Mark A. Morgan, Sarah H. Kim, and Sameer A. Patel
SIMPLE AND SKINNING VULVECTOMY
Procedure Overview
Simple vulvectomy involves the excision of vulvar skin with subcutaneous tissue, without dissection to the deep fascia of the vulva and perineum.1 This procedure is indicated for extensive in situ or microinvasion carcinoma of the vulva (< 1 mm of invasion), vulvar dystrophy, and Paget disease, where the lesions are not amenable to local excision or other forms of conservative therapy. For noninvasive lesions (except Paget disease), it may be acceptable to just remove the skin (a skinning vulvectomy) without removal of any underlying subcutaneous fat.2 A total vulvectomy includes excision of the entire vulva, clitoris, and perineal tissue. For preinvasive lesions of the vulva, total vulvectomy (simple or skinning) is rarely used now, with wide local excision or even more conservative treatments such as laser ablation being much more common.1
Box 27-1 Master Surgeon’s Corner
For multifocal disease, several local excisions with primary closure may be preferable to extensive vulvectomy.
Z-plasty and rhomboid flaps are often useful for closing larger defects. This is especially true near the perineum where primary closure may cause introital strictures and dyspareunia.
Preoperative Preparation
Bowel preparation is usually not required but may be used when perineal and perianal excision is required.
Operative Procedure
Initial Steps
General or regional anesthesia using epidural or spinal anesthesia is used for extensive resections. For limited excisions, local anesthesia and deep sedation or laryngeal mask anesthesia may be adequate. The patient is placed in dorsal lithotomy position using “candy cane” or Allen stirrups. Bladder catheterization is recommended for complete vulvectomy. Prophylactic antibiotics are given. After the skin is prepared and sterile draping is applied, excision margins are marked on the vulva with a pen.
Incision and Dissection
It is helpful to inject the proposed incision line lesion with a dilute lidocaine and epinephrine solution (eg, 1% lidocaine with 1:100,000 epinephrine), and then the superficial skin incision is made. The incision starts from above the labial folds on the mons pubis and is extended down the lateral fold of the labia majora and across the posterior fourchette (Figure 27-1). The clitoris is spared when possible. A dry pack is used to occlude the small bleeding vessels in the skin until this incision is completed, and cautery may be used for simple vulvectomy. If a skinning vulvectomy is performed, the dissection should be with the scalpel or sharp curved scissors to avoid cautery artifact. If the clitoris is excised, the suspensory ligament and the crura of the clitoris are divided and ligated. Depending on the depth of the incision, as the 4 and 8 o’clock positions on the vulva are approached, the pudendal artery and vein may be identified and clamped. The periurethral and vaginal incisions are made if necessary to complete the excision. Depending on the location of the lesion, the clitoris and labia minora may be spared. If the dissection involves the perineum, care must be taken to avoid the anal sphincter. The specimen should be oriented with marking stitch for pathologic evaluation.
FIGURE 27-1. Simple vulvectomy removes the skin plus underlying dermis but does not reach the deep fascia.
Closure
Primary closure of the simple vulvectomy is made by using interrupted 2-0 or 3-0 synthetic absorbable sutures (Figure 27-2). Skinning vulvectomies usually require split-thickness skin grafts for closure. During closure of a simple vulvectomy, it is important to eliminate tension on the suture line, and this is often best done with vertical mattress sutures. Vulvar skin and subcutaneous tissues can be undermined and mobilized using sharp scissors or electrocautery. The posterior wall of the vagina is undermined and brought out to the posterior fourchette so that contracture of the vaginal introitus is avoided. The closure of the wound is continued superiorly to the mons pubis, and the periurethral mucosa is everted and sutured to the skin. If the defect is large, local advancement or transposition flaps can be used (see Chapter 32C). Transposition flaps such as the Z-plasty or the rhomboid flap are useful to prevent introital stenosis if there is a large perineal defect. Dressings are not necessary and difficult to keep in place. An antibiotic ointment may be useful, however, in keeping the incision line moist.
FIGURE 27-2. Primary closure after simple vulvectomy.
Box 27-2 Caution Points
Bleeding is most likely around the urethra and posterolaterally from pudendal vessels.
Closing the mons over the urethral meatus will result in distortion of the urinary stream.
Introital stricture is most likely to occur when closing the perineum under tension and may be prevented by using transposition flaps.
