The standard radical mutilating surgery for the treatment of invasive vulval carcinoma is, today, being replaced by a conservative and individualised approach. Surgical conservative modifications that are currently considered safe, regarding vulval lesion, are separate skin vulval-groin incisions, drawn according to the lesion diameter, and wide local radical excision or partial radical vulvectomy with 1–2 cm of clinically clear surgical margins. Regarding inguinofemoral lymph nodes management, surgical conservative modifications not compromising patient survival are omission of groin lymphadenectomy only when tumour stromal invasion is ≤1 mm, unilateral groin lymphadenectomy only in well-lateralised early lesions and total or radical inguinofemoral lymphadenectomy with preservation of femoral fascia when full groin resection is needed. Sentinel lymph node dissection is a promising technique but it should not be routinely employed outside referral centres. Pelvic nodes are better managed by radiation. Locally advanced vulval carcinoma can be managed by ultraradical surgery, exclusive radiotherapy or chemoradiation.
Historical aspects/Introduction
Until the end of the 1980s, the en bloc radical vulvectomy and bilateral dissection of the inguinofemoral and pelvic lymph nodes, described by Taussig and Way , represented the standard surgical approach to any primary vulval lesion, regardless of its site or size.
This technique, in extension, consists of a large butterfly incision including portions of buttock, genitocrural folds and Scarpa’s triangle skin. In depth, the surgical excision is achieved through the removal of the entire vulva with the inguinofemoral lymph nodes and lymphatics in between along with the sartorius and adductor longus muscle fascia, and the femoral fascia ( Fig. 1 ).
The rationale behind this mutilating surgery, according to the dominant Halstedian surgical philosophy, was the belief that the large resection of healthy tissue to obtain clear surgical margins is essential to improve survival; in addition, it was based on the knowledge of lymphatic drainage derived from Sappey studies during that time. This author was the first anatomist in 1874 to demonstrate that the vulval lymphatics drain mainly to the ipsilateral inguinofemoral nodes located in Scarpa’s triangle before reaching the pelvic node .
However, in this publication there are also illustrations ( Fig. 2 A,B ) showing that the perineum and vulva lymphatic channels cross the buttocks and genitocrural folds and this has probably influenced the setting of the large vulval incision, known as the Way–Taussig radical vulvectomy. In his monograph, Taussig published in 1923 (4), at page 154, an illustration of vulval lymphatics ( Fig. 2 C) that looks like Sappey illustration ( Fig. 2 B).
From a clinical point of view, this en bloc excision showed improvement in the 5-year survival rate from 20% to 60% , but it was associated with important complications like wound breakdown with secondary intention healing, disabling lymphoedema, introital scaring, infections, and fatal thromboembolism.
This large butterfly incision ( Fig. 3 -A ) has been reduced by keeping the margin within the genitocrural folds and by sparing Scarpa’s triangle skin ( Fig. 3 -B), after Parry-Jones demonstrated in 1963, by the injection of patent blue dye and colloidal iron, that vulval lymphatics do not spread into the thigh .
Between the late 1970s and the early 1980s, the new ‘conservative and individualised surgical oncologic philosophy’, questioned the standard application of a single mutilating operation for all patients and the poor attention paid to quality of life and treatment-related morbidity. The transition to this less mutilating surgery, maintaining the same oncologic radicality, reflected the increased surgical knowledge gained during that time .
However, this more conservative and individualised surgical approach to invasive vulval cancer has led to the development of various surgical procedures indicated by different terms which create confusion and contradictions.
This point has been specifically addressed firstly by Levenback et al. , observing the lack of consensus among 50 gynaecologists in defining the procedure of inguinal lymphadenectomy, which is mainly due to the lack of agreement regarding correct anatomic terminology.
Reviewing the classic, chiefly used Italian, French, German and English textbooks of anatomy, Micheletti et al. have observed some discrepancies and lack of uniformity in descriptions of the fascial structures and the lymph nodes of the vulval and inguinal region.
As a consequence herein, vulval and Scarpa’s or femoral triangle anatomy will be addressed from a surgical point of view; therefore, not all anatomical and structural elements will be broached, but only those landmarks displaying a specific surgical relevance, such as extension and depth of the vulval and groin area, will be illustrated.
Vulval surgical anatomy elements
Extension
The external borders of the vulva are represented anteriorly by the mons pubis, laterally by the genitocrural folds which divide the labia majora from the root of the thigh, and posteriorly by the perineum . The internal borders are represented by the hymenal ring.
