Vulvar and Vaginal Excisional Procedures
SIMPLE AND SKINNING VULVECTOMY
Simple vulvectomy involves the excision of vulvar skin with subcutaneous tissue, without dissection to the deep fascia of the vulva and perineum.1 This procedure is indicated for extensive in situ or microinvasion carcinoma of the vulva (< 1 mm of invasion), vulvar dystrophy, and Paget disease, where the lesions are not amenable to local excision or other forms of conservative therapy. For noninvasive lesions (except Paget disease), it may be acceptable to just remove the skin (a skinning vulvectomy) without removal of any underlying subcutaneous fat.2 A total vulvectomy includes excision of the entire vulva, clitoris, and perineal tissue. For preinvasive lesions of the vulva, total vulvectomy (simple or skinning) is rarely used now, with wide local excision or even more conservative treatments such as laser ablation being much more common.1
Box 27-1 Master Surgeon’s Corner
For multifocal disease, several local excisions with primary closure may be preferable to extensive vulvectomy.
Z-plasty and rhomboid flaps are often useful for closing larger defects. This is especially true near the perineum where primary closure may cause introital strictures and dyspareunia.
Bowel preparation is usually not required but may be used when perineal and perianal excision is required.
General or regional anesthesia using epidural or spinal anesthesia is used for extensive resections. For limited excisions, local anesthesia and deep sedation or laryngeal mask anesthesia may be adequate. The patient is placed in dorsal lithotomy position using “candy cane” or Allen stirrups. Bladder catheterization is recommended for complete vulvectomy. Prophylactic antibiotics are given. After the skin is prepared and sterile draping is applied, excision margins are marked on the vulva with a pen.
Incision and Dissection
It is helpful to inject the proposed incision line lesion with a dilute lidocaine and epinephrine solution (eg, 1% lidocaine with 1:100,000 epinephrine), and then the superficial skin incision is made. The incision starts from above the labial folds on the mons pubis and is extended down the lateral fold of the labia majora and across the posterior fourchette (Figure 27-1). The clitoris is spared when possible. A dry pack is used to occlude the small bleeding vessels in the skin until this incision is completed, and cautery may be used for simple vulvectomy. If a skinning vulvectomy is performed, the dissection should be with the scalpel or sharp curved scissors to avoid cautery artifact. If the clitoris is excised, the suspensory ligament and the crura of the clitoris are divided and ligated. Depending on the depth of the incision, as the 4 and 8 o’clock positions on the vulva are approached, the pudendal artery and vein may be identified and clamped. The periurethral and vaginal incisions are made if necessary to complete the excision. Depending on the location of the lesion, the clitoris and labia minora may be spared. If the dissection involves the perineum, care must be taken to avoid the anal sphincter. The specimen should be oriented with marking stitch for pathologic evaluation.
FIGURE 27-1. Simple vulvectomy removes the skin plus underlying dermis but does not reach the deep fascia.
Primary closure of the simple vulvectomy is made by using interrupted 2-0 or 3-0 synthetic absorbable sutures (Figure 27-2). Skinning vulvectomies usually require split-thickness skin grafts for closure. During closure of a simple vulvectomy, it is important to eliminate tension on the suture line, and this is often best done with vertical mattress sutures. Vulvar skin and subcutaneous tissues can be undermined and mobilized using sharp scissors or electrocautery. The posterior wall of the vagina is undermined and brought out to the posterior fourchette so that contracture of the vaginal introitus is avoided. The closure of the wound is continued superiorly to the mons pubis, and the periurethral mucosa is everted and sutured to the skin. If the defect is large, local advancement or transposition flaps can be used (see Chapter 32C). Transposition flaps such as the Z-plasty or the rhomboid flap are useful to prevent introital stenosis if there is a large perineal defect. Dressings are not necessary and difficult to keep in place. An antibiotic ointment may be useful, however, in keeping the incision line moist.
FIGURE 27-2. Primary closure after simple vulvectomy.
Box 27-2 Caution Points
Bleeding is most likely around the urethra and posterolaterally from pudendal vessels.
Closing the mons over the urethral meatus will result in distortion of the urinary stream.
