Choosing the best surgical treatment for each woman involves 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 possibly local lymph nodes, regardless of the stage of the cancer, because they wanted to be sure that no undetected cancer cells remained. Such extensive surgery resulted in a good chance of cure, but it caused disfigurement and impaired the woman's ability to function sexually if the clitoris were removed. The removal of all the lymph nodes in the groin often led to disabling swelling of the leg on that side.

Today, the importance of sexuality to a woman's quality of life 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 avoids removing lymph nodes if the cancer has not spread. However, the use of sentinel lymph node biopsy has not been conclusively shown to be as effective as standard groin dissections. Studies are on-going to evaluate their role (see below) 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 cases.

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

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

Excision: 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, it may be called a simple partial vulvectomy.

Vulvectomy: There are several operations in which part of the vulva or all 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 VIN3, 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 vulvectomy. In a complete radical vulvectomy, the entire vulva and deep tissues, including the clitoris, are removed.

• An operation to remove the lymph nodes near the vulva is called a groin dissection. It is important to remove these lymph nodes if they contain cancer.

If these procedures are used to remove a large area of skin from the vulva, skin grafts from other parts of the body may be needed to cover the wound. However, the surgical wounds resulting from these procedures can usually be closed without grafts and provide a very satisfactory appearance. If a graft is required, the gynecologic oncologist may perform the surgery and consult with a plastic/reconstructive surgeon.

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 this will be done in your case, because there is no set way of doing it.

Inguinal (groin) node dissection: Because vulvar cancer often spreads to lymph nodes in the groin, these must be removed. Usually only lymph nodes on the same side as the cancer are removed. If the cancer is in the middle, then both sides may have to be done. In the past, this was done with one large incision extending from the incision used to remove the vulva and the cancer. Now, doctors favor making a separate incision about 1 cm 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, may or may not be closed off by the surgeon. Some surgeons will try and save the saphenous vein in an effort to prevent leg swelling, which is often a problem with this surgery. After the surgery, a suction drain is placed into the incision for a few days, and the wound is closed.

Sentinel lymph node biopsy: This is a new and very promising procedure that can help some women avoid the side effects of inguinal node dissection. It can find the lymph nodes that drain lymph fluid from the area of the vulva where the cancer developed. These lymph nodes will then be checked for any spread of cancer, because if the cancer does spread, these lymph nodes will be the first place it will go. So far, this approach is still experimental and not regarded as standard treatment.

On the day before surgery, a small amount of radioactive material and/or blue dye is injected into the tumor site. The groin is scanned to identify the side (left or right) that picks up the radioactive material. This will be the side that will be operated on. During the surgery to remove the cancer, blue dye will be injected into the tumor site. This allows the surgeon to find the sentinel node by its blue color. Often both the radioactive detector is used with the blue dye. The suspicious lymph node is removed for microscopic examination (this examination takes a day or two). If cancer cells are found, the remaining lymph nodes in this area are surgically removed. If the sentinel node does not contain cancer cells, further lymph node surgery is not needed.

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.

Sexual impact of vulvectomy: After vulva 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.

Women often fear their partners will feel "turned off" by the scarring and loss of the outer genitals, especially if they enjoy oral stimulation of the woman as part of lovemaking. Some women may be able to have surgery to rebuild the outer and inner lips of the genitals.

Women who have had a vulvectomy may have problems reaching 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 an area. Women may also notice numbness in their genital area after radical vulvectomy. Feeling may return over the next few months.

In 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 use skin grafts to widen the entrance.

When the lymph nodes in the groin have been removed, women often have swelling of their genital area or legs. This can result in pain and fatigue. It also can be a problem during sex. A couple needs to use good communication to cope with such problems.

Pelvic exenteration: Pelvic exenteration is an extensive operation that includes vulvectomy and 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.

Complications and side effects of vulvar surgery: Removal of wide areas of vulvar skin may result in failure of the wound to heal, failure of the skin graft to take, or wound infections. The more tissue removed, the greater the risk of significant complications.

Removal of lymph nodes during a radical vulvectomy with radical lymphadectomy can result in poor fluid drainage from the legs, causing fluid retention, prominent swelling of the legs, and increased risk of infections. Support stockings or special compression devices often help this rare complication called lymphedema. Women with lymphedema should also take these precautions:

• avoid infections of the affected leg or legs

• carefully protect the leg and foot from sharp objects and care for any cuts, scratches, or burns without delay

• avoid sunburn of the affected leg(s) and avoid cutting or tearing cuticles of the toenails

• report any redness, swelling, or other signs of infection to the nurse or doctor without delay

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. Last Revised: 06/21/2006