Postoperative Care
The bladder catheter may be removed on postoperative day 1 unless there is concern regarding the periurethral closure. The patient can usually ambulate the day after surgery. Perineal hygiene with saline rinse, especially after urination and bowel movements, is useful. Sitz baths should be avoided for 3 to 4 weeks to prevent the synthetic absorbable sutures from dissolving prematurely. Stool softeners are helpful, but attempts at constipating are usually unsuccessful and can lead to fecal impaction.
Box 27-3 Complications and Morbidity
Wound separation/breakdown
Cellulitis
Stricture of vaginal introitus
Distortion of urethral meatus
RADICAL VULVECTOMY
Procedure Overview
Historically, vulvar cancer has been treated by en bloc radical vulvectomy with bilateral dissection of the inguinal nodes.3 Because of the high complication rate and psychosexual implications of such radical surgery, this approach has been replaced by radical local excision and ipsilateral groin dissection for unilateral, small tumors.4 For posterior lesions, this may allow preservation of the clitoris. For centrally located tumors, bilateral groin dissection is recommended and can be performed through separate incisions (3-incision technique). An attempt should be made to obtain 2-cm margins, although a recent study suggested that 8-mm margins may be adequate.5 Conservative surgery tailored to the lesion location and size has the advantage of preserving vulvar tissue and allowing primary closure of the wound defect. This results in less psycho-sexual disturbance, fewer wound complications, and a shorter hospital stay without compromising survival.6
Box 27-4 Master Surgeon’s Corner
The incisions may be individualized according to the location and size of the tumor, but the dissection should extend to the deep fascia, and at least 1-cm margins should be obtained.
Vertical mattress sutures close the deep layer and skin. This method reduces tension on the skin, provides flexibility in closing irregular wounds, is fast, and results in good cosmesis.
Although inguinal lymphadenectomy is usually performed prior to the vulvar procedure, in medically frail patients, it may be prudent to do the vulvar excision first in case the operation needs to be abandoned prematurely.
If possible, leave at least 1 cm or more of mucosa surrounding the urethra to facilitate the closure and avoid distortion of the urethral meatus.
Preoperative Preparation
Women undergoing radical vulvectomy should be counseled about the altered appearance and effect on sexual sensation and function. Preoperative urinary or fecal continence should be evaluated, and the potential for an altered urinary stream and incontinence should be explained. The risk and consequences of wound breakdown and infection should be explained. A mechanical bowel preparation is recommended to avoid fecal soilage during or immediately after the surgery.
Operative Procedure
Initial Steps
General or regional anesthesia is required. The patient is placed in modified dorsal lithotomy position using Allen stirrups, giving adequate exposure to the lower abdomen, perineum, and inner thighs. Prophylactic antibiotics and heparin are given prior to the incision. A urethral catheter is placed in the bladder after the skin is prepared and sterile draping is applied.
A radical vulvectomy performed through an incision separate from the inguinal lymphadenectomy is most common, but the dissection can be tailored to the size and location of the lesion as long as adequate margins are obtained and a deep dissection to the fascia or symphysis pubis is performed (Figure 27-3).
FIGURE 27-3. Types of radical vulvectomy incisions. A. Classic “single-incision” radical vulvectomy with bilateral groin node dissection (en bloc). B. Left partial radical vulvectomy with unilateral groin node dissection. C.“Tripleincision” radical vulvectomy with bilateral groin node dissection. D. Anterior partial radical vulvectomy with bilateral groin node dissection. E. Posterior partial radical vulvectomy with bilateral groin node dissection.
Incision and Dissection
The skin incision may start superiorly or inferiorly (Figure 27-4). Starting superiorly has the advantage of using the symphysis pubis as a guide to the deep fascia of the vulva. The incision continues laterally in the labiocrural folds to the deep fascia, and then the dissection proceeds medially to the mons pubis and vagina at the level of the inferior fascia of the urogenital diaphragm (Figure 27-5). Electrocautery can be used for much of the dissection. At the 4 and 8 o’clock positions on the posterolateral vulva, the internal pudendal vessels are identified and ligated. If the clitoris needs to be excised, the suspensory ligament is clamped, transected, and ligated. It may also be necessary to suture the rich vascular network surrounding the clitoris. The labia minora are retracted laterally, and an inner elliptical incision then circumscribes the vaginal introitus and vulvar vestibule. Medially, the vascular vestibular tissue along the vagina is clamped, divided, and ligated. During the posterior dissection, it is important to avoid damaging the anal sphincter (Figure 27-6). A finger in the rectum may help guide the dissection and clarify the location of the rectum and anal sphincter. If necessary, the anterior third of the anal sphincter or distal third of the urethra can be removed and continence maintained.
