Surgery for vulvar cancer
Choosing the best surgical treatment for each woman means balancing the importance of maintaining sexual functioning with the need to remove all the cancer. In the past, surgeons removing a vulvar cancer also took out a large amount of surrounding normal tissue and often nearby lymph nodes as well, regardless of the stage of the cancer. They did this because they wanted to be sure that no undetected cancer cells remained. Such extensive surgery resulted in a good chance of cure, but it was deforming and impaired the woman's sexual function if the clitoris had been removed. The removal of 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. It has also been established that, when cancer is detected early, it is not necessary to remove so much surrounding healthy tissue to achieve a cure. In addition, the sentinel node biopsy procedure is an alternative to removing many lymph nodes if the cancer has not spread (this is discussed further on). When cancer is more advanced, an extensive procedure may be necessary. Radiation can be combined with chemotherapy and surgery to kill more cancer cells in advanced cancers.
The following types of surgery are listed in order of how much tissue is removed (from least to most):
A focused laser beam vaporizes (burns off) the layer of vulvar skin containing abnormal cells. Laser surgery is used as a treatment for VIN (vulvar pre-cancer). It is not used to treat invasive cancer.
The cancer and a margin of normal-appearing skin (usually about ½ inch) around 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.
In this type of operation, all or part of the vulva is removed.
- A skinning vulvectomy means only the top layer of skin affected by the cancer is removed. Although this is an option for treating extensive VIN, this operation is rarely done.
- In a simple vulvectomy, the entire vulva is removed.
- A radical vulvectomy can be complete or partial. When part of the vulva, including the deep tissue, is removed, the operation is called a partial radical vulvectomy. In a complete radical vulvectomy, the entire vulva and deep tissues, including the clitoris, are removed. A complete radical vulvectomy is not often needed.
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. However, most of the time the surgical wounds resulting from these procedures can be closed without grafts and still provide a very satisfactory appearance. If a skin graft is required, the gynecologic oncologist may do it. Otherwise, it may be done by a plastic/reconstructive surgeon after the gynecologic oncologist has done the vulvectomy.
Reconstructive surgery is available for women who have had more extensive surgery. A reconstructive surgeon will 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 is 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 are having this procedure, ask the surgeon to explain how it will be done, because there is no set way of doing it.
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.
If the bladder is removed, a new way to store and eliminate urine is needed. Usually a short segment of intestine is used to function as a new bladder. This may be connected to the abdominal wall so that urine is drained periodically when the woman places a catheter into a small opening (called a urostomy). Or urine may drain continuously into a small plastic bag attached to the front of the abdomen 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 fecal material 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, the woman will not need bags or external appliances.
Inguinal lymph node dissection
Because vulvar cancer often spreads to lymph nodes in the groin, these may need to be removed. This procedure 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. Now, doctors prefer to remove the lymph nodes through a separate incision located about 1 to 2 cm (less than ½ to 1 inch) below and parallel to the groin crease. The incision is made fairly deep, down through membranes that cover the major inguinal vein and artery. This will expose most of the lymph nodes, which are then removed. 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 suction drain is placed into the incision and the wound is closed. The drain remains in place until it is not draining much fluid.
Sentinel lymph node biopsy
This is a newer procedure that can help some women avoid having a full inguinal node dissection. This procedure finds and removes 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 remaining lymph nodes in this area need to be removed. If the sentinel nodes do not contain cancer cells, further lymph node surgery is not 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 is 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 that 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, 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 spread.
Complications and side effects of vulvar surgery
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.
Removal of wide areas of vulvar skin may result in 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.
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.
Lymphedema: Removal of groin lymph nodes (lymphadenectomy) can result in poor fluid drainage from the legs. This makes the 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 this is higher if radiation is given after surgery. Information about lymphedema and how to manage it can be found in Understanding Lymphedema (For Cancers Other Than Breast Cancer).
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 may return over the next few months.
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.
Lymphedema resulting from removal of lymph nodes in the groin area can cause pain and fatigue. This also can be a problem during sex. A couple will need to use good communication to cope with such problems.
For more information about the sexual impact of cancer treatment, see Sexuality for the Woman With Cancer. For more general information about surgery as a cancer treatment, see A Guide to Cancer Surgery.
Last Medical Review: 07/02/2014
Last Revised: 02/16/2016