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Vulvar wide local excision and simple vulvectomy

Vulvar wide local excision and simple vulvectomy
Author:
John W Moroney, MD
Section Editor:
Barbara Goff, MD
Deputy Editor:
Alana Chakrabarti, MD
Literature review current through: May 2024.
This topic last updated: Dec 14, 2023.

INTRODUCTION — Vulvar lesions are a common gynecologic problem. Lesions that are symptomatic and/or suspicious for malignancy are usually biopsied first to establish a tissue diagnosis and enable formulation of a treatment plan. Treatment options include pharmacologic therapies, ablative techniques, and surgical excision. The treatment strategy should balance the need for complete removal with preservation of vulvar function and cosmesis.

Vulvar excisional procedures can be categorized as either simple (ie, wide local excision, simple vulvectomy) or radical based on the longitudinal depth of the extirpation. Simple vulvar excision typically involves removal of the epidermis, dermis, 2 to 3 mm of underlying adipose tissue, and at least a 1 cm margin. By contrast, radical excision entails removal of simple structures as well as subcutaneous adipose tissue extending to, and often including deep vulvar anatomical structures.

Skinning vulvectomy, a technique used for removal of extensive vulvar lesions that results in skin edges that do not reapproximate and requires harvesting and placement with a split-thickness skin graft for closure, is rarely performed. It is beyond the scope of practice of most gynecologic surgeons and is thus not covered in this topic review.

The treatment of benign or premalignant vulvar lesions treated with wide local excision or simple vulvectomy is discussed here, with a focus on excisions performed in the operating room. Preoperative preparation, surgical planning, and operative technique may differ when performed for small lesions in the office setting. Other related issues are discussed separately:

(See "Vulvar lesions: Diagnostic evaluation".)

(See "Vulvar squamous intraepithelial lesions (vulvar intraepithelial neoplasia)".)

(See "Squamous cell carcinoma of the vulva: Staging and surgical treatment".)

(See "Radical vulvectomy".)

SURGICAL ANATOMY — Relevant anatomy includes the following vulvar and associated structures [1]:

Labia majus

Labia minus

Clitoris and clitoral prepuce

Urethral meatus

Vaginal orifice (introitus)

Paraurethral (Skene) and greater vestibular (Bartholin) gland openings

Mons pubis

Perineum

The excisional procedures of the vulva described here are limited to the superficial tissue layers and 2 to 3 mm of underlying adipose tissue (figure 1). Deep vulvar anatomy is shown in the figure (figure 2).

PATIENT SELECTION

One or two focal lesions: Wide local excision — Wide local excision is generally performed for patients with one or two focal benign or premalignant lesions for which a 1 cm radial margin is adequate; possible indications may include:

Vulvar squamous intraepithelial lesions. (See "Vulvar squamous intraepithelial lesions (vulvar intraepithelial neoplasia)", section on 'Excision'.)

Occasionally, a wide local excision is performed to obtain a tissue diagnosis of a lesion suspicious for invasion (ie, a large lesion that appears malignant but biopsies show only vulvar intraepithelial neoplasia [VIN]). More radical surgery may subsequently be needed if invasive disease is diagnosed, which occurs in approximately 5 to 18 percent of cases [2]. (See "Vulvar squamous intraepithelial lesions (vulvar intraepithelial neoplasia)", section on 'Treatment'.)

Paget disease of the vulva. (See "Vulvar cancer: Epidemiology, diagnosis, histopathology, and treatment", section on 'Paget disease of the vulva'.)

Concerning pigmented lesions and anatomically limited, in situ melanotic lesions; as with all patients undergoing wide local excision, a punch biopsy should be performed first. (See "Locoregional mucosal melanoma: Epidemiology, clinical diagnosis, and treatment", section on 'Vulvovaginal melanoma'.)

Anatomically limited vulvar dermatologic conditions. (See "Vulvar lesions: Differential diagnosis of vesicles, bullae, erosions, and ulcers".)

Small lateralized vulvar carcinomas (with resection taken down to the deep fascia). This form of wide local excision is sometimes termed "radical local excision." (See "Vulvar cancer: Epidemiology, diagnosis, histopathology, and treatment", section on 'Treatment'.)

