The wide radical excision of the vulva procedure arose from the move toward individualized treatment for patients with vulvar cancer in the wake of the universal treatment period when all patients underwent en bloc radical vulvectomy with bilateral inguinal lymphadenectomy popularized by Stanley Way in the 1950s and 1960s (Chapter 15). In properly selected patients, radical wide excision has been associated with recurrence and survival outcomes similar to radical vulvectomy, while offering a substantial reduction in morbidity and improved quality of life and self-image.

Although the scope of resection should be tailored to the individual patient’s anatomy and lesion topography, there are three major variations of wide radical excision of the vulva: lateral, anterior, and posterior types. Classically defined, radical wide excision of the vulva includes a 2-cm resection margin of visibly disease-free tissue in all dimensions. Depending on the anatomic region of resection, the deep margins of resection are the pubic aponeurosis anteriorly, the pubic rami and superficial perineal fascia laterally, the deep fascia of the vulva medially, and the levator plate/ischiorectal fossa/anal sphincter posteriorly. At least one study suggests that a surgical margin of at least 1 cm prior to tissue fixation yields similar recurrence rates compared to the more traditional 2-cm specification. Obtaining adequate surgical margins can be particularly challenging in the area of the perineum and posterior fourchette. If a satisfactory surgical margin cannot be achieved in these areas, the patient may be better treated with preoperative irradiation combined with chemotherapy followed by completion surgery. 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 inguinal lymphadenectomy (Chapter 16). For midline lesions, lesions of the anterior vulva or mons pubis, and cases with microscopically positive ipsilateral groin nodes, a bilateral inguinal lymphadenectomy is the procedure of choice.

In preparation for wide radical excision of the vulva, all patients should undergo a comprehensive history and physical examination focusing on those areas that may indicate a reduced capacity to tolerate 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 electrocardiogram for women aged 50 years and older. Preoperative computed tomography imaging of the abdomen and pelvis is usually unnecessary. A chest radiograph should be obtained.

Prophylactic antibiotics (Cephazolin 1, Cefotetan 1 to 2 g, or Clindamycin 800 mg) should be administered 30 minutes prior to incision, and thromboembolic prophylaxis (e.g., pneumatic compression devices and subcutaneous heparin) should be initiated prior to
surgery. The instrumentation required includes a basic vaginal surgery set and Allen Universal Stirrups (Allen Medical Systems, Cleveland, OH). Enemas should be administered the evening before surgery. Preoperative mechanical bowel preparation (oral polyethylene glycol solution or sodium phosphate solution with or without bisacodyl) combined with forced constipation for a period of several days may facilitate healing by reducing the likelihood of fecal contamination of the incision in the immediate postoperative period if there is an extensive posterior component to the dissection.

Either general or regional anesthesia is acceptable. The patient should be positioned in 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 Foley catheter is placed. Examination under anesthesia should pay particular attention to the size and topography of the vulvar lesion, the vagina and cervix, and the groin lymph nodes. Generally, the inguinal lymphadenectomy (Chapter 16) is performed prior to the vulvar resection and the thighs are initially positioned in 15° of flexion and slightly externally rotated. The thighs are repositioned into hyperflexion for the vulvar resection.

The surgical principles of wide radical excision of the vulva are the same as for radical vulvectomy (Chapter 15); however, the specific anatomic boundaries of resection and techniques are tailored to the anatomic region of the vulva—anterior, lateral, or posterior location (Figure 17.1

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