FIGURE 27-4. Radical vulvectomy without en bloc inguinal node dissection.
FIGURE 27-5. Radical vulvectomy. The incision is carried down to the inferior fascia of the urogenital diaphragm.
FIGURE 27-6. Radical vulvectomy, posterior dissection.
Closure
In most cases, the wound can be closed primarily (Figure 27-7). Vertical mattress sutures are useful to reduce tension on the suture line. The periurethral mucosa can be everted and secured to the skin closure to reduce urinary stream obstruction. If the dissection extended to the anus, a perineum should be reconstructed by plicating the superficial transverse perineal muscles in the midline and closing the skin with vertical mattress sutures. The vaginal mucosa should then be everted and sutured to the perineum. Primarily, 2-0 and 3-0 synthetic absorbable sutures are used, but in areas of increased tension, carefully placed permanent suture can be used to help prevent delayed wound separation as the absorbable sutures dissolve. Closed suction drains are usually not necessary, but can be placed in the ischiorectal fossa or under the closure of the vagina and brought out through the perineum.
FIGURE 27-7. Radical vulvectomy, primary closure.
Box 27-5 Caution Points
Bleeding is most likely to occur around the urethra and posterolaterally from the internal pudendal vessels.
The anal sphincter is at risk for injury when dissecting posteriorly.
Avoid excessive undermining of the vulvar skin to prevent devascularization.
Postoperative Care
The patient is kept on bed rest for the first 2 to 3 days of the initial postoperative period. The Foley catheter is left in place at least until the patient becomes ambulatory. If a complete radical vulvectomy has been performed or the dissection is close to the urethra, the patient may be discharged to home with a catheter for 1 to 2 weeks. Deep vein thrombosis prophylaxis is recommended until discharge but may be continued for 1 month. Peri-neal hygiene with saline rinses may be used, but Sitz baths should be avoided for 3 to 4 weeks to prevent the absorbable sutures from dissolving prematurely.
Box 27-6 Complications and Morbidity
Wound separation/breakdown
Wound cellulitis
Stricture of vaginal introitus
Sexual dysfunction
Hematoma/seroma
Venous thromboembolism
Rectovaginal or rectoperineal fistul
Urinary or fecal incontinence
Vulvar Reconstruction
Local excision of vulvar cancers will result in defects involving skin and subcutaneous tissue with minimal mucosal resection. The defects can often be closed primarily in layers or with vertical mattress sutures. Several alternative options for reconstruction exist, and selection of the appropriate method of reconstruction is dependent on the size of the defect, location of the defect, and the amount of laxity and excess tissue in the surrounding area. Options for vulvar reconstruction using advancement flaps and transposition flaps are described in Chapter 32C.
INGUINOFEMORAL LYMPHADENECTOMY
Procedure Overview
Vulvar cancer spreads through local extension and in predictable pattern along lymphatic channels that course through the labia majora, medial to the labiocrural folds. The lymphatics then travel laterally to the superficial lymph nodes in the groin and then to the deep femoral lymph nodes below the cribriform fascia of the upper, inner thigh (Figure 27-8). From there, cancer can spread via the femoral canal to the lymphatics surrounding the external iliac vessels and cephalad to the para-aortic lymph node chain. It is believed that most early lymphatic spread is by embolization rather than direct permeation along lymph channels, so currently inguinofemoral lymphadenectomy is most often performed through separate incisions at the time of a radical local resection of vulvar cancer.7 Historically, this lymphadenectomy was performed en bloc as part of a radical vulvectomy. Crossover lymphatic drainage to the contralateral groin is rare, except for midline lesions, so a unilateral dissection may be sufficient for lateralized lesions. Spread is almost always to superficial nodes initially, so sentinel lymph node techniques may be applicable (see Sentinel Lymph Node Dissection section). Aberrant channels have been found that go directly to deep femoral nodes, so a slightly increased recurrence rate may be seen when omitting a deep dissection.8 A higher recurrence rate has been noted if only superficial nodes are dissected.9
FIGURE 27-8. The inguinofemoral lymph nodes are located below the fascia of Scarpa and drain into the deep femoral nodes through the fossa ovalis.
Patients with resectable vulvar squamous carcinoma and a depth of invasion greater than 1 mm or with lymphovascular invasion should be considered for surgical evaluation of the inguinal lymph nodes either by inguinofemoral lymph node dissection or by sentinel node techniques. Unilateral groin dissection is sufficient for lateral lesions 2 cm or less in size. Bilateral groin dissection is indicated for larger lesions, for central lesions, or in the presence of gross disease in the ipsilateral groin. If the groin contains 1 or more clinically positive lymph nodes, the groin dissection is performed before administration of radiotherapy.