Wide local excision is rarely contraindicated for medical reasons. These procedures are minimally invasive and are well tolerated even by patients with medical comorbidities.

Extensive or multifocal lesions: Simple vulvectomy — Simple vulvectomy (partial or complete) is performed for patients with extensive or multifocal benign (eg, extensive condyloma) or preinvasive diagnoses of the vulva that are not amenable to removal with wide local excision. (See 'One or two focal lesions: Wide local excision' above.)

Simple vulvectomy is more extensive than wide local excision and is termed "partial" or "complete" based on the percentage of vulvar tissue excised:

Partial: <80 percent of tissue excised

Complete: ≥80 percent of tissue excised

Superficial vulvar and perineal anatomic structures (eg, clitoris) are removed only if mandated by the extent of disease and if ablation is not possible. In most cases of simple vulvectomy, a partial rather than complete procedure can be performed with a goal of minimizing morbidity and preserving vulvar comfort, cosmesis, and sexual function.

As with wide local excision, simple vulvectomy is rarely contraindicated for medical reasons and is often reserved for older patients in whom preservation of vulvar appearance and sexual function is not a priority.

PREOPERATIVE EVALUATION AND PREPARATION

Informed consent — Before undergoing a wide local excision or simple vulvectomy, patients with nonneoplastic and/or vulvar intraepithelial neoplasia should be counseled about alternative treatment options (eg, pharmacologic, laser ablation, cavitational ultrasonic aspiration [CUSA]). The least invasive treatment that will maximize detection of invasive disease and minimize recurrence risk should be favored. (See "Vulvar squamous intraepithelial lesions (vulvar intraepithelial neoplasia)", section on 'Treatment'.)

Treatment planning and patient counseling should include a discussion regarding potential effects on sexual function and body image. In younger patients with extensive lesions, alternative therapies may provide a better cosmetic result [2-5]. (See 'Complications' below.)

Patients should also be informed of the potential need for further surgery (such as for malignancy, positive margins, or recurrent disease).

Evaluation — A routine preoperative medical history is taken, including gynecologic history, medical comorbidities, medications, and allergies.

Physical examination and a complete pelvic examination are performed, with attention to the vulva, vaginal orifice, perineum, anus, and inguinofemoral lymph nodes. A biopsy is performed, if not already done. Punch biopsies are generally preferred because they include the epidermis, dermis, basement membrane, and underlying adipose tissue allowing for determination of invasion more readily than other biopsy methods (eg, shave biopsy). This is described in detail separately. (See "Vulvar lesions: Diagnostic evaluation", section on 'Use of biopsy'.)

Older patients or those with medical comorbidities may require preoperative medical consultation. (See "Overview of the principles of medical consultation and perioperative medicine".)

Imaging studies and laboratory evaluation (except for a pregnancy test, if appropriate) are generally not required.

Prophylactic antibiotics — In our practice, we administered cefazolin to most patients. However, there is substantial variation in clinical practice, and some experts may reasonably choose to not administer prophylactic antibiotics. While there is a potential for wound infection due to breach of the epithelium in the presence of typical skin and vaginal flora, and the American College of Obstetricians and Gynecologists (ACOG) recommends the use of prophylactic antibiotics for vaginal colporrhaphy and sling procedures (for which the risks are probably similar) [6], there is a paucity of data detailing the incidence of infection following simple vulvar excisional procedures.

Use of preoperative antibiotics prior to gynecologic surgery is discussed in detail separately. (See "Gynecologic surgery: Overview of preoperative evaluation and preparation", section on 'Antibiotic prophylaxis'.)

Thromboprophylaxis — For most patients undergoing vulvar wide local excision or simple vulvectomy in the operating room, mechanical thromboprophylaxis (with either graduated compression stockings or serial compression devices) is adequate; early ambulation is also advised. This is in accordance with both American College of Chest Physicians (CHEST) and ACOG guidelines [7,8]. By contrast, patients undergoing smaller excisions in the office may not require any thromboprophylaxis.

Patients at high risk for thromboembolism require additional thromboprophylaxis; this is discussed in detail separately. (See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients", section on 'Selecting thromboprophylaxis'.)

