Chapter 101 - Vulvectomy

Summary

Vulvectomy is performed for both preinvasive and malignant conditions of the vulva. This procedure may vary in extent from a skinning procedure performed for multi-centric intraepithelial neoplasia to a radical vulvectomy combined with bilateral inguinofemoral lymph node dissections for invasive carcinoma. The radical procedure has changed during the past decade; it may range from a hemivulvectomy with unilateral inguinofemoral lymph node dissection to a radical vulvectomy with bilateral inguinofemoral lymph nodes dissection. A three-incision method for radical vulvectomy with bilateral lymph node dissection is preferred over en bloc removal because the multiple incision method has a significantly decreased rate of wound breakdown.

Lateralizing stage T1 lesions that are smaller than 2 cm are treated with a radical hemivulvectomy and ipsilateral lymph node dissection. For larger or midline lesions, attempts are made to perform a radical vulvectomy and bilateral inguinofemoral lymph node dissections through separate incisions (three-incision technique). This approach generally results in fewer postoperative complications (e.g., wound infections) and a shorter hospital stay. The time necessary for this operation is 2–5 hours, and varies according to the extent of resection and reconstruction. Depending on the extent of resection, gracilis or rectus abdominis myocutaneous flaps, Z-plasty full-thickness pedicle flaps, or V–Y advancement flaps may be needed to fill the operative defect. Large defects in the vulva can be reconstructed with split-thickness skin grafts. Closed suction drains are often placed in the operative site to reduce the formation of lymphocysts and to improve wound healing. General, regional, or combination anesthesia can be equally efficacious. Intraoperative transfusions are not routinely required during a radical vulvectomy.