Box 27-7 Master Surgeon’s Corner
Deep femoral lymph nodes are located medial to the femoral vein. In dissecting these nodes, there is no need to remove the fascia lateral to the femoral vein where there is risk of injuring the femoral nerve.
The great saphenous vein enters the common femoral vein near where the deep external pudendal artery crosses the common femoral vein from its origin on the medial side of the femoral artery. This artery should be clipped or ligated prior to the dissection around the saphenous vein.
Dissection in the superficial compartment should be deep to the level of the superficial inferior epigastric artery cephalad to the inguinal ligament. This ensures adequate blood supply to the skin and minimizes the risk of flap necrosis.
There are no deep femoral nodes distal to the fossa ovalis (or the insertion of the saphenous vein into the femoral vein). Dissection distal to this site is not necessary.
Preoperative Preparation
All patients should have a thorough examination with careful inspection of the inguinal regions. Although vulvar cancer is a surgically staged disease, preoperative evaluation with a computed tomography scan may also be helpful in detecting occult disease. Positron emission tomography and magnetic resonance imaging have also been evaluated, but they usually do not obviate the need for surgical dissection.9
Operative Procedure
Initial Steps
General or regional anesthesia is required, and the patient is placed in modified dorsal lithotomy position. Adequate exposure to the lower abdomen is obtained by not flexing the hips until the groin dissection is complete. Allen stirrups are usually used. If only a groin dissection is to be performed, the patient can be positioned supine, with the legs in a frog-leg position with the hips abducted and externally rotated and the knees flexed 90 degrees. Prophylactic antibiotics are given prior to the skin incision, and a catheter is placed in the bladder after the patient is prepped and draped.
Incision
Incisions separate from the vulvectomy are most commonly used (Figure 27-9), but for large laterally placed vulvar tumors, the incisions can be combined in a “butterfly” configuration. The superficial inguinal lymphadenectomy removes lymph nodes that lie superficial to the cribriform fascia of the medial thigh and the inguinal ligament. The anterior superior iliac spine and the pubic tubercle are identified, and the groin incision is made 2 cm above and parallel to the inguinal ligament. The incision is carried through the full thickness of skin and the subcutaneous tissues to the aponeurosis of the external oblique muscle.
FIGURE 27-9. Incision for inguinofemoral lymph node dissection, 2 cm above and parallel to the inguinal ligament.
Superficial Nodal Dissection
Allis forceps are applied to the dermal surface of the upper skin incision to provide traction, and the fat pad is removed from 3 to 4 cm above the inguinal ligament and 3 to 4 cm medial to the anterior superior ischial spine. Care must be taken not to dissect too close to the skin because this will devascularize the skin and may lead to flap necrosis. The medial border of the dissection is the pubic tubercle and the adductor longus muscle. Once the fat pad containing superficial inguinal nodes is cleared off the external oblique apo-neurosis and mobilized off the lower margin of inguinal ligament, the dissection proceeds inferiorly toward the deep fascia of the thigh to create the caudal skin flap (Figure 27-10). The dissection is performed in a lateral to medial direction, and the superficial circumflex iliac and superficial inferior epigastric vessels are identified and cauterized or ligated as they penetrate the cribriform fascia. Anteromedially, the long saphenous vein is identified and may be preserved by carefully dissecting the surrounding lymphatic tissue for its branches (Figure 27-11). If it is divided, it should be ligated with a transfixing stitch of permanent suture.
FIGURE 27-10. Completion of the upper and medial portions of the inguinofemoral lymph node dissection.
FIGURE 27-11. Preservation of the saphenous vein during inguinofemoral lymph node dissection.
Deep Nodal Dissection
If deep femoral lymphadenectomy is performed, the dissection is taken deeper into the femoral triangle beneath the cribriform fascia by incising the fascia over the femoral artery near the inguinal ligament and continuing inferiorly just below the saphenous vein. Dissecting medially involves dissection or ligation of the deep external pudendal artery and greater saphenous vein. This exposes the femoral triangle, bounded medially by the adductor longus muscle and laterally by the sartorius muscle. Superiorly, the inguinal ligament forms the base of the triangle. The floor of the triangle is made of the pectineus and iliopsoas muscles. The deep nodes are located medial to the femoral vein and continue cephalad beneath the inguinal ligament into the pelvis as the external iliac nodal chain. Cloquet node is the most superior deep inguinal node and is variably present. The deep nodes can be removed in continuity with superficial groin nodes if desired. The sartorius muscle may be transposed to cover the defect in the deep fascia and to protect the femoral vessels. The sartorius muscle is transected from its tendinous attachment to the anterior spine, rotated medially, and sutured to the inguinal ligament just above the femoral vessels. If the deep dissection is medial to the femoral artery, however, transposition is not usually necessary. It is also possible to remove the deep nodes by placing traction on the lymphovascular fatty tissue above the cribriform fascia, further minimizing the risk to the femoral vessels.10 The skin is closed with staples or interrupted vertical mattress sutures. A closed suction drain is brought out laterally above the groin and secured.
