Surgery for Vulvar Cancer

Surgery is the main treatment for vulvar cancer. Each woman's surgery must balance the need to remove all of the cancer with the importance of her ability to have a sex life. It's also important to consider how close the tumor is to the urethra and anus, because changes in how waste leaves the body can also have a huge impact on quality of life. (The vulva includes the labia, the opening to the vagina, and the clitoris. See What is Vulvar Cancer? for details.)

In the past, the vulvar tumor and a large amount of nearby normal tissue were removed. In most cases, nearby lymph nodes were taken out, too, regardless of the stage of the cancer. This was done to be sure that no cancer cells were left behind. Such extensive surgery resulted in good cancer outcomes, but it was deforming and impaired the woman's sexual function as well as how she passed urine and stool. And taking out all the lymph nodes in the groin often led to disabling swelling of the leg (lymphedema) on that side.

Today, the importance of quality of life and sexuality is well recognized. Doctors have also learned that, when cancer is found early, there's no need to remove so much surrounding healthy tissue. Also, the sentinel node biopsy procedure is an option to removing many lymph nodes if the cancer has not spread (this is discussed below).

Still, when cancer is more advanced, an extensive procedure may be necessary. In some cases, radiation can be combined with chemotherapy and surgery to kill more cancer cells in advanced cancers.

Vulva surgery

The following types of surgery are listed in order of how much tissue is removed from the vulva (from least to most):

Laser surgery

A focused laser beam vaporizes (burns off) the layer of vulvar skin containing abnormal cells. Laser surgery may be used as a treatment for VIN (vulvar pre-cancer). It's not used to treat invasive cancer.

Excision

The cancer and an edge (margin) of normal, healthy skin (usually at least ½ inch) around it and a thin layer of fat below it are excised (cut out). This is sometimes called wide local excision. If extensive (a lot of tissue is removed), it may be called a simple partial vulvectomy.

Vulvectomy

In this type of operation, all or part of the vulva is removed.

• A skinning vulvectomy removes only the top layer of skin affected by the cancer. This is an option for treating extensive VIN, but this operation is rarely done.
• In a simple vulvectomy, the entire vulva is removed (the inner and outer labia; sometimes the clitoris, too) as well as tissue just under the skin.
• A partial or modified radical vulvectomy removes part of the vulva, including the deep tissue.
• In a complete radical vulvectomy, the entire vulva and deep tissues, including the clitoris, are removed. A complete radical vulvectomy rarely needed.

Vulvar reconstruction

Sometimes these procedures remove a large area of skin from the vulva, requiring skin grafts from other parts of the body to cover the wound. But, most of the time the surgical wounds can be closed without grafts and still provide a very satisfactory appearance. If a skin graft is needed, the gynecologic oncologist may do it. Otherwise, it may be done by a plastic/reconstructive surgeon after the vulvectomy.

Reconstructive surgery is available for women who have had more extensive surgery. A reconstructive surgeon can take a piece of skin and underlying fatty tissue and sew it into the area where the cancer was removed. Several sites in the body can be used, but it's complicated by the fact that the blood supply to the transplanted tissue needs to be kept intact. This is where a skillful surgeon is needed because the tissue must be moved without damaging the blood supply. If you're having flap reconstruction, ask the surgeon to explain how it will be done, because there's no set way of doing it.

Pelvic exenteration

Pelvic exenteration is an extensive operation that when used to treat vulvar cancer includes vulvectomy and often removal of the pelvic lymph nodes, as well as removal of one or more of the following structures: the lower colon, rectum, bladder, uterus, cervix, and vagina. How much has to be removed depends on how far the cancer has spread into nearby organs. This is very complex surgery that can lead to many different kinds of complications.

If the bladder is removed, a new way to store and pass urine is needed. Usually a short piece of intestine is used to function as a new bladder. This may be connected to the abdominal wall so that urine can be drained when the woman places a catheter into a small opening (called a urostomy). Or urine may drain continuously into a small plastic bag that sticks to the belly over the opening.

If the rectum and part of the colon are removed, a new way to eliminate solid waste will be needed. This is made by attaching the remaining intestine to the abdominal wall so that stool can pass through a small opening (called a colostomy) into a small plastic bag worn on the front of the abdomen. Sometimes it's possible to remove a piece of the colon and then reconnect it. In that case, bags or external appliances aren't needed.

Lymph node surgery

Because vulvar cancer often spreads to lymph nodes in the groin, these may need to be removed. Treating the lymph nodes is important when it comes to the risk of cancer coming back and long-term outcomes. Still, there's no one best way to do this. Talk to your doctor about what's best for you, why it's best, and what the treatment side effects might be.