Introital stricture is most likely to occur when closing the perineum under tension and may be prevented by using transposition flaps.
The bladder catheter may be removed on postoperative day 1 unless there is concern regarding the periurethral closure. The patient can usually ambulate the day after surgery. Perineal hygiene with saline rinse, especially after urination and bowel movements, is useful. Sitz baths should be avoided for 3 to 4 weeks to prevent the synthetic absorbable sutures from dissolving prematurely. Stool softeners are helpful, but attempts at constipating are usually unsuccessful and can lead to fecal impaction.
Box 27-3 Complications and Morbidity
Stricture of vaginal introitus
Distortion of urethral meatus
Historically, vulvar cancer has been treated by en bloc radical vulvectomy with bilateral dissection of the inguinal nodes.3 Because of the high complication rate and psychosexual implications of such radical surgery, this approach has been replaced by radical local excision and ipsilateral groin dissection for unilateral, small tumors.4 For posterior lesions, this may allow preservation of the clitoris. For centrally located tumors, bilateral groin dissection is recommended and can be performed through separate incisions (3-incision technique). An attempt should be made to obtain 2-cm margins, although a recent study suggested that 8-mm margins may be adequate.5 Conservative surgery tailored to the lesion location and size has the advantage of preserving vulvar tissue and allowing primary closure of the wound defect. This results in less psycho-sexual disturbance, fewer wound complications, and a shorter hospital stay without compromising survival.6
Box 27-4 Master Surgeon’s Corner
The incisions may be individualized according to the location and size of the tumor, but the dissection should extend to the deep fascia, and at least 1-cm margins should be obtained.
Vertical mattress sutures close the deep layer and skin. This method reduces tension on the skin, provides flexibility in closing irregular wounds, is fast, and results in good cosmesis.
Although inguinal lymphadenectomy is usually performed prior to the vulvar procedure, in medically frail patients, it may be prudent to do the vulvar excision first in case the operation needs to be abandoned prematurely.
If possible, leave at least 1 cm or more of mucosa surrounding the urethra to facilitate the closure and avoid distortion of the urethral meatus.
Women undergoing radical vulvectomy should be counseled about the altered appearance and effect on sexual sensation and function. Preoperative urinary or fecal continence should be evaluated, and the potential for an altered urinary stream and incontinence should be explained. The risk and consequences of wound breakdown and infection should be explained. A mechanical bowel preparation is recommended to avoid fecal soilage during or immediately after the surgery.
General or regional anesthesia is required. The patient is placed in modified dorsal lithotomy position using Allen stirrups, giving adequate exposure to the lower abdomen, perineum, and inner thighs. Prophylactic antibiotics and heparin are given prior to the incision. A urethral catheter is placed in the bladder after the skin is prepared and sterile draping is applied.
A radical vulvectomy performed through an incision separate from the inguinal lymphadenectomy is most common, but the dissection can be tailored to the size and location of the lesion as long as adequate margins are obtained and a deep dissection to the fascia or symphysis pubis is performed (Figure 27-3).
FIGURE 27-3. Types of radical vulvectomy incisions. A. Classic “single-incision” radical vulvectomy with bilateral groin node dissection (en bloc). B. Left partial radical vulvectomy with unilateral groin node dissection. C. “Tripleincision” radical vulvectomy with bilateral groin node dissection. D. Anterior partial radical vulvectomy with bilateral groin node dissection. E. Posterior partial radical vulvectomy with bilateral groin node dissection.
Incision and Dissection
The skin incision may start superiorly or inferiorly (Figure 27-4). Starting superiorly has the advantage of using the symphysis pubis as a guide to the deep fascia of the vulva. The incision continues laterally in the labiocrural folds to the deep fascia, and then the dissection proceeds medially to the mons pubis and vagina at the level of the inferior fascia of the urogenital diaphragm (Figure 27-5). Electrocautery can be used for much of the dissection. At the 4 and 8 o’clock positions on the posterolateral vulva, the internal pudendal vessels are identified and ligated. If the clitoris needs to be excised, the suspensory ligament is clamped, transected, and ligated. It may also be necessary to suture the rich vascular network surrounding the clitoris. The labia minora are retracted laterally, and an inner elliptical incision then circumscribes the vaginal introitus and vulvar vestibule. Medially, the vascular vestibular tissue along the vagina is clamped, divided, and ligated. During the posterior dissection, it is important to avoid damaging the anal sphincter (Figure 27-6). A finger in the rectum may help guide the dissection and clarify the location of the rectum and anal sphincter. If necessary, the anterior third of the anal sphincter or distal third of the urethra can be removed and continence maintained.
