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Radical vulvectomy

Radical vulvectomy
Literature review current through: Jan 2024.
This topic last updated: Apr 12, 2021.

INTRODUCTION — 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 [1]. This operation had a high morbidity rate with approximately 50 percent of the wounds experiencing breakdown.

Increasing knowledge and understanding of the disease has allowed surgical procedures for the treatment of carcinoma of the vulva to become more conservative and individualized to each patient. Such procedures are given a variety of names preceded by the word "radical," including hemivulvectomy, partial vulvectomy, anterior (horseshoe) vulvectomy, posterior (horseshoe) vulvectomy, local excision, and wide local excision. Whatever the procedures are named, all must observe the fundamental aim of complete excision of the primary tumor with dissection down to the level of the deep fascia of the thigh and/or the periosteum of the pubis and inferior fascia of the urogenital diaphragm. Although adenocarcinoma of the vulva is treated in much the same fashion as squamous cell carcinoma, involvement of the Bartholin gland is thought to require radical resection. The management of malignant melanoma remains controversial. (See "Bartholin gland masses" and "Surgical management of primary cutaneous melanoma or melanoma at other 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 an inguinofemoral lymph node dissection is planned it is usually performed first, unless the patient's medical condition is frail; in such patients it is best to begin with excision of the vulvar 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.

In cases where the extent of tumor involvement would require resections that may lead to bladder and anal dysfunction, use of combined chemotherapy and radiation (chemoradiation) may reduce the volume and extent of the tumor and allow subsequent sphincter-sparing surgery to be performed. Multidisciplinary collaboration is the keystone of treatment planning for locally advanced cancer of the vulva. (See "Squamous cell carcinoma of the vulva: Staging and surgical treatment".)

RADICAL VULVECTOMY — Radical vulvectomy implies removal of the entire vulva down to the level of the deep fascia of the thigh, the periosteum of the pubis, and the inferior fascia of the urogenital diaphragm. Because it is normally performed for malignant disease, the exact margins are defined by the extent of the tumor, but enough adjacent tissue should be removed to ensure a minimum 2 cm margin around a carcinoma. While the optimum tumor-free margin at surgery is considered to be 2 cm allowing for a minimum pathologic margin of 8 mm [2], studies suggest that the extent of the pathologic tumor-free margin may not impact recurrence rates and closer negative margins may be tolerated, especially when the tumor extends close to the clitoris or anus [5-9]. Nevertheless, the surgeon should aim for a 2 cm margin where feasible.

Radical vulvectomy is often performed in conjunction with either a unilateral or bilateral inguinofemoral lymph node dissection. The types of incisions used are individualized depending primarily on the site and size of the tumor (figure 1). The procedures of radical hemivulvectomy, radical partial vulvectomy, and radical local excision/resection are incorporated in this description.

Preoperative preparation — All women undergoing radical vulvar surgery require careful explanation and counseling about the effects of the procedure. Good bowel preparation is advised before surgery, particularly when a posterior dissection is expected. In view of the extensive dissection that may be necessary close to the anus, signs of anal sphincter weakness should be documented before surgery. Symptoms of urinary incontinence should also be carefully assessed. Urinary incontinence may be an issue postoperatively, particularly with anterior radical vulvectomies, and may require surgical or medical management, or both.

Operative procedure — General, epidural, or spinal anesthesia is administered. The patient is placed in Allen stirrups with the hips abducted 45 degrees and flexed 45 degrees. It is helpful to position the patient so that the perineum protrudes over the bottom of the operating table. A pad or cushion is placed under the sacrum. The Bovie pad is placed away from the thigh in case skin flaps need to be raised.

The skin is prepared to include all areas that may be required for skin flaps. The patient is examined carefully to identify the limits of spread and then a pen is used to mark where the skin should be incised, both externally and within the vagina. A urethral catheter is inserted into the bladder. If frozen sections are required to ensure that the intended resection margins are clear of tumor, they should be taken at this time. They can be cut as small ellipses in the line of the incision. Only biopsies should be sent for frozen section, not the vulvectomy specimen.

For a total radical vulvectomy the skin incision is begun posteriorly and extended laterally on both sides, similar to the procedure for a simple vulvectomy, but the excision margins are wider and the dissection is taken all the way through the subcutaneous fat to the deep fascia. (See "Vulvar wide local excision and simple vulvectomy".)

