Superficial Vulvectomy
Kenneth D. Hatch
GENERAL PRINCIPLES
Superficial vulvectomy is most often performed for excision of vulvar intraepithelial neoplasia (VIN).
VIN 1 is not considered a cancer precursor and excision is not recommended.
VIN 2 and VIN 3 may be cancer precursors and excision or laser is recommended.
Superficial vulvectomy can be used for either complete excision of the VIN or for an excisional biopsy of a lesion that is suspicious for invasive cancer.
VIN 3 may be either basaloid type or differentiated type. The basaloid histology affects younger women, is highly associated with HPV, more likely to be multicentric, frequently involves the anus, and is associated with cigarette smoking. The patients with differentiated type are older and have a high incidence of lichen sclerosus, hyperkeratosis, and lichen planus.
Definition
Removal of the skin and its appendages down to the superficial fascia (Colles) or the subcutaneous fat when Colles fascia is not present.
When 80% or more of the vulva is removed it is termed a total superficial vulvectomy.
When less than 80% of the vulva is removed it is termed a partial simple vulvectomy.
The clitoris is considered part of the vulva.
Differential Diagnosis
Conditions that may be similar to VIN are condyloma acuminatum, Paget disease, basal cell cancer, vulva hyperplasia, lichen sclerosus, or monilial infection.
Anatomic Considerations
The skin is comprised of the epidermis, the dermis, and the subcutaneous fat (Fig. 1.1).
Hair follicles extend into the subcutaneous fat as deep as 5 mm.
VIN 3 may extend into the hair follicles in up to 48% of the patients (Fig. 1.2).
Excision of VIN 3 on the hair-bearing areas of the vulva will need to be full thickness.
Laser vaporization may be used for VIN 2/3 if the lesion is entirely on the mucosal surface of the labia minora or the vaginal introitus (Fig. 1.3A-C).
The clitoral glans may be treated with laser as there is only an epidermal layer.
If VIN 3 is lasered on the hair-bearing areas of the vulva, one has to laser through the epidermis and dermis. This is a third-degree burn and will take 4 weeks to heal.
Lesions greater than 1 cm in size are better treated with excision and primary closure. Healing will be faster.
Nonoperative Management
VIN may be treated with imiquimod when there is significant amount of condyloma accuminata along with the VIN. After 3 months of three-times weekly imiquimod treatment the condyloma lesions will usually regress. The remaining VIN will be easier to treat.
PREOPERATIVE PLANNING
Small lesions may be treated as an outpatient. Conscious sedation plus local anesthetic can be used on the smaller lesions. Larger lesions where the surgery will go more than 30 minutes will be best treated under general anesthesia. The patients will receive an antibiotic.
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