Vulvar Surgery

Surgery is the main treatment for vulvar cancer. In women, the operation must balance the need to remove all of the cancer with the importance of preserving sexual function. Surgery can have a major impact on quality of life. It is also important to consider how close the tumor is to the urethra and anus.

The external genital organs are collectively called the vulva. The vulva includes the vaginal opening, the outer lips (labia majora), the inner lips (labia minora), the clitoris, the hymen and the urinary opening (urethra).

In the past, the vulvar tumor was removed together with a large amount of nearby normal tissue. In most cases, nearby lymph nodes were also removed, whatever the stage of the cancer. This was done to make sure no cancer cells were left behind. Such extensive operations produced good cancer outcomes, but they caused disfigurement and disrupted the woman's sexual function as well as urination and bowel movements, and removing all the lymph nodes in the groin often led to swelling of the leg on that side (lymphedema). Today, the importance of quality of life and sexuality is much better understood. Physicians have also realized that when cancer is detected early, there is no need to remove a lot of the surrounding healthy tissue. Even so, when the cancer is very advanced, an extensive procedure may be necessary. In some cases of advanced cancer, radiation and chemotherapy may be combined with surgery to kill more cancer cells.

Types of Vulvar Surgery

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

• Laser surgery

A focused laser beam burns away the layer of vulvar skin containing abnormal cells. Laser surgery can be used as a treatment for VIN (vulvar intraepithelial neoplasia). VIN can simply be described as a premalignant lesion of the vulva, that is, one that is more likely than normal tissue to turn into cancer. The laser method is not used to treat invasive cancer.

• Excision

The cancer is excised (cut out) together with a margin of the normal, healthy skin around it and a thin layer of fat beneath it. This is sometimes called a wide local excision. If it is extensive (a lot of tissue is removed), it may be called a simple partial vulvectomy.

• Vulvectomy

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

• Vulvar reconstruction

Procedures sometimes remove a large area of skin from the vulva and require skin grafts from other parts of the body to close the wound. Often, however, surgical wounds can be closed without grafts and still give a quite satisfactory appearance. If a skin graft is needed, the gynecologic oncologist can perform it, or it can be done by a plastic/reconstructive surgeon after the vulvectomy.

Reconstructive surgery is suitable for women who have had more extensive surgery. A reconstructive surgeon can take a piece of skin and the underlying fatty tissue and stitch it into the area where the cancer was removed. Several areas of the body can be used, but the blood flow to the transplanted tissue must be kept intact. Because the tissue must be moved without damaging its blood supply, this is where the need for a skilled surgeon should be especially emphasized.

• Pelvic exenteration

When used to treat vulvar cancer, pelvic exenteration is an extensive operation that includes a vulvectomy, usually removal of the pelvic lymph nodes, and removal of one or more of the following structures: the lower colon, rectum, bladder, uterus, cervix and vagina. How much needs to be removed depends on how far the cancer has spread to nearby organs. It is a complex operation that can lead to many different types of complications. In operations where the bladder, rectum and large intestine are removed, further surgery will be needed to create new pathways so that the functions of these structures can be maintained.

• Lymph node surgery

Because vulvar cancer often spreads to the lymph nodes in the groin, they may need to be removed. Treating the lymph nodes is important for the risk of the cancer coming back and for long-term outcomes. You should always have detailed discussions with your specialist about what is best for you, why it is best and what the side effects of treatment may be.

• Vulvectomy vs. labiaplasty

Labiaplasty, routinely considered a cosmetic procedure, involves removing inner lip tissue that the patient and clinician describe as "excessive." Typically, this means labia minora tissue that extends beyond the labia majora. Although the end result of a labiaplasty may be similar to that of a vulvectomy targeting the labia minora, the purpose of the two is different. Vulvectomy is performed to reduce the risk of disease or of cancer spreading. Labiaplasty is performed to relieve friction, swelling and general discomfort, and also to improve the overall appearance of the vulva.

• Regarding reconstructive procedures;

In the treatment of vulvar cancers, especially advanced or recurrent tumors, plastic surgical reconstruction broadens the range of available surgical treatments and provides improved cosmetic results as well as a favorable oncological course. The use of plastic surgery makes it possible to apply therapeutic measures suited to the nature and stage of the tumor as well as to the patient's condition. More importantly, research findings show an equally satisfactory rate of successful wound healing even in patients who have undergone extensive surgical procedures.

Complications and Side Effects of Vulvar Surgery

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

Because tissue is removed on one or both sides of the urethral opening, the urine stream may go to one side. Other complications of vulvar and groin lymph node surgery include fluid-filled cysts forming near the surgical wounds, blood clots that can travel to the lungs, urinary tract infections and decreased sexual desire.

After vulvar surgery, women often feel discomfort when wearing tight trousers or jeans because the "padding" around the urethral opening and vaginal entrance is gone. The area around the vagina may look different than before.

• Lymphedema: Removing the groin lymph nodes can cause poor fluid drainage from the legs, leading to fluid buildup and severe leg swelling that does not go down at night. Lymphedema can also cause pain and fatigue. It can also lead to problems with sexuality, and good communication within a couple is very important in coping with such problems.
• Effect of vulvectomy on sexuality: Because of concerns about the appearance of the external genitals after surgery, some women may want surgery to restore the aesthetic appearance of these structures.

Women who have had a vulvectomy may find it difficult to reach satisfaction during intercourse. Women may notice numbness in the genital area after a radical vulvectomy, but as the nerves slowly heal, sensation may return within a few months. If scar tissue formed after surgery narrows the vaginal opening, penetration may be painful; safe and suitable products that prevent painful irritation can be used. When scarring is severe, the surgeon may sometimes use skin grafts to widen the opening. Sometimes a special type of physical therapy called pelvic floor therapy may be helpful.

After Surgery

It is important to know what to expect when you wake up from vulvar cancer surgery. How long you stay in the hospital depends on which operation you had.

Activity

• You will need to rest for about 1–4 weeks after surgery.
• Unless your doctor advises otherwise, avoid lifting heavy loads for several weeks (usually up to 6 weeks); ask your doctor how much weight you can lift.
• Avoid any vaginal contact for 6 weeks.
• You can start driving once your pain is under control without narcotic painkillers. This is usually about 1–2 weeks after surgery.
• You will need to increase your activity gradually. Start with short walks every day and increase the distance.

Vaginal Discharge

• It is common to have discharge or some bleeding after surgery, which may be yellow, bright red, pink or brown; this is normal.

Constipation

• Constipation is common after surgery.
• Make sure you drink plenty of fluids every day.
• Try to stay active regularly, even with short daily walks.
• You may need to take a stool softener as recommended by your doctor.
• If your doctor considers it necessary after surgery, you may need to use a laxative. If you have no bowel movements after taking this medicine, or if you have nausea or vomiting, contact your doctor as soon as possible.

Vulvar Care

• Keep your vulva clean by rinsing it with lukewarm water and gently patting rather than rubbing, then dry it.
• Do not wear tight trousers or underwear. Wear cotton underwear only.
• Do not wear pantyhose.
• Do not use pads or tampons that contain deodorant or plastic.
• Do not use perfumed soap or scented toilet paper.
• Do not use sprays or talcum powder.
• After one week, a daily sitz bath in shallow, lukewarm water can help healing. It should not be long or hot, and avoid soaking in soapy water.
• Avoid spreading your legs wider than shoulder width, especially when getting into a car or in and out of anywhere.
• Clinical follow-up will be very important; make an appointment for 2 weeks after surgery. If other or further treatment is needed, it will be helpful to discuss it at this stage.