Box 27-8 Caution Points
When dissecting lateral to medial in the superficial compartment, the superficial inferior epigastric, circumflex iliac and external pudendal vessels may be encountered twice, near the skin and at their origin from the femoral vessels. They should be cauterized or ligated at each location.
Small branches of the saphenous vein are encountered during the medial part of the deep dissection and should be ligated.
Lymphatic drainage often increases several days after surgery when the patient begins to ambulate more. Low output in the hospital can be misleading.
Postoperative Care
Patients usually remain in bed for 24 to 48 hours, and deep vein thrombosis prophylaxis should be maintained at least during the hospital stay. Position and ambulation will often be dictated by the extent of the vulvar dissection if performed. The suction drainage is continued until incision is healed and the dissected space is obliterated. The drain output is carefully monitored. Because lymphatic drainage often increases several days after surgery, most patients should go home with the drains in place. The incision over the skin flap is inspected for signs of necrosis or infection. A lymphocyst increases the risk of skin necrosis. The staples and drains can usually be removed in 10 to 14 days.
Box 27-9 Complications and Morbidity
Intraoperative bleeding secondary to venous or arterial tear
Wound separation/breakdown, skin flap necrosis
Wound cellulitis
Lymphedema
Lymphangitis
Hematoma, seroma, lymphocyst formation
Decreased sensation over the medial thigh
Venous thromboembolism
SENTINEL LYMPH NODE DISSECTION
Procedure Overview
The sentinel lymph node (SLN) is defined as the first node that receives drainage from a primary tumor. Assessment of the SLN has recently been introduced into the treatment of early-stage squamous cell vulvar cancer in an attempt to limit morbidity while providing an accurate assessment of regional nodes. Levenback et al11,12 began developing the SLN mapping technique for vulvar cancer in 1993 using isosulfan blue dye based on the technique described for cutaneous melanoma. However, the combination of a radioactive tracer and blue dye is the most accurate technique for SLN detection and frozen-section analysis. In addition, ultrastaging of the nodal sample minimizes the need for reoperations and decreases the risk of false negatives. In early-stage vulvar cancer, the groin recurrence rate is low with a negative SLN, and survival is excellent. However, the procedure requires a multi-disciplinary approach, and the authors recommended that the procedure should be performed at least 5 to 10 times a year to maintain competence.
All patients with SLN metastases require additional treatment to the groin, independent of the size of metastasis in the SLN, and currently, this includes inguinofemoral lymphadenectomy.13
Box 27-10 Master Surgeon’s Corner
The isosulfan blue dye should be given intradermally at the junction of the tumor and normal tissue at least 10 minutes before the groin incision is made.
Any lymph node that exhibits blue dye or radioactivity is biopsied.
The SLN biopsy is performed before the excision of the primary vulvar lesion.
Preoperative Preparation
Preoperative examination and imaging are recommended to rule out gross nodal involvement. A computed tomography scan can detect local and distant disease.
If the radioisotopes are used, a preoperative radio-lymphoscintigram is performed to detect the localization of the SLN(s). This image is used to guide the site and size of the incision and to localize the SLN. The procedure requires peritumoral injection with technetium 99m radioisotope bound to nanoparticles. Using a 27-guage needle, 0.1 to 0.5 mCi of the radiolabeled colloid is injected intradermally at the leading edge of the vulvar lesion 2 to 4 hours preoperatively. Radiocolloid tracer is transported to the SLN and is identified with a gamma counter applied to the patient. The time interval for maximum tracer accumulation in SLN is 1.5 hours after injection, and it remains there for at least 2 to 6 hours after injection.