FIGURE 27-4. Radical vulvectomy without en bloc inguinal node dissection.
FIGURE 27-5. Radical vulvectomy. The incision is carried down to the inferior fascia of the urogenital diaphragm.
FIGURE 27-6. Radical vulvectomy, posterior dissection.
In most cases, the wound can be closed primarily (Figure 27-7). Vertical mattress sutures are useful to reduce tension on the suture line. The periurethral mucosa can be everted and secured to the skin closure to reduce urinary stream obstruction. If the dissection extended to the anus, a perineum should be reconstructed by plicating the superficial transverse perineal muscles in the midline and closing the skin with vertical mattress sutures. The vaginal mucosa should then be everted and sutured to the perineum. Primarily, 2-0 and 3-0 synthetic absorbable sutures are used, but in areas of increased tension, carefully placed permanent suture can be used to help prevent delayed wound separation as the absorbable sutures dissolve. Closed suction drains are usually not necessary, but can be placed in the ischiorectal fossa or under the closure of the vagina and brought out through the perineum.
FIGURE 27-7. Radical vulvectomy, primary closure.
Box 27-5 Caution Points
Bleeding is most likely to occur around the urethra and posterolaterally from the internal pudendal vessels.
The anal sphincter is at risk for injury when dissecting posteriorly.
Avoid excessive undermining of the vulvar skin to prevent devascularization.
The patient is kept on bed rest for the first 2 to 3 days of the initial postoperative period. The Foley catheter is left in place at least until the patient becomes ambulatory. If a complete radical vulvectomy has been performed or the dissection is close to the urethra, the patient may be discharged to home with a catheter for 1 to 2 weeks. Deep vein thrombosis prophylaxis is recommended until discharge but may be continued for 1 month. Peri-neal hygiene with saline rinses may be used, but Sitz baths should be avoided for 3 to 4 weeks to prevent the absorbable sutures from dissolving prematurely.
Box 27-6 Complications and Morbidity
Stricture of vaginal introitus
Rectovaginal or rectoperineal fistul
Urinary or fecal incontinence
Local excision of vulvar cancers will result in defects involving skin and subcutaneous tissue with minimal mucosal resection. The defects can often be closed primarily in layers or with vertical mattress sutures. Several alternative options for reconstruction exist, and selection of the appropriate method of reconstruction is dependent on the size of the defect, location of the defect, and the amount of laxity and excess tissue in the surrounding area. Options for vulvar reconstruction using advancement flaps and transposition flaps are described in Chapter 32C.
Vulvar cancer spreads through local extension and in predictable pattern along lymphatic channels that course through the labia majora, medial to the labiocrural folds. The lymphatics then travel laterally to the superficial lymph nodes in the groin and then to the deep femoral lymph nodes below the cribriform fascia of the upper, inner thigh (Figure 27-8). From there, cancer can spread via the femoral canal to the lymphatics surrounding the external iliac vessels and cephalad to the para-aortic lymph node chain. It is believed that most early lymphatic spread is by embolization rather than direct permeation along lymph channels, so currently inguinofemoral lymphadenectomy is most often performed through separate incisions at the time of a radical local resection of vulvar cancer.7 Historically, this lymphadenectomy was performed en bloc as part of a radical vulvectomy. Crossover lymphatic drainage to the contralateral groin is rare, except for midline lesions, so a unilateral dissection may be sufficient for lateralized lesions. Spread is almost always to superficial nodes initially, so sentinel lymph node techniques may be applicable (see Sentinel Lymph Node Dissection section). Aberrant channels have been found that go directly to deep femoral nodes, so a slightly increased recurrence rate may be seen when omitting a deep dissection.8 A higher recurrence rate has been noted if only superficial nodes are dissected.9