The tissues can be separated relatively easily from the deep fascia and pubic ramus with scalpel, scissors, or Bovie until the intended vaginal resection margin is reached. An assistant holds forceps ready to clip vessels as they become visible so that dissection can proceed rapidly. Branches of the pudendal artery require attention as they are encountered posterolaterally.

It is important to avoid damaging the anal sphincter, while at the same time ensuring an adequate margin around a tumor placed posteriorly on the vulva or perineum. A finger in the rectum helps to guide the operator under these circumstances. As with a total vulvectomy, the posterior margin of the specimen is elevated with forceps, which can be held by the assistants while dissection proceeds. If necessary, the anterior third of the anal sphincter can be removed with the specimen.

Superolaterally, if a triple-incision procedure is being performed, the subcutaneous tissues that contain the lymphatics extending toward the groins on each side are taken with the specimen by dissecting under the "skin bridge" that is left between the vulvectomy and groin dissection. Superiorly, the dissection is carried down toward the clitoral attachments by sweeping the specimen off the periosteum of the pubic bones conserving the deep fascia until the clitoral attachments are reached (picture 2A-B). The suspensory ligament of the clitoris may be clamped, divided, and ligated at this point.

The vaginal incision is now made circumferentially, ensuring that the required margin around the tumor is maintained. The tip of a scalpel or Kelly forceps is passed through the specimen in the midline to isolate the crura (picture 3 and picture 4). They are held with forceps, divided, and then suture ligated with absorbable sutures. The specimen is detached completely, and hemostasis is secured with Bovie and sutures. Venous sinuses around the urethra and vaginal margin may be difficult to control without use of a running suture. The specimen is sent for histology with the orientation marked.

Closure — In many cases the wound can be closed primarily without resorting to special techniques. Care is taken to appose the skin above the urethral meatus to the residual skin of the mons pubis. Marker sutures may be inserted to assess the way in which the edges will come together. Closure may be facilitated following resection of posterior lesions if the residual vagina is mobilized off its lateral attachments and the rectum posteriorly.

A suction drain with wide holes is inserted on one or both sides and brought out through the perineum (picture 5). Paraffin gauze is placed over the wounds and covered by a gauze dressing held in place by a diaper made out of a sterile disposable drape.

Postoperative care — The patient is kept on bed rest for the first two to three days of the initial postoperative period. Pneumatic calf compression, active leg movements, and subcutaneous low molecular weight heparin are recommended to minimize the risk of deep venous thrombosis and embolism.

The suction drains are left in place for at least three days and a urethral catheter is used to drain the bladder until the patient is ambulatory. The wound is inspected daily to ensure continued healing and to detect early signs of infection. The perineum is cleansed with sterile saline after the first 48 hours and dried with a hair dryer. Sitz baths are begun a few days later.

The patient is given a low residue diet and constipating agents for three days, particularly if the anal sphincter or rectum was repaired. Following this period, stool softeners are prescribed.

Complications — Some superficial wound breakdown is common, but this usually heals with conservative management. If the wound has been closed with skin flaps and necrosis has occurred, the dead skin should be debrided. Hematomas/seromas, although unusual if adequate drainage is maintained, may require evacuation. Signs of infection should prompt the taking of specimens for culture and instituting antibiotics. Urinary tract infection, thromboembolism, and osteitis pubis are additional potential complications.

Late sequelae include stenosis of the vaginal introitus and pelvic organ prolapse.

ANCILLARY PROCEDURES — Additional procedures, which depend upon the characteristics of the primary tumor, may be required to ensure complete excision of the carcinoma.

Wider margins — Extensive areas of skin may need to be excised with the primary tumor. The methods available for closure of the resulting defect should be considered when planning the procedure. In the event of being unable to fashion flaps, the defect can be packed with povidone-iodine soaked gauze and then allowed to granulate, with careful postoperative nursing care.

The most widely used supplementary method of closure is by skin flaps, which may be of the transposition type, such as the rhomboid flap (particularly useful for small posterior defects [10]), the anterior obturator artery perforator flap [11], myocutaneous flaps (eg, gracilis [12], tensor fascia lata [13], and rectus abdominis [14]), lotus petal flaps [15,16], or V-Y advancement flaps [17].

Urethral surgery — If the tumor involves the urethra, the distal 1 cm can be excised without affecting continence. The residual urethral mucosa is included in the closure.