Other preoperative measures — Some surgeons treat postmenopausal patients who have atrophic vulvar and vaginal tissue with topical estrogen for two to six weeks prior to surgery. However, the author does not do this in his practice. (See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Treatment", section on 'Vaginal estrogen therapy'.)

Bowel preparation is not indicated for patients undergoing wide local excision or vulvectomy (simple or complex). (See "Gynecologic surgery: Overview of preoperative evaluation and preparation", section on 'Bowel preparation'.)

SURGICAL PLANNING

Setting and positioning — Simple vulvar excisions are typically performed in an operating room but can be performed in clinic settings if adequate analgesia and strict sterile technique can be ensured. The procedure is typically performed by an experienced gynecologic surgeon; referral to a gynecologic oncologist may be needed if excision of the lesion risks significant negative functional or anatomic sequelae (ie, because of its proximity to the urethra, anus, or clitoris).

The patient is positioned in high dorsal lithotomy (ie, hips flexed to 90 degrees) and sterilely prepared and draped.

Anesthesia — Local, regional, or general anesthesia may be used based on patient-specific comorbidities, the anticipated extent of the excision, and preferences of the patient and surgeon.

Surgical margins — Vulvar wide local excision and simple vulvectomy procedures remove the epidermis, dermis, and 2 to 3 mm of underlying adipose tissue; the radial margin is typically at least 1 cm. The exact extent of a resection margin (radial and depth), however, depends on multiple factors including histologic diagnosis, estimation of the likelihood of invasive cancer, size of the lesion, and location relative to other structures (eg, urethra, anus, clitoris) [9]. The primary goal is to obtain negative margins.

In selected patients with a benign or preinvasive lesion, a margin of <1 cm may be planned to avoid damage to a vital structure or significant distortion of the vulva. If the margin taken is small and there is concern that the entire lesion will not have been excised, concomitant laser ablation of the surrounding skin may be performed. (See "Vulvar squamous intraepithelial lesions (vulvar intraepithelial neoplasia)", section on 'Ablative therapy'.)

Margins in patients with vulvar carcinoma are discussed separately. (See "Vulvar cancer: Epidemiology, diagnosis, histopathology, and treatment", section on 'Treatment'.)

OPERATIVE TECHNIQUE

Procedure — A complete simple vulvectomy procedure is described here. Modifications to this technique are made for a wide local excision and partial simple vulvectomy when less tissue is excised.

An indwelling bladder catheter is placed. The incision can be marked with a skin-marker to plan the extent and axis of the excision. The shape of the excision should be elliptical, running in long axis parallel to neighboring structures to be preserved. Thus, for lesions on the labia majus, the ellipse would run anterior-posterior. By contrast, lesions close to the vaginal orifice are often better excised with the ellipse running oblique to the anterior-posterior axis of the introitus. The incision should leave as much skin of the vaginal orifice epithelium surrounding the urethra as possible (1 cm or more); this facilitates closure and avoids distortion of the urethral meatus. Estimation of histologic margins should also account for anticipated tissue retraction during fixation. The clitoris is spared, if possible (figure 3).

There is variation among surgeons regarding whether to start the incision posteriorly or anteriorly. In our practice, we start posteriorly so that venous oozing from the incision does not affect visualization in the direction of travel. The excised portion of the incision is grasped with a toothed forcep or Allis clamp and consistent tension is applied, allowing the operator to elevate and stretch the skin (figure 4). The epidermis, dermis, and underlying adipose tissue are dissected from the underlying perineal tissues using scissors, scalpel, or electrocautery. Caudal mobilization of the distal vaginal mucosa just beyond the resection margin can help facilitate a tension-free closure. Care must be taken to avoid damaging the rectum during dissection; a finger placed in the rectum when dissecting close to the anus or distal posterior vagina can help decrease this risk.

The incision is then extended anteriorly and laterally on both sides. The lateral skin edges of the specimen are grasped with forceps or Allis clamps and sharp dissection is performed (using curved scissors, a scalpel, or electrosurgery), staying within the subcutaneous fat and aiming for the resection margin in the vagina. It is not necessary to resect deeply.

The specimen is then detached from the distal vagina laterally and posteriorly. Scissors or a knife are used to cut radially through the specimen to the vaginal margin, and the specimen is separated on both sides to an anterior point level with, but lateral to, the urethral meatus (figure 5).

