Vaginectomy: Partial and Complete
Kenneth D. Hatch
GENERAL PRINCIPLES
Cancer of the vagina is most commonly treated with radiation therapy. Some patients with cancer of the upper vagina with thickness of the vaginal wall less than 1 cm may undergo radical vaginectomy. Microinvasion to a depth of 2.5 mm or less can be treated with partial vaginectomy and lymph node dissection. Vaginal intraepithelial neoplasia (VAIN) can be treated with either partial vaginectomy or laser.
Definition
Partial vaginectomy for VAIN should include resection of the full thickness of vaginal skin. This includes the mucosal epidermis and the lamina propria. The muscularis and adventitia are left behind to maintain the normal size and shape of the vagina as it heals.
Vaginectomy for microinvasive cancer should include the entire vaginal wall including the muscularis and the adventitia.
Radical vaginectomy for early invasive cancer would include removing the paracolpos much like a radical hysterectomy for cervical cancer.
Anatomic Considerations
The vaginal skin consists of the glycogenated mucosa, the lamina propria, muscularis, and adventitia. There are no skin appendages penetrating through the mucosa. For VAIN lesions, removal of just the mucosa with the CO2 laser is the standard treatment. If there is a question of microinvasion on pap, biopsy, or colposcopic appearance, then excision is indicated. Incision may be indicated if the lesion goes into the uterosacral recess of the vaginal cuff in posthysterectomy patients.
Nonoperative Management
Radiotherapy is the most common treatment for cancer of the vagina.
IMAGING AND OTHER DIAGNOSTICS
If a patient is being considered for radical vaginectomy, she should have PET/CT to rule out metastatic disease as this would make her ineligible for vaginectomy.
An MRI may also be considered to determine the thickness of the lesion and the condition of the tissue planes.
PREOPERATIVE PLANNING
Colposcopy is an important part of the preoperative evaluation. The lesion may extend further in the vagina than expected by gross visualization.
SURGICAL MANAGEMENT
The bulk of surgical treatment should be discussed in the following heads and the techniques section. Here, consider indications and other more general concerns.
Positioning
Lithotomy position with leg support stirrups.
PROCEDURES AND TECHNIQUES
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