If any more than the distal 1 cm of the urethra must be excised, the patient will require an additional procedure to prevent urinary incontinence. In some women this will be an anterior exenteration with formation of neobladder. An alternative procedure in the palliative setting is to tie off the residual proximal urethra and bury the stump inwards to the bladder in a similar fashion to burying an appendix stump at appendectomy. Through a suprapubic incision the space of Retzius is entered and the upper urethra and bladder neck are exposed (figure 2). A rubber drain is passed around the urethra, which is mobilized around with the bladder neck, and then transected and transfixed. The anterior bladder is opened through a midline incision and the upper urethra is inverted into the bladder using forceps. The edges of the inverted bladder neck exteriorly are approximated. The bladder incision is then closed with continuous suture around a suprapubic catheter.

Vaginectomy (partial or total) — The extent and site of vaginal involvement will dictate the amount of surgery required. Involvement of the lower lateral wall can be managed by resection as necessary. If the tumor involves the anterior or posterior walls of the vagina, care must be taken not to damage the bladder or rectum while achieving clear margins around the tumor. Extensive involvement of the vagina may require removal of the bladder or anorectum, depending upon the site of involvement. (See "Vaginectomy".)

Excision of anus and distal rectum — Several procedures have been described for the excision of tumor involving the anus and rectum. When the lesion just encroaches on the anus, or there is a suspicion of encroachment, the anterior third of the anus and anal sphincter can be excised without major impact on continence [18]. The external anal sphincter is repaired with interrupted 0 polyglactin sutures. For extra support of the sphincter mechanism, the distal limbs of the puborectalis may be plicated together anterior to the anus. The skin can be closed with rhomboid flaps [10].

In many cases, partial resection of the anus would be insufficient and anovulvectomy [19,20], anoproctectomy [21], or posterior exenteration can be used. Anoproctectomy is a more extensive procedure than anovulvectomy. Anovulvectomy with sigmoid colostomy is a useful procedure in older women as it is often well tolerated and avoids the need for an extensive abdominal procedure in addition to the perineal procedure. The procedure is optimally performed in two stages. First, a sigmoid end colostomy is raised in the left iliac fossa. Two weeks later, in the perineal phase, the tumor is excised widely including the anus and lower rectum. The rectum is transected and left opening into the perineal wound. It is usually secured to the posterior edge of the residual vagina and to the skin margins. The two phases may be performed during the same surgery, with the lower bowel being irrigated from above to clean away fecal material.

Sigmoid colostomy — This procedure was traditionally performed using a midline abdominal incision; however, in many cases, it can now be carried out using a single circular incision (ie, "trephine") over the site of the intended colostomy [22] or by using a laparoscopic technique [23,24].

Preoperative bowel preparation is recommended and general, epidural, or spinal anesthesia can be used. The patient should be placed in the supine position in Allen stirrups. If a trephine colostomy is planned, a 24 French Foley catheter is inserted into the rectum. The balloon end is inflated to hold it in place, and the external end is connected to the bellows used for sigmoidoscopy.

For a trephine colostomy, a 1 inch circular incision is made in the skin of the abdomen at the site of the intended colostomy and the disc of skin is removed (figure 3). Using an electrocautery instrument on cutting current, the incision is taken down through the subcutaneous fat to the rectus sheath. The external oblique aponeurosis is incised obliquely in the line of the muscle fibers. The underlying internal oblique and transversus muscles are separated and the retractors inserted to expose the peritoneum. The peritoneum is picked up with hemostats and incised carefully. The intended stoma is gently stretched with the fingers to allow adequate room for the bowel.

The descending colon and sigmoid are identified. Babcock forceps are applied and used to gently elevate the bowel through the stoma site until a window of mesentery is visible (figure 4). It may be difficult to identify the nature of the bowel loop raised, although the presence of tenia will confirm large bowel. Before incising the bowel, a soft bowel clamp is applied above and the rectum and sigmoid are inflated with air from below to confirm the identity of the distal and proximal bowel.

A small window is made in the mesentery at the apex of the loop of bowel and widened enough to allow a gastrointestinal anastomosis (GIA) stapler gun to be inserted (figure 5). The bowel is transected, and the distal end is inspected for hemostasis and placed back within the abdomen.

The proximal part is prepared for the stoma. The staple line is excised and discarded. The bowel is opened out and sutured to the skin with interrupted 3/0 polyglactin mucocutaneous sutures.