Operative Procedure
Injection of Blue Dye
Both radioisotope and blue dye are used to help in accurate localization of the SLN. Lithotomy position is required to delineate the primary vulvar lesion. General or regional anesthesia is required to obtain adequate access to the vulva and groin region. The injection of blue dye is given intradermally in the operating room at least 10 minutes before the groin incision is made. Approximately, 4 mL of isosulfan blue dye is injected circumferentially at the junction of the tumor and normal tissue (Figure 27-12). The dye reaches the lymph node through microlymphatics in about 5 minutes, and the median stain time of dye in the SLN is 21 minutes.
FIGURE 27-12. Sentinel lymph node biopsy; circumferential injection of isosulfan blue dye around tumor site.
Isolation of SLN
The intraoperative handheld gamma probe is used to accurately localize the SLN in the operating room, using 10-fold higher measured radiation than the basal count at the primary injection site as a cutoff. After the SLN is detected and marked, a small incision is made in the groin, parallel to inguinal ligament, directly over the point of maximum radiation count. The fatty lymphatic tissue is carefully dissected through the area until blue-stained lymphatic channels and lymph node(s) are visualized. Visualization of isosulfan blue dye and increased radioisotope counts detected with gamma counter facilitate the identification of the SLN. Any lymph node that exhibits blue dye or radioactivity is biopsied. After removal of the first node, the gamma counter is used to assess the remainder of the groin node basin. This indicates whether the correct node has been removed or if there is another SLN. Nodes are usually re-examined with the probe ex vivo to confirm radioactivity. SLNs are sent for pathologic evaluation as separate specimens. The resultant groin incision is closed transversely with interrupted 2-0 or 3-0 delayed-absorbable sutures. After node dissection, the appropriate vulvar operation is performed.
Box 27-11 Caution Points
SLN procedure is not recommended for tumors larger than 4 cm or multifocal lesions.
Suspicious inguinal adenopathy is a contraindication to SLN dissection.
Inability to evaluate the groins, particularly in a patient with a larger primary tumor or a midline tumor, is a contraindication to SLN.
Postoperative Care
Care relates primarily to the concurrent vulvar surgery. Drains are usually not necessary, and patients can ambulate the day of surgery.
Box 27-12 Complications and Morbidity
Wound complication (infection or lymphocyst)
Lymphedema
Sensory deficit
Allergy to isosulfan blue dye
UPPER VAGINECTOMY
Procedure Overview
An upper vaginectomy is most often performed for high-grade vaginal dysplasia (vaginal intraepithelial neoplasia [VAIN] stage 2 or 3) and carcinoma in situ or early invasive stage I vaginal cancer (see Chapter 10). This is usually after hysterectomy but may be performed for lesions in the posterior upper third of the vagina with the uterus intact. Two-year cure rates approach 90%. Occult invasion has been seen in up to 12% of upper vaginectomies performed for VAIN.14 Alternative treatments such as vaginal 5-fluorouracil and laser vaporization have been used with lower success rates and have the disadvantage of not providing a tissue specimen for pathologic evaluation. Upper vaginectomy has also been performed using a loop electrosurgical excision procedure. High success rates with minimal morbidity have been reported in small series.15
Box 27-13 Master Surgeon’s Corner
Prior radiation therapy and postmenopausal status may make Lugol iodine ineffective in delineating lesions because the entire vagina will not be glycogenized.
When excising the vaginal cuff, especially after radiation therapy, the dissection should proceed posterior to anterior. Entry into the peritoneum is not a major problem and may facilitate identification of the bladder.
Full-thickness excision of vaginal mucosa is required to rule out invasion. Entry into the subvaginal spaces facilitates this.
Giving 5 mL of indigo carmine after induction of anesthesia will color the urine blue and make an inadvertent injury to the bladder or ureters more apparent. This is more useful after hysterectomy.
Preoperative Preparation
All patients should undergo colposcopic evaluation of the entire vagina and cervix (if present) and careful inspection of the external genitalia. No special bowel preparation or antibiotics are necessary. Vaginal retractors and long instruments (forceps, needle holders, Allis clamps, and long knife handle) are required. Electrocautery and suction are also helpful. Patients should be informed of the risk of bladder or rectal injury and dyspareunia.
Operative Procedure
Initial Steps
Lithotomy position is required, and “candy cane” stirrups provide the best access for the surgeon and assistants, although Allen stirrups may also be used. Bladder catheterization is only required if the patient has a distended bladder or large cystocele. Lugol iodine applied to vagina is helpful to delineate the lesions, and 3% acetic acid may help identify hyper-keratotic lesions. General or regional anesthesia is usually required to obtain adequate access to the entire vagina.