Depth
Moving from the surface ( Fig. 4 ), the vulva is superficially covered by the skin, and the floor of the vulva is represented by the inferior fascia of the urogenital diaphragm or perineal membrane, which becomes the femoral fascia in the thigh. Between the skin and the inferior fascia of the urogenital diaphragm is the fatty tissue, which is divided into a superficial and deep portion by the superficial fascia or Colles’ fascia.
This stratified anatomical knowledge is surgically relevant, as it permits to identify three progressive depths or planes, which serve to identify the three major types of vulval excision:
Superficial or Skinning Excision (total or partial) : removal of only the skin/mucous membrane, living in situ the underlying fatty tissue and fascial structures (excision indicated for squamous intraepithelial neoplasia).
Simple Excision (total or partial) : removal of the skin/mucous membrane along with the superficial portion of the fatty tissue lying on the superficial fascia (excision indicated for Paget disease and superficially invasive neoplasia).
Deep or Radical Excision (total or partial) : removal of the vulval tissue in all its thickness from the surface to the urogenital diaphragm or perineal membrane (excision indicated for frankly invasive neoplasia).
Vulval surgical anatomy elements
Extension
The external borders of the vulva are represented anteriorly by the mons pubis, laterally by the genitocrural folds which divide the labia majora from the root of the thigh, and posteriorly by the perineum . The internal borders are represented by the hymenal ring.
Depth
Moving from the surface ( Fig. 4 ), the vulva is superficially covered by the skin, and the floor of the vulva is represented by the inferior fascia of the urogenital diaphragm or perineal membrane, which becomes the femoral fascia in the thigh. Between the skin and the inferior fascia of the urogenital diaphragm is the fatty tissue, which is divided into a superficial and deep portion by the superficial fascia or Colles’ fascia.
This stratified anatomical knowledge is surgically relevant, as it permits to identify three progressive depths or planes, which serve to identify the three major types of vulval excision:
Superficial or Skinning Excision (total or partial) : removal of only the skin/mucous membrane, living in situ the underlying fatty tissue and fascial structures (excision indicated for squamous intraepithelial neoplasia).
Simple Excision (total or partial) : removal of the skin/mucous membrane along with the superficial portion of the fatty tissue lying on the superficial fascia (excision indicated for Paget disease and superficially invasive neoplasia).
Deep or Radical Excision (total or partial) : removal of the vulval tissue in all its thickness from the surface to the urogenital diaphragm or perineal membrane (excision indicated for frankly invasive neoplasia).
Groin surgical anatomy elements
Most controversies are encountered concerning groin surgery , and this is probably due to the fact that the macroscopic anatomic knowledge is nearly always taken for granted, copied from article to article and from book to book without being questioned, and rarely interpreted from a surgical point of view . These controversies have been addressed by Micheletti and co-workers through original anatomic and embryological studies , whose findings integrated with classic anatomical knowledge are herein presented.
Extension
The term groin encompasses Scarpa’s triangle also named femoral triangle. The base of this triangle is the inguinal ligament, which extends from the anterior superior iliac spine (ASIS) to the pubic tubercle. The lateral side is the medial margin of the sartorius muscle, the medial side is the lateral margin of the adductor longus muscle and its apex is the junction point of the sartorius and adductor longus muscles ( Fig. 5 ).
Depth
Moving from the surface, the groin is superficially covered by the skin . The fatty tissue is divided by the superficial or Camper’s fascia into a superficial (subcutaneous) portion, which includes vessels but no lymph nodes, and into a deep portion ( Fig. 5 ). The superficial fascia in thin women may not always be surgically evident, but efforts may be made to find it in order to be preserved. The rationale for preserving the superficial fascia and the above subcutaneous tissue is to avoid skin necrosis.
Between the superficial fascia and the femoral fascia are included: fatty tissue, vessels (superficial circumflex iliac vessels, superficial epigastric vessels, external pudendal vessels and the saphenous veins) and the superficial inguinofemoral lymph nodes ( Fig. 6 )
The fossa ovalis or saphenous opening is an aperture in the femoral fascia allowing the passage of the great saphenous vein and other small vessels. In the context of the fossa ovalis, the femoral artery and vein are respectively situated laterally and medially. The superior, lateral and inferior boundaries of the fossa ovalis are delineated by the falciform ligament. The fossa ovalis is covered by the lamina cribrosa ( Fig. 6 ), which should not be considered part of the femoral fascia but an independent structure resulting from the thickening of the connective tissue covering the fossa ovalis. The surgical relevance of the fossa ovalis is related to the fact that the deep femoral lymph nodes are always situated within the fossa ovalis.