The laparoscopic technique entails placement of a 5 mm port at a convenient site away from the intended site of the colostomy for carbon dioxide distension and camera placement. The port would normally be placed either in the left upper quadrant, at the umbilicus, or in the right iliac fossa. The left iliac fossa and the suprapubic areas are best avoided in patients with carcinoma of the vulva. After visualization of the intraabdominal situation, additional 5 mm ports can be placed, if necessary, to effect mobilization of the sigmoid colon sufficient for the colostomy to be fashioned without tension. The procedure is then completed as for the trephine technique, although distension is not necessary for discrimination between the proximal and distal ends [23,24].

Anovulvectomy — General, epidural, or spinal anesthesia can be administered. The patient is placed in Allen stirrups in the modified ski position with the thighs abducted 45 degrees and flexed 45 degrees. It is important to position the patient so that the perineum and anus extend over the end of the table to allow access behind the anus.

The incision margins are marked with a pen. The exact extent of resection depends on the size of the tumor, but encompasses the anus. A number one polyglactin suture is inserted circumferentially around the anal margin, pulled tight, and tied to stop anal leakage and provide traction on the anal canal and rectum. The dissection differs from a radical vulvectomy only in the posterior part.

Mayo scissors are used for dissection in the ischiorectal fossa. In the midline posteriorly the fascia of the anococcygeal raphe may be palpated and divided. The levator muscles are incised on both sides and the anus and lower rectum are freed laterally and posteriorly. The rectum is transected above the tumor together with the posterior vagina, usually after the rest of the surgical specimen has been mobilized. Skin flaps may be required to close the defect. During closure of the wound, the rectal mucosa can be secured to the posterior vaginal edge and the perineal skin closure.

Postoperative care is similar to that for women who have undergone radical vulvectomy. The patient will intermittently discharge a small amount of mucus from the rectum into the perineum, but this is not usually a problem. Occasionally, the mucus may be retained in the residual rectum and requires release either digitally or by dilation of the perineal opening.

Partial excision of pubic symphysis and ischial rami — Excision of the central part of the pubic symphysis or parts of the ischial pubic rami can be performed with the Gigli saw in cases of central involvement. The opinion of an orthopedist should be sought because of potential problems with pelvic stability.

Inguinofemoral lymph node dissection and sentinel lymph node biopsy — The inguinofemoral lymph nodes are the most important prognostic indicator in squamous cell carcinoma of the vulva [25].

The identification of a sentinel inguinofemoral lymph node (SLN) may reduce the need for a complete inguinofemoral node dissection and, thus, reduce morbidity. When indicated, this procedure is now the standard of care for identification of the status of the inguinofemoral lymph nodes. The rationale for this is discussed elsewhere [8,9,26]. (See "Squamous cell carcinoma of the vulva: Staging and surgical treatment", section on 'Sentinel lymph node biopsy'.)

Identification of the sentinel node is facilitated by the use of a combination of vital dyes in conjunction with preoperative lymphoscintigraphy [27] or single photon emission computed tomography [28]. One to three hours before surgery, approximately 2 mCi of technetium 99m-labeled sulfur colloid in a volume of 1 cc is injected intradermally around and in front of the leading edge of the vulvar carcinoma in the radiology department [29]. Scintigraphy produces an image of signal from the sentinel node or nodes and their approximate anatomical site. At the time of surgery, 5 to 10 minutes prior to dissection of the groin, 1 to 3 mL of a vital blue dye such as isosulphan blue is injected intradermally around the leading edge of the tumor using an insulin-type syringe and fine-gauge needle (picture 6). The dye can usually be seen entering the lymphatics. The site of the groin incision is determined by use of a hand-held gamma probe, which identifies the sentinel node based on its high count, usually at least 10 times the basal count (picture 7). Care must be taken to point the probe slightly away from the tumor to avoid contamination from the peritumoral injection site. A 2 to 4 cm incision is made over the area and dissection takes place to identify the hot "blue" node assumed to be the sentinel node. Additional nodes identified as being possible sentinel nodes should be removed based on interpretation of the preoperative lymphoscintigram together with the gamma probe and dye findings following removal of the initial node. If the sentinel node is not detected, then a completed inguinofemoral lymph node dissection should be performed. The node(s) should be sent for frozen section so that if it is positive for metastatic disease, the appropriate inguinofemoral lymph node dissection can be performed. If negative, the wounds are closed with subcuticular suture without drainage (picture 8).