Inguinal lymph node dissection

Surgery to remove lymph nodes in the groin is called an inguinal lymph node dissection. Usually only lymph nodes on the same side as the cancer are removed. If the cancer is in or near the middle, then both sides may have to be done.

In the past, the incision (cut in the skin) that was used to remove the cancer in the vulva was made larger to remove the lymph nodes, too. Now, doctors remove the lymph nodes through a separate incision about 1 to 2 cm (less than ½ to 1 inch) below and parallel to the groin crease. The incision is deep, down through membranes that cover the major nerves, veins, and arteries. This exposes most of the inguinal lymph nodes, which are then removed as a solid piece. A major vein, the saphenous vein, may or may not be closed off by the surgeon. Some surgeons will try to save it in an effort to reduce leg swelling (lymphedema) after surgery, but some doctors will not try to save the vein since the problem with swelling is mainly caused by the lymph node removal.

After the surgery, a drain is placed into the incision and the wound is closed. The drain stays in until it's not draining much fluid.

Sentinel lymph node biopsy

This procedure can help some women avoid having a full inguinal node dissection. It's used to find and remove the lymph nodes that drain the area where the cancer is. These lymph nodes are known as sentinel lymph nodes because cancer would be expected to spread to them first. The lymph nodes that are removed are then looked at under the microscope to see if they contain cancer cells. If they do, then the rest of the lymph nodes in this area need to be removed. If the sentinel nodes do not contain cancer cells, further lymph node surgery isn't needed. This procedure can be used instead of an inguinal lymph node dissection for cancers that are fairly small (less than 4 cm) as long as there's no obvious lymph node spread.

To find the sentinel lymph node(s), a small amount of radioactive material and/or blue dye is injected into the tumor site on the day before surgery. The groin is scanned to identify the side (left or right) that picks up the radioactive material. This is the side where the lymph nodes will be removed. During the surgery to remove the cancer, blue dye will be injected again into the tumor site. This allows the surgeon to find the sentinel node by its blue color and then remove it. Sometimes 2 or more lymph nodes turn blue and are removed.

If a lymph node near a vulvar cancer is abnormally large, it's more likely to contain cancer and a sentinel lymph node biopsy is usually not done. Instead, a fine needle aspiration (FNA) biopsy or surgical biopsy of that lymph node is done to check for cancer cells.

Complications and side effects of vulvar surgery

Removal of wide areas of vulvar skin often leads to problems with wound healing, wound infections, or failure of the skin graft to take. The more tissue removed, the greater the risk of these complications. Good hygiene and careful wound care are important.

The urine stream might go to one side because tissue on one or both sides of the urethral opening has been removed.

Other complications of vulvar and groin node surgery include formation of fluid-filled cysts near the surgical wounds, blood clots that may travel to the lungs, urinary infections, and reduction of sexual desire or pleasure.

After vulvar surgery, women often feel discomfort if they wear tight slacks or jeans because the "padding" around the urethral opening and vaginal entrance is gone. The area around the vagina also looks very different.

Lymphedema: Removal of groin lymph nodes (lymphadenectomy) can result in poor fluid drainage from the legs. This makes fluid build up and leads to leg swelling that is severe and doesn’t go down at night. This is called lymphedema. The risk of lymphedema is higher if radiation is given after surgery. Lymphedema can also cause pain and fatigue. This can also cause problems with sex and a couple will need to use good communication to cope with such problems. See Sex and the Adult Female with Cancer for more on the sexual impact of cancer treatment.

Sexual impact of vulvectomy: Women often fear their partners will feel turned off by the scarring and loss of the outer genitals, especially during oral sex. Some women may be able to have surgery to rebuild the outer and inner lips of the genitals.

It may be difficult for women who have had a vulvectomy to reach orgasm. The outer genitals, especially the clitoris, are important in a woman's sexual pleasure. For many women, the vagina is just not as sensitive. Women may also notice numbness in their genital area after a radical vulvectomy, but feeling might return over the next few months as nerves slowly heal.

When touching the area around the vagina, and especially the urethra, a light caress and the use of a lubricant can help prevent painful irritation. If scar tissue narrows the entrance to the vagina, penetration may be painful. Vaginal dilators can sometimes help stretch the opening. When scarring is severe, the surgeon can sometimes use skin grafts to widen the entrance. Sometimes, a special type of physical therapy called pelvic floor therapy may help.