Radical vulvar surgery

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Roland Matthews

Introduction

Radical vulvectomy and groin node dissection have been the standard treatment for cancer of the vulva since 1912 when this procedure was first described by Basset. Because carcinoma of the vulva is rare, accounting for only 0.4% of all cancers in women, scientific comparisons of variations on this operation have often been limited by studies with small or heterogeneous samples. Traditionally, an en bloc radical resection of the entire vulva and bilateral inguinal nodes through the trapezoid or 'butterfly' incision was the treatment of choice for all vulvar carcinomas. Currently, unilateral radical vulvectomy and ipsilateral inguinal node dissection are considered to be adequate treatment of a lateral lesion which does not approach the clitoris or perineal body. Bilateral inguinal node dissection is indicated in cases of midline lesions or if positive lymph nodes are encountered during the ipsilateral groin node dissection associated with a lateral lesion. The current trend is toward individualization of treatment, more conservative surgery, and preservation of sexual function.

Indications

Vulvectomy can be performed for all stages of cancer of the vulva, in any woman with a resectable lesion. In borderline cases, radiation and chemotherapy can be used to increase resectability of larger lesions.

Anatomic considerations

Vascular supply

The rich blood supply to the vulva is derived from the internal pudendal artery, a terminal branch of the anterior division of the hypogastric artery, and the superficial and deep external pudendal arteries, which originate from the femoral artery. The internal pudendal artery and vein continue into the posterior labial vessels, which supply the posterior portion of the labia majora, labia minora and vestibule. The anterior labial branches of the external pudendals and the small artery of the ligamentum teres, a branch of the inferior epigastric, also contribute to the vascular supply. During the groin node dissection care must be taken to avoid injury to the femoral vessels and the saphenous vein.

Groin Labia Majora

Figure 1

Lithotomy position, allowing two-team approach

1 2 cm margins (outlines marked with marking pen), extending into vagina

2 Urethra

3 Labia minora

4 Lesion

Nerve supply

The nerve supply of the vulva is derived from a variety of sources. The mons pubis and upper labia majora are innervated by the ilioinguinal nerve and the genital branch of the genitofemoral nerve. The superficial perineal branches of the pudendal nerve supply the labia majora and the structures of the external genitalia. The deep branches supply the clitoris, vestibular bulb and muscles of the region. The femoral nerve lies outside the femoral sheath and therefore does not require dissection.

Muscles involved

The major portion of the bulbocavernosus, ischiocavernosus and superficial transverse perineal muscles are included in the radical vulvectomy dissection. The sartorius and adductor longus muscles represent the lateral and medial borders of the groin node dissection. The posterior border is made mostly of the pectineus, with some psoas and iliacus muscles.

Operative procedure

The patient is placed in the dorsal lithotomy or Lloyd Davis position to allow a two-team approach to the procedure. The surgical site and the planned