Inguinofemoral lymph node dissection is performed when the primary tumor exceeds 4 cm in dimension, in the case of multifocal invasive disease, and/or in some cases following the identification of metastasis in an SLN or where no SLN can be identified. The dissection is often bilateral in the case of tumors encroaching on, or crossing, the midline and where a unilateral SLN metastasis is present. If cancer recurs in a previously undissected groin, the outlook is grim [30].

For the management of malignant melanoma, the practice of inguinofemoral lymph node dissection is controversial but is probably not indicated for primary disease. (See "Surgical management of primary cutaneous melanoma or melanoma at other unusual sites".)

Superficial versus deep lymphadenectomy — Lymph drainage from the vulva rarely bypasses the superficial nodes (figure 6), so it has been suggested that a superficial node dissection is all that is required for most patients with small carcinomas, provided these nodes are negative [31]. A retrospective series suggested that groin relapse in patients with negative nodes on superficial inguinal lymphadenectomy was caused by metastatic disease in unresected inguinal nodes [32]. Since it has been shown that the deep lymph nodes can be removed relatively easily without extensively disrupting the deep fascia [33] and with minimal additional morbidity, they should be removed routinely as part of an inguinofemoral lymph node resection [8,9].

Operative procedure — General, epidural, or spinal anesthesia is used. If an inguinofemoral lymph node dissection alone is to be performed, the patient is placed supine with the legs abducted 30 degrees and externally rotated. If the vulva is also to be removed, the patient is placed in Allen stirrups in the same position. The legs can be repositioned after the groin node dissection so that the hips and knees are flexed.

Provided the inguinofemoral lymph nodes are clinically negative, the groin incision runs 2 cm below and parallel to the inguinal ligament starting 3 cm distal and medial to the anterior superior iliac spine and ending below the superficial inguinal ring (figure 7 and picture 9). If there is concern for inguinofemoral lymph node metastases, an elliptical skin incision can be made in the same line so that this overlying segment of skin can be excised with the nodes.

The incision is taken through the full thickness of the skin and 2 to 3 mm into the fat. Allis forceps are applied to the dermal surface of the upper skin incision to provide traction while Mayo scissors or scalpel are used to dissect down through the subcutaneous fat to expose the glistening fascia of the aponeurosis of the external oblique muscle 3 cm above the inguinal ligament (picture 10). Care must be taken not to dissect too close to the skin of the flaps because this will jeopardize the blood supply and may lead to flap necrosis. Scarpa (superficial) fascia, when prominent, can occasionally be mistaken for the external oblique aponeurosis, but does not have the glistening silver color. Once the external oblique aponeurosis is identified, the fatty tissue containing the inguinal nodes can be dissected off easily so that the lower margin of the inguinal ligament is exposed.

The caudal skin flap is now raised and dissection is taken down through the subcutaneous fat to the deep fascia of the thigh, approximately 6 cm from the inguinal ligament. Although the initial incision and dissection should span the entire length of the caudal flap, it is easier to identify the deep fascia at the lateral end. Once the deep fascia has been reached, dissection of the fatty bundle containing the inguinofemoral lymph nodes off the deep fascia is performed from lateral to medial (picture 11). Laterally, the circumflex iliac vessels need to be electrocauterized, but throughout the dissection care must be taken to control bleeding. A finger is passed beneath the round ligament as it exits from the superficial inguinal ring. Traction on the proximal end of the round ligament and the medial end of the inguinofemoral lymph node fatty bundle facilitates the dissection of tissues containing lymphatic vessels leaving the vulva (picture 6).

The fatty nodal bundle is grasped with forceps and elevated by the operator or assistant. Anteromedially the great saphenous vein (GSV) is identified ascending into the thigh from the medial side. The vein can be left in situ, but it is generally easier to ligate and divide it at the distal margin of the dissection.

Following division of the GSV, the tissues on the medial and caudal side are dissected from the deep fascia. The proximal GSV in the nodal bundle is followed down to the saphenofemoral junction. Although the pulsation of the femoral artery is a good landmark for identifying the position of the common femoral vein, it is best approached by following down the medial side of the GSV. The proximal GSV is dissected free on all sides and suture ligated approximately 0.5 to 1 cm from the saphenofemoral junction, taking care not to narrow the common femoral vein. The specimen is removed, usually by dividing the lymphatic tissues entering the femoral canal.

The deep femoral nodes may have been removed with the specimen but if not, residual tissue is dissected from the anterior and medial surfaces of the femoral vein above the lower limit of the fossa ovalis (figure 8). Any fatty tissue in the femoral canal is excised.

If the deep fascia has been extensively removed to expose much of the femoral artery and vein in the floor of the femoral triangle, and especially following preoperative radiation, a sartorius muscle flap can be swung across to protect the femoral vessels. The muscle forms the lateral boundary of the femoral triangle running from the medial condyle of the tibia to the anterior superior iliac spine. A finger is passed underneath the belly of the upper part of the muscle and, using cutting Bovie, the muscle is divided close to the anterior superior iliac spine (figure 9). It is then swung across and sutured to the inguinal ligament just above the femoral vessels (figure 10).

Before closure, the skin flaps are checked to ensure that they are viable. If not, they need to be trimmed back to viable skin. The skin is closed with staples or interrupted vertical mattress sutures, ensuring that the skin edges are neatly apposed and everted. A suction drain is brought out laterally above the groin and secured. If a large defect is left, such as after radical resection of disease in the groin, the defect can be closed with a skin flap.

Postoperative management — Suction drainage is applied to allow time for the incision to heal and the underlying space to be obliterated. The drain can be removed once the wound has healed, even if significant volumes of lymph are still draining. The wound is kept dry but inspected for signs of necrosis or infection. The staples can be removed when the wound has healed cleanly.

Complications — The most common complications of inguinofemoral lymph node dissection are wound infection, wound breakdown, and lymphedema. In one large series, these complications occurred in two-thirds of patients [34]. The risk was highest in patients who had positive nodes, postoperative radiation therapy, or excision of the saphenous vein, and those who were over age 65.

Intraoperative complications of inguinofemoral lymph node dissection are unusual, provided that care is taken with the dissection. A small tear in the femoral vein should be repaired with 5-0 prolene while a larger tear may require a patch from the residual GSV. Damage to the femoral artery will necessitate repair with 5-0 prolene. A divided inguinal ligament can be repaired with 0 polyglactin or prolene.

It is not unusual for large volumes of lymph to collect in the drains. Infection can occur early or chronically and is usually responsive to antibiotics.

A randomized trial that compared the use of fibrin sealant followed by sutured closure with standard sutured closure found no improvement in the development of lower extremity lymphedema [35]. Persistent lymphocyst is uncommon as usually the wound becomes adherent to the underlying tissues, obliterating the cavity that allows the fluid to collect. Repeated aspiration of lymphocysts may be attempted. (See "Complications of gynecologic surgery", section on 'lymphedema and lymphocyst'.)

The prevalence of chronic groin complications correlates with the extent of lymph node dissection and whether postoperative radiation therapy was administered. Chronic swelling of the leg (lymphedema) may occur as a consequence of the dissection, particularly if performed in association with radiation therapy, and this may be associated with recurrent bouts of infection (lymphangitis). Infections can be treated with elevation and antibiotics, but the swelling may be less responsive to therapy. The patient can try compression stockings and elevation and may benefit from treatment at a lymphedema center.

The skin flaps may necrose partially or completely, particularly after radiation treatment. Dead tissue should be excised, and the wound should be allowed to granulate. Localized loss of sensation of the skin in the thigh area may also occur.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Vulvar cancer and vaginal cancer".)

SUMMARY AND RECOMMENDATIONS

Radical vulvectomy is a procedure traditionally performed for the treatment of vulvar carcinoma. Ancillary procedures performed with radical vulvectomy can include distal urethrectomy, vaginectomy, pubic symphysectomy, anovulvectomy, posterior exenteration, sigmoid colostomy, and superficial and deep inguinal lymph node dissection. (See 'Introduction' above.)

Modifications to radical surgery have focused on limiting the extent of tissue removal and reducing the need for complete inguinal node dissections to reduce morbidity. Such modifications have included less radical resection of the cancer and the use of sentinel node sampling. (See 'Radical vulvectomy' above.)

Bladder and anal sphincter function may be preserved by limiting the extent of surgery and treating patients with chemotherapy and radiation. (See 'Operative procedure' above.)

Musculocutaneous transposition flaps may be necessary to close large defects on the vulva and perineum. (See 'Operative procedure' above.)

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Topic 3280 Version 23.0

References

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