Radical vulvectomy has two major variations: en bloc radical vulvectomy and bilateral inguinal lymphadenectomy and the technique with separate vulvar and groin incisions. Historically, all cases of vulvar cancer were treated by the classic en bloc radical vulvectomy popularized by Stanley Way in the 1950s and 1960s. This procedure demonstrated superior outcomes compared to simple vulvectomy and as a result became the therapeutic approach for virtually all cancers of the vulva. Advances in the understanding of disease etiology, natural history, and prognostic factors precipitated changes in practice focusing more on individualization of care and paralleled the more contemporary realization that it is possible to adhere to the important principles of wide excision of the primary tumor and diagnostic/therapeutic removal of groin lymph nodes without performing radical vulvectomy with bilateral inguinal lymphadenectomy on all patients. In addition, recent advances in irradiation therapy combined with sensitizing chemotherapy have greatly reduced the requirement for radical vulvectomy as primary treatment of locally advanced vulvar cancer. Today, the procedure using separate groin incisions (or wide radical excision, described in Chapter 17) is the preferred technique for most cases of locally advanced disease not amenable to treatment with chemoradiation, since it is associated with less risk of wound breakdown and overall morbidity.

The most common indication for radical vulvectomy is invasive squamous carcinoma of the vulva Stages II-IVA: nonlateralized T2 lesions (>2 cm in maximal diameter), T3 lesions (adjacent spread to the lower urethra, vagina, or anus), and T4 lesions (spread to the upper urethra, bladder or rectal mucosa, or pubic bone) not amenable to radical wide excision or combined chemoradiation. Additional indications may include extensive Paget disease of the vulva with an underlying adenocarcinoma, advanced adenocarcinoma of the Bartholin gland with infiltration of vulvar soft tissues, locally advanced vulvar melanoma without evidence of regional or distant spread, and extensive verrucous carcinoma of the vulva (generally not treated with radiation therapy, which may aggravate the disease and lead to dedifferentiation). Extensive hidradenitis suppurativa not amenable to more conservative resection may also be managed by radical vulvectomy, although there is no requirement for formal node dissection.

Traditionally, radical vulvectomy is defined by a visibly normal tissue resection margin of at least 2 cm in all directions; the deep margins of resection are the pubic aponeurosis anteriorly, the pubic rami and superficial perineal fascia laterally, and the levator plate/ischiorectal fossa/anal sphincter posteriorly. At least one study has suggested that a 1 cm margin of uninvolved tissue prior to pathological processing may be adequate, and this is particularly applicable to the areas of the perineal body/rectovaginal septum and introitus/urethra, where a 2-cm surgical margin may be impractical due to the proximity of underlying or juxtaposed structures to be retained.

In preparation for radical vulvectomy, all patients should undergo a comprehensive history and physical examination focusing on those areas that may indicate a reduced capacity to tolerate surgery. The vagina and cervix should be thoroughly evaluated to exclude a synchronous lesion or metastatic lesion. Routine laboratory testing should include a complete blood count, serum electrolytes, age-appropriate health screening studies, and electrocardiogram for women aged 50 years and older. Preoperative computed tomography imaging of the abdomen and pelvis is advisable, particularly if the groin nodes are clinically suspicious. A chest radiograph should be obtained, or alternatively computed tomography scanning can be extended to include the chest.

Prophylactic antibiotics (Cephazolin 1, Cefotetan 1 to 2 g, or Clindamycin 800 mg) should be administered 30 minutes prior to incision, and thromboembolic prophylaxis (e.g., pneumatic compression devices and subcutaneous heparin) should be initiated prior to surgery. The instrumentation required includes a basic vaginal surgery set and Allen Universal Stirrups (Allen Medical Systems, Cleveland, OH). Enemas should be administered the evening before surgery. Preoperative mechanical bowel preparation (oral polyethylene glycol solution or sodium phosphate solution with or without bisacodyl) combined with forced constipation for a period of several days may facilitate healing by reducing the likelihood of fecal contamination of the incision in the immediate postoperative period if there is an extensive posterior component to the dissection.

Either general or regional anesthesia is acceptable. The patient should be positioned in dorsal lithotomy position using Allen-type stirrups with the buttocks protruding slightly over the edge of the operating table. The vulva, vagina, and thighs are prepped and a Foley catheter is placed. Examination under anesthesia should pay particular attention to the size and topography of the vulvar lesion, the vagina and cervix, and the groin lymph nodes.