From a surgical point of view, it is important to know exactly the distribution of the inguinofemoral lymph nodes related to the fascial structures, because, as remarked by Levenback and co-workers , there still exist some discrepancies. The femoral fascia and the lamina cribrosa divide the inguinofemoral lymph nodes into two compartments, superficial and deep .
The superficial inguinofemoral lymph nodes ( Fig. 6 ) are divided into:
- a)
The superficial inguinal lymph nodes, or superficial inguinal upper group lymph nodes, are situated along the line of the inguinal ligament, superficially to the femoral fascia. The most lateral of these lymph nodes is situated medially or not far laterally to the superficial circumflex iliac vessels . This anatomotopographic knowledge is important as it modifies the classic surgical limit of the lateral extension, represented by the ASIS, of the inguinal lymphadenectomy. Therefore, the superficial circumflex iliac vessels represent the best and easily detectable landmark at which the lateral surgical dissection along the inguinal ligament should stop. Leaving the tissue in situ between these vessels and the ASIS, devoid of lymph nodes but probably inhabited by some lymphatic channels, could decrease the incidence of wound seroma and lymphoedema.
- b)
The superficial femoral lymph nodes, also named superficial inguinal lower group or superficial subinguinal lymph nodes, lie vertically along the terminal part of the great saphenous vein before it enters the femoral vein, at the fossa ovalis, superficially to the femoral fascia.
The deep inguinofemoral lymph nodes, ranging from one to three in number, are always situated within the fossa ovalis, medial to the femoral vein ( Fig. 5 ). No lymph nodes are located beneath the femoral fascia distal to the lower margin of the fossa ovalis and lateral to the femoral artery.
Regarding the lymph node of Cloquet or Rosenmuller, it must be known that its presence has no particular surgical relevance and that today is considered an inconstant lymph node, being absent in approximately 50% of the cases and, when present, unilateral in approximately 30%.
Management of the vulval lesion
Today, the paradigm of en bloc vulval and groin dissection in favour of separate incisions for the vulva and the groin ( Fig. 7 ) can be considered a standard approach. In addition, the radical removal of the tumour can be achieved through a more tissue-sparing vulval surgery .
Separate vulval-groin incision
The pioneers of radical vulvectomy and inguinofemoral lymphadenectomy through three separate incisions were Stoeckel in 1930 , Taussig in 1940 and Byron et al., in 1962 . But it was Hacker et al. at the beginning of the 1980s who demonstrated that excellent surgical local control can be obtained through the triple-incision approach. Later, several other groups confirmed the validity of this more conservative approach .
The rationale behind the triple-incision approach is the histological re-evaluation of the en-bloc specimens which have revealed no in-transit metastases in the skin bridge between the vulva and the groin, suggesting that the lymphatic spread pattern occurs as emboli directly to the lymph nodes rather than through a continuous pattern. The only possible risk of relapse in the skin bridges, with a rate of recurrence from 1% to 6% , is the presence of macroscopic inguinofemoral lymph node; nevertheless, the triple incision is still recommended .
Conservative vulval surgery
Any unifocal well-localised vulval lesion can be safely removed through a local radical excision instead than a total vulvectomy. To describe this more conservative surgery, various names have been used, including modified vulvectomy, conservative vulvectomy, radical hemivulvectomy, partial vulvectomy, wide local excision, radical wide excision or radical local excision. This heterogeneous terminology shows a clear lack of consensus in defining conservative vulval surgery, mainly due to differences between different languages; in some cases, this is due to disagreement between topographic and surgical anatomical terminology .
To be oncologically radical, the surgical incision, in extension, should remove 1–2 cm of clinically clear surgical margins which means >8 mm of histological tumour-free margins , in depth should reach the perineal membrane or urogenital diaphragm. This anatomical structure is named inferior fascia of the urogenital diaphragm by some authors or deep fascia by others ; in any case, whatever name is employed, it must be known that this fascial structure is coplanar with the fascia lata and the fascia over the pubic symphysis.
This more conservative approach has been proven to provide equivalent results to en bloc excision in term of local control ; in addition, it often allows an easier closure without margin tension, a reduced risk of wound breakdown, a better preservation of vulval function and a reduced long-term psychosexual impact.
Both total and conservative vulval surgery, depending on location and size of the lesion, can be associated with distal urethrectomy, usually without loss of continence, or to anorectal resection.
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