Radical vulvectomy has 2 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 Taussig and Way in the 1940s and 1960s.1,2,3 This procedure demonstrated superior outcomes compared with 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.4,5,6 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.7 Today, radical vulvectomy using separate groin incisions or radical wide excision is the preferred technique for most cases of locally advanced disease not amenable to treatment with chemoradiation, because this approach is associated with less risk of wound breakdown and overall morbidity.
INDICATIONS AND CLINICAL APPLICATIONS
The surgical management of vulvar cancer has evolved over the past 3 decades. Contemporary surgical treatment principles include tailoring the radicality of resection of the primary lesion (eg, wide radical excision), more conservative techniques for assessing regional lymph nodes (eg, unilateral lymphadenectomy, sentinel node biopsy), and the liberal use of reconstructive surgical techniques to restore anatomy and function. The main indication for radical vulvectomy is invasive squamous carcinoma of the vulva stages II to IVA: non-lateralized 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’s disease of the vulva with an underlying adenocarcinoma, advanced adenocarcinoma of the Bartholin’s 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 hydradenitis suppurativa not amenable to more conservative resection may also be managed by radical vulvectomy, although there is no requirement for formal node dissection.
The wide radical excision of the vulva procedure arose from the move toward individualized treatment for patients with vulvar cancer. In properly selected patients, radical wide excision has been associated with similar recurrence and survival outcomes as radical vulvectomy while offering a substantial reduction in morbidity and improved quality of life and self-image. Radical wide excision as an alternative to radical vulvectomy is generally indicated for malignant tumors up to 2 cm in diameter without clinically apparent nodal involvement. For lateralized lesions (> 2 cm from the midline), radical wide excision is combined with unilateral inguinofemoral lymphadenectomy or sentinel lymph node biopsy. The procedure of choice for midline lesions, lesions of the anterior vulva or mons pubis, and cases with microscopically positive ipsilateral groin nodes is bilateral inguinofemoral lymphadenectomy.
Inguinal lymphadenectomy is primarily indicated for the diagnostic assessment, treatment (resection of gross adenopathy), or both of squamous carcinoma of the vulva. Recent data indicate that sentinel lymph node biopsy may be a safe and accurate alternative to inguinal lymphadenectomy for patients with stage I and II squamous tumors. Inguinal lymphadenectomy is also indicated for patients with invasive adenocarcinoma of the vulva and vulvar melanoma as well as patients with invasive cancer of the lower one-third of the vagina. Rarely, inguinal lymphadenectomy is performed for the purpose of resecting gross lymph node metastases and surrounding subclinical nodal disease as part of the therapeutic approach in selected patients with advanced ovarian or endometrial cancers.
Both radical wide excision and radical vulvectomy, with or without groin node dissection, may be incorporated as a part of a larger procedure for an extensive locally recurrent gynecologic cancer involving multiple pelvic viscera and structures (eg, extended pelvic exenteration with vulvar resection).
The topographic, vascular, and lymphatic anatomy of the vulva is described in Chapter 2. 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 ani muscles/ischiorectal fossa/anal sphincter posteriorly. From an anatomic perspective, primary closure of the en bloc radical vulvectomy defect requires extensive undermining of the surrounding tissues of the lower anterior abdominal wall and medial thigh or coverage with 1 or more of the vulvovaginal reconstructive techniques described in Chapters 16, 17, and 18. At least one study has suggested that a 1-cm margin of uninvolved tissue prior to pathologic 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.8 For wide radical excision procedures, the scope of the operation is tailored to the location of the lesion with the anatomically relevant deep margins of resection outlined above.
Box 5-1 KEY SURGICAL INSTRUMENTATION
Basic vaginal surgery tray
Allen Universal Stirrups (Allen Medical Systems, Cleveland, OH)
Electrosurgical unit (Bovie)
Weitlaner and skin hook retractors
In preparation for radical vulvar surgery, all patients should undergo a comprehensive history and physical examination, focusing on areas that may indicate a reduced capacity to tolerate major 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 electrocardiography for women 50 years of age or older. Preoperative computed tomography (CT) or combined positron emission tomography/CT imaging of the abdomen and pelvis is advisable, particularly if the groin nodes are clinically suspicious. Chest radiography should be obtained, or, alternatively, CT scanning can be extended to include the chest.