If excision of the clitoris is planned, the dissection is started anterolaterally and extended posteriorly and medially toward the clitoral attachments. The suspensory ligament is divided and ligated. The skin across the anterior vaginal orifice above and lateral to the urethral meatus is incised using scalpel or scissors, joining with the internal incision around the distal vagina. The anterolateral and posterolateral pillars of the clitoris are isolated, and a Kelly forcep is used to clamp and divide the crura of the clitoris followed by suture ligation with 0 polyglactin suture. The specimen is then completely detached, and hemostasis is obtained with 3-0 polyglactin figure-of-eight sutures and cautery.

To assist the pathologist with postoperative assessment and processing, it is helpful to place an orientation suture in an area of normal tissue at the periphery of the specimen (usually at the 12 o'clock position) and to draw a diagram on the printed pathology form that is delivered to pathology with the specimen marking the sites of disease.

Closure — An assessment is made of how best to reapproximate the tissue edges. The patient's legs may be lowered partially to reduce tension on the repair. If it appears the edges may be under too much tension when brought together, the lateral and posterior vagina and skin edges may be further undermined. When undermining vulvar skin, care must be taken to leave sufficient subcutaneous adipose tissue attached to the underside of skin to prevent devascularization. It is best to start by freeing up the lateral and posterior vaginal edges. Local skin flaps may be required. Small open areas may be allowed to granulate. Care should be taken to close the defect in a manner that does not restrict access to the distal vagina, with a goal of leaving space for insertion of two fingers at the vaginal orifice.

For larger or more irregular defects, closure is started by inserting dermal stay sutures around critical structures such as the urethral meatus and anal verge. In deep wounds, subcutaneous tissue is reapproximated to bring skin edges closer together and decrease tension. The intervening defects are then closed; we typically use interrupted 3-0 polyglactin horizontal mattress sutures for approximation of keratinized skin to nonkeratinized mucosa and simple interrupted sutures for keratinized skin-to-skin approximation. Prior to each stitch being placed around the introitus, it should be assured that the closure is being performed evenly and that a difficult to close area will not be left until the end, when it may be too late to correct without requiring removal and revision of sutures.

For larger excisions, a suction drain (eg, small fluted drain) may be brought out on one or both sides of the perineum and secured with permanent suture to the skin. It is important to make sure that the skin closure is airtight so that the negative pressure of the bulb will be effective. A drain is rarely needed for wide local excisions.

POSTOPERATIVE CARE — Most patients undergoing wide local excision or simple vulvectomy are discharged home the day of surgery. Inpatient stays are reserved for patients with more extensive dissections, significant medical comorbidities, poor mobility, or wounds that require extensive skilled nursing support. In all cases, early clinic follow-up is planned to enable intensified wound care support if the wound edges begin to separate, or infection is observed.

Essential elements of postoperative care consist of keeping the wound clean and dry, and avoiding persistent pressure on the wound, most commonly a result of sitting upright for long periods of time.

Ambulation – In our practice, we encourage the patient to be out of bed and to ambulate as soon as possible. When in bed or in a chair, patients are encouraged to avoid sitting upright and are asked to rotate left and right away from the midline every few hours. Use of a donut-shaped foam or pillow that distributes weight away from the incision is recommended.

Bladder catheter – In cases with extensive periurethral excision, the bladder catheter may be left in place for three to five days until the wound edges are healing with no sign of breakdown. A longer period of catheterization may be necessary in patients who are chronically incontinent to allow the wound to heal in a relatively dry environment.

Perineal hygiene – Perineal hygiene with sitz baths and gentle cleansing with a saline rinse are encouraged, followed by carefully drying the area with a dryer on the cool setting. Exposure to the air is helpful, so underwear is discouraged, and the patient reclines with knees apart whenever possible. Topical lidocaine can be provided for as needed use after cleansing.

COMPLICATIONS — There are few published data regarding the incidence of complications following simple vulvar excisions for benign or premalignant disease. In one retrospective study including 227 patients undergoing vulvar surgery for noncancerous lesions in whom prophylactic antibiotics were administered, wound complications at up to eight weeks postoperatively included [10]:

Any wound complication (30 percent).

