa J, et al. Vertical rectus abdominis musculocutaneous flap: a good option for reconstruction of large inguinofemoral defects with exposure of the femoral vessels: brief report focusing on management of advanced vulvar carcinoma. Int J Gynecol Cancer 2011; 21:565.
- Sawada M, Kimata Y, Kasamatsu T, et al. Versatile lotus petal flap for vulvoperineal reconstruction after gynecological ablative surgery. Gynecol Oncol 2004; 95:330.
- Hoffman MS, LaPolla JP, Roberts WS, et al. Use of local flaps for primary anal reconstruction following perianal resection for neoplasia. Gynecol Oncol 1990; 36:348.
- Grimshaw, RN, Ghazal, Aswad, S, Monaghan, JM. The role of ano-vulvectomy in locally advanced carcinoma of the vulva. Int J Gynecol Cancer 1991; 1:15.
- Adams J, Daly JW. Proctectomy combined with vulvectomy for carcinoma of the vulva. Obstet Gynecol 1979; 54:643.
- Senapati A, Phillips RK. The trephine colostomy: a permanent left iliac fossa end colostomy without recourse to laparotomy. Ann R Coll Surg Engl 1991; 73:305.
- Fuhrman GM, Ota DM. Laparoscopic intestinal stomas. Dis Colon Rectum 1994; 37:444.
- Ludwig KA, Milsom JW, Garcia-Ruiz A, Fazio VW. Laparoscopic techniques for fecal diversion. Dis Colon Rectum 1996; 39:285.
- Homesley HD, Bundy BN, Sedlis A, et al. Assessment of current International Federation of Gynecology and Obstetrics staging of vulvar carcinoma relative to prognostic factors for survival (a Gynecologic Oncology Group study). Am J Obstet Gynecol 1991; 164:997.
- Hacker NF. Current treatment of small vulvar cancers. Oncology (Williston Park) 1990; 4:21.
- DiSaia PJ, Creasman WT, Rich WM. An alternate approach to early cancer of the vulva. Am J Obstet Gynecol 1979; 133:825.
- Gonzalez Bosquet J, Magrina JF, Gaffey TA, et al. Long-term survival and disease recurrence in patients with primary squamous cell carcinoma of the vulva. Gynecol Oncol 2005; 97:828.
- Micheletti L, Borgno G, Barbero M, et al. Deep femoral lymphadenectomy with preservation of the fascia lata. Preliminary report on 42 invasive vulvar carcinomas. J Reprod Med 1990; 35:1130.
- Gaarenstroom KN, Kenter GG, Trimbos JB, et al. Postoperative complications after vulvectomy and inguinofemoral lymphadenectomy using separate groin incisions. Int J Gynecol Cancer 2003; 13:522.
- Carlson JW, Kauderer J, Walker JL, et al. A randomized phase III trial of VH fibrin sealant to reduce lymphedema after inguinal lymph node dissection: a Gynecologic Oncology Group study. Gynecol Oncol 2008; 110:76.
- Karakousis CP, Emrich LJ, Rao U. Groin dissection in malignant melanoma. Am J Surg 1986; 152:491.
- Levenback CF, van der Zee AG, Rob L, et al. Sentinel lymph node biopsy in patients with gynecologic cancers Expert panel statement from the International Sentinel Node Society Meeting, February 21, 2008. Gynecol Oncol 2009; 114:151.
- Oonk MH, van de Nieuwenhof HP, van der Zee AG, de Hullu JA. Update on the sentinel lymph node procedure in vulvar cancer. Expert Rev Anticancer Ther 2010; 10:61.
- RADICAL VULVECTOMY
- Preoperative preparation
- Operative procedure
- Postoperative care
- ANCILLARY PROCEDURES
- Wider margins
- Urethral surgery
- Vaginectomy (partial or total)
- Excision of anus and distal rectum
- - Sigmoid colostomy
- - Anovulvectomy
- Partial excision of pubic symphysis and ischial rami
- Groin node dissection
- - Superficial versus deep lymphadenectomy
- - Operative procedure
- - Postoperative management
- - Complications
- Sentinel node biopsy
- SUMMARY AND RECOMMENDATIONS