Enemas should be administered the evening before surgery. Prophylactic antibiotics (cephazolin 1 g, cefotetan 1–2 g, or clindamycin 800 mg) are administered prior to incision, and thromboembolic prophylaxis (eg, pneumatic compression devices and/or subcutaneous heparin) should be initiated prior to surgery.
Box 5-2 MASTER SURGEON’S PRINCIPLES
A minimum of 1 to 2 cm of visibly disease-free surgical margins should be sought in all dimensions
Achieving a satisfactory deep surgical margin can be challenging with posterior vulvar lesions involving the perineal body and/or posterior vaginal wall because of the proximity to the rectum/anus
Preservation of the greater saphenous vein during inguinofemoral lymphadenectomy reduces the risk of lower extremity lymphedema
Either general or regional anesthesia is acceptable. The patient should be positioned in the 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 transurethral catheter placed.
Traditional en bloc radical vulvectomy includes removal of the vulva, mons pubis, and a contiguous “horn” of skin and underlying fatty tissue extending from the vulva over each groin (Figure 5-1). The procedure is initiated by starting anteriorly, with the patient’s thighs flexed at a 15° angle in the Allen stirrups; the legs are repositioned into hyperflexion later to facilitate the posterior dissection. The cephalad skin incision is curvilinear and connects a point 2 cm medial and 2 cm inferior to each anterior superior iliac spine and extends along the superior border of the mons pubis. Bilateral vulvar incisions are created by extending downward along the groin crease into the labiocrural folds on each side. Using the knife blade, the skin of anterior portion of the specimen is incised down to the mid-point of the vulva. The electrosurgical unit (ESU) is utilized for deeper dissection. Lateral incisions are carried into the posterior vulva and directed medially and anteriorly to the anus, tailored to the extent of disease.
The anterior curvilinear incision is extended into the deep tissues between the lower abdominal wall and upper border of the mons pubis, through Camper’s fascia and Scarpa’s fascia, exposing the lower border of the anterior rectus sheath fascia and inguinal ligaments. An advancement flap of anterior abdominal wall skin and subcutaneous fat is then raised superiorly from the anterior rectus sheath to facilitate incision closure. This flap can be extended as far as the umbilicus if necessary. Working inferiorly, the subcutaneous tissue is dissected off of the underlying symphysis pubis, and the lateral incisions of each groin are carried into the subcutaneous tissue and extended down to the labiocrural folds, exposing the femoral triangle on each side (Figure 5-2). The superficial epigastric and external pudendal vessels are ligated with 2-0 or 3-0 delayed absorbable suture and divided as they are encountered. At this point, the bilateral inguinofemoral lymphadenectomy is performed (see below).
Following completion of the inguinofemoral lymphadenectomy, the anterior portion of the specimen is undermined along the fascia of the anterior abdominal wall and medial thigh. Closed suction drains are placed in each groin and brought out through separate incisions in the lateral abdominal wall. The groin incisions are closed in layers using interrupted simple stitches of 3-0 delayed absorbable suture. The skin can be closed with staples or a series of vertical mattress sutures of 2-0 or 3-0 delayed absorbable sutures. The legs are repositioned into hyperflexion (45° or more) to provide exposure for the lower vulvar dissection. The labiocrural fold incisions are extended lateral to the labial fat pads, past the perineal body, and then directed medially around the anus to meet in the midline. The specimen is drawn sharply downward and separated from the symphysis pubis until the lower border of the pubic arch is reached. The dissection is taken down to the pubic aponeurosis and the suspensory ligament of the clitoris, the clitoral shaft, and clitoral vessels clamped, divided, and the pedicle(s) secured with 1-0 delayed absorbable suture ligatures.
The lateral incisions are developed down to the pubic arches and, working medially, the specimen is dissected from the inferior urogenital diaphragm. The inferior pudendal vessels are ligated with 2-0 or 3-0 delayed absorbable suture and divided. The inner vulvar incision is created by circumscribing the urethra and vaginal introitus. The dissection is carried inferiorly along the inferior fascia of the urogenital diaphragm and around the urethra, which is identified by palpating the Foley catheter. The specimen is reflected inferiorly and dissected off of the perineal body (Figure 5-3). The posterior dissection is completed by working from lateral to medial, carefully dissecting the deep vulvar tissue from the external anal sphincter and meeting in the midline at the posterior fourchette.