Incision and Dissection
The lesion should be infiltrated with a dilute lido-caine and epinephrine solution (eg, 1% lidocaine with 1:100,000 epinephrine) and then circumscribed using a #11 blade. Stay sutures may be placed to help elevate the margins. The incision should be through the full thickness of the vaginal wall and should enter into the subvaginal spaces in proximity to the lesion (vesicovaginal, rectovaginal, pararectal, or paravesical). The edges of the lesion are grasped with Allis clamps, and the procedure can be completed with sharp-curved scissors or the scalpel (Figure 27-13). If there was a prior hysterectomy for cervical dysplasia, the vaginal cuff often must be excised. The resultant vaginal defect is closed transversely with interrupted 2-0 or 3-0 delayed-absorbable sutures.
FIGURE 27-13. Upper vaginectomy after prior hysterectomy.
Box 27-14 Caution Points
Limit infiltration of lidocaine with epinephrine to 30 mL. Make sure the epinephrine dilution is at least 1:100,000; 30 mL of a 1:1000 solution would give 30 mg of epinephrine, a lethal dose.
Injury to the bladder or entry into the peritoneum is most likely to occur when excising the vaginal cuff after a hysterectomy. Both injuries can be repaired vaginally, but cystoscopy should be available to ensure a ureteral injury does not occur during bladder repair.
Postoperative Care
Bladder catheterization is not required unless an injury has occurred. Most patients can be discharged on the day of surgery. Light vaginal bleeding may occur for 2 to 4 weeks, and patients should be instructed not to place anything in the vagina for at least 4 weeks, when they should be seen for a postoperative visit. Strenuous exercise should be avoided until then as well. For extensive resections or entry into the peritoneum, intercourse should be avoided for 6 to 8 weeks.
Box 27-15 Complications and Morbidity
Bladder injury resulting in fistula (more common after hysterectomy)
Rectal injury resulting in infection or fistula
Vaginal shortening and stenosis resulting in dyspareunia
Vaginal cuff dehiscence (more likely after radiation and entry into the peritoneal cavity)
RADICAL VAGINECTOMY
Procedure Overview
A radical vaginectomy is most often performed for an early invasive stage I vaginal cancer in the upper vagina in combination with an abdominal radical hysterectomy (see Chapter 25). This approach was commonly used for diethylstilbestrol-associated clear cell carcinomas of the cervix and upper vagina.16 Radical vaginectomy may also be performed for treatment of primary vaginal cancer (especially distal lesions) or recurrent cervical cancer in the vagina after prior hysterectomy.17 However, when cervical cancer recurs after definitive radiotherapy (external beam and brachytherapy), a pelvic exenteration is usually required. In rare instances, radical vaginectomy, with or without hysterectomy, can be used for vaginal melanoma. Although radiation therapy is considered the standard treatment for stage II vaginal cancer, one series has reported encouraging results using neoadjuvant chemotherapy followed by radical vaginal resection.18 Similar to radical hysterectomy, a nerve-sparing approach can be performed.19
Box 27-16 Master Surgeon’s Corner
Most vaginal cancers occur in the upper posterior vagina, making them potentially treatable with an extended radical hysterectomy with subtotal vaginectomy.
Entry into the pararectal and paravesical spaces both abdominally and vaginally facilitates the dissection and minimizes blood loss. A combined approach helps to delineate the distal vaginal margins.
Dissection in the rectovaginal septum and vesicovaginal space is critical to avoid injury to the rectum and bladder. This can be facilitated by hydrodissection with saline or a dilute solution of lidocaine with epinephrine (see Upper Vaginectomy section).
Distal vaginal lesions should include dissection of inguinal lymph nodes. SLN techniques have not been adequately studied but may be applicable.
Preoperative Preparation
All patients should undergo colposcopic evaluation of the entire vagina and cervix (if present) and careful inspection of the external genitalia. Although experience is limited, based on evidence for cervical cancer, computed tomography/positron emission tomography scan may be the best approach to exclude lymphatic or distant metastasis. Magnetic resonance imaging may be helpful in characterizing the lesion’s local extent and relation to bladder and rectum. Cystoscopy and proctoscopy are also useful to rule out local extension to these organs. A mechanical bowel preparation is helpful. Based on experience with hysterectomy, prophylactic antibiotics should be used, as well as deep vein thrombosis prophylaxis. Bladder catheterization is required. If there is a vaginal phase, special vaginal retractors and long instruments (forceps, needle holders, Allis clamps, and knife handle) are required. If an upper vaginectomy is combined with an abdominal radical hysterectomy, the equipment is identical as for radical hysterectomy (see Chapter 25). Patients should be informed of the risk of bladder or rectal injury and dysfunction. Depending on what reconstructive techniques are chosen, a shortened or strictured vagina and dyspareunia are common.