Wound separation (28 percent) – Separation of the wound edges (both small and extensive) can generally be left to heal by secondary intention.

Wound infection (7.5 percent) – Superficial skin infection, if noted early, can be treated with broad spectrum antibiotics and continued perineal hygiene. Antibiotic regimens for vulvar infection are discussed in detail separately. (See "Vulvar abscess", section on 'Antimicrobial agents'.)

Hematoma formation (0.5 percent).

Seroma (0.5 percent).

Longer-term complications may include [11,12]:

Stricture of the introitus and/or symptomatic scar formation.

Sexual dysfunction – In one retrospective study including 41 patients who underwent vulvectomy, more patients after compared with before surgery experienced sexual dysfunction; however, there was no correlation between sexual dysfunction and extent of surgery or type (eg, type of vulvectomy, volume of tissue excised) [13].

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

General principles – Simple excisional procedures (wide local excision, simple vulvectomy) are most often performed for treatment of benign or premalignant conditions of the vulva, including vulvar intraepithelial neoplasia (VIN), Paget disease, or symptomatic dermatologic conditions. They are distinguished from radical vulvectomy primarily by the depth of the extirpation. (See 'Introduction' above.)

Patient selection

Patients with one or two focal lesions – Wide local excision is generally performed when one or two focal benign or premalignant lesions are present for which a 1 cm radial margin is adequate. (See 'One or two focal lesions: Wide local excision' above.)

Simple vulvectomy – Simple vulvectomy (partial or complete) is performed for patients with extensive or multifocal benign (eg, extensive condyloma) or preinvasive diagnoses of the vulva that are not amenable to removal with wide local excision. Simple vulvectomy is more extensive than wide local excision and is termed "partial" or "complete" based on the percentage of vulvar tissue excised (partial: <80 percent; complete: ≥80 percent). (See 'Extensive or multifocal lesions: Simple vulvectomy' above.)

Preoperative planning

Informed consent Before undergoing a wide local excision or simple vulvectomy, patients are counseled about alternative treatment options (eg, pharmacologic, ablative, cavitational ultrasonic aspiration [CUSA]). The least invasive treatment that will maximize detection of invasive disease and minimize recurrence risk should be favored. (See 'Informed consent' above.)

Prophylactic antibiotics – For most patients undergoing vulvar wide local excision or simple vulvectomy, we suggest use of prophylactic antibiotics (Grade 2C). However, there is substantial variation in clinical practice, and some experts may reasonably choose to not administer prophylactic antibiotics. While there is potential for wound infection due to breach of the epithelium in the presence of typical skin and vaginal flora, and prophylactic antibiotics are used for similar risk vaginal procedures, there is a paucity of data detailing the incidence of infection following simple vulvar excisional procedures. (See 'Prophylactic antibiotics' above.)

Thromboprophylaxis – Graduated compression stockings or serial compression devices are adequate for most patients undergoing wide local excision or simple vulvectomy in the operating room; early ambulation is encouraged. Patients at high risk for thromboembolism require additional thromboprophylaxis. Thromboprophylaxis is discussed in detail separately. (See 'Thromboprophylaxis' above and "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients", section on 'Selecting thromboprophylaxis'.)

Surgical margins – Vulvar wide local excision and simple vulvectomy procedures typically remove the epidermis, dermis, 2 to 3 mm of underlying adipose tissue, and at least a 1 cm radial margin. The exact extent of a resection margin (radial and depth), however, depends on multiple factors including histologic diagnosis, estimation of the likelihood of invasive cancer, size of the lesion, and location relative to other structures (eg, urethra, anus, clitoris). The main goal is to have negative margins. (See 'Surgical margins' above.)

Postoperative care – Essential elements of postoperative care consist of keeping the wound clean and dry, and avoiding persistent pressure on the wound, most commonly a result of sitting upright for long periods of time. (See 'Postoperative care' above.)

Complications – Complications include wound separation, infection, hematoma, seroma formation, chronic pain, and sexual dysfunction. (See 'Complications' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges C William Helm, MD, MBBChir, FRCS, MRCOG, who contributed to earlier versions of this topic review.

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