Operative Procedure
Initial Steps
If an abdominal radical hysterectomy with an extended vaginectomy is performed, the supine position may be adequate. The lithotomy position using Allen stirrups is required if a vaginal approach is performed exclusively or if a vaginal approach is used in combination with an abdominal hysterectomy. General and/or regional anesthesia is usually required to obtain adequate access to the abdomen and entire vagina.
Abdominal Approach
If a combined abdominal-vaginal approach is used to perform a radical hysterectomy with extended radical vaginectomy, the procedure begins as a standard type III radical hysterectomy (see Chapter 25). This can be performed using a vertical or transverse skin incision and may also use laparoscopic or robotic techniques. A pelvic lymphadenectomy should be performed first and suspicious lymph nodes sent for frozen-section analysis. An inguinal-femoral lymph node dissection is indicated for distal vaginal lesions. The parametrial dissection should continue all the way to the pelvic floor, and the rectovaginal septum needs to be dissected all the way to the perineum (Figure 27-14).
FIGURE 27-14. Radical vaginectomy using a combined abdominal and perineal approach.
Perineal Approach
From below, a circumferential vaginal incision should be made through the full thickness of the vaginal wall and should enter into the subvaginal spaces at least 2 cm distal to the lesion. The edges of the posterior vagina should be grasped with Allis or Chrobak forceps and elevated so that the rectovaginal septum can be dissected cephalad until the posterior cul-de-sac is reached. As the dissection proceeds in a cephalad direction, the avascular pararectal spaces can be entered laterally to further mobilize the vagina (Figure 27-15). Care should be taken not to injure the levator muscles during this dissection because troublesome bleeding will ensue. The uterosacral ligaments may be encountered near the apex of the vagina, and these can be cauterized or clamped and cut at the border of the rectum. Allis forceps should then be placed on the anterior vagina, and dissection should proceed in the vesicovaginal space until the anterior cul-de-sac is reached. If the patient has had a hysterectomy, there is no separate anterior and posterior cul-de-sac. During the anterior dissection, the paravesicle spaces should be entered and the ureters should be identified by palpation. The connective tissue attaching the bladder and ureter to the vagina or cervix (the bladder pillars) needs to be cut to free the ureter from the specimen. If the connective tissue lateral to the vagina (paracolpos and parametrium) has not been dissected from above, this should be clamped as lateral as possible and cut. Entry into the cul-de-sac is then performed to either excise the entire vaginal specimen or complete the extended radical hysterectomy.
FIGURE 27-15. Radical vaginectomy, sagittal view.
Reconstruction will depend on the amount of vagina removed and the wishes of the patients. Rectus abdominis and gracilis myocutaneous flaps can be used as for a pelvic exenteration (see Chapter 32C). In some cases, for small mid to lower vaginal lesions, partial vaginectomy may be performed and repaired with local transposition flaps.
Box 27-17 Caution Points
Entry into the pararectal spaces from below should be above where the levator muscles attach to the perineal muscles. Dissection too low or too lateral will result in troublesome bleeding from the levator muscles.
Injury to the bladder or ureter is more likely to occur when excising the vaginal cuff after a hysterectomy. Cystoscopy and ureteral catheterization before surgery may facilitate the dissection and help avoid injury.
Postoperative Care
Bladder catheterization is required for 1 to 2 weeks, and a postvoid residual urine should be measured after the catheter is removed. Patients should continue deep vein thrombosis prophylaxis for at least until discharge. Light vaginal bleeding may occur for 2 to 4 weeks, and patients should be instructed not to place anything in the vagina for at least 4 weeks, when they should be seen for a postoperative visit. Strenuous exercise should be avoided for up to 3 months.
Box 27-18 Complications and Morbidity
Bladder injury resulting in fistula
Bladder dysfunction (initially retention, but overactivity can develop later)
Rectal injury resulting in infection or fistula
Vaginal shortening and stenosis resulting in dyspareunia
Vaginal Reconstruction
When vaginectomy is performed at the time of exenterative surgery, gracilis or rectus abdominis myocutaneous flaps are commonly used for reconstruction. However, when vaginectomy is performed for dysplasia or cancer without removal of the bladder and/or rectum, there is usually less room for those bulky flaps. In that case, transposition flaps are more useful. Vaginal reconstruction using transposition flaps is described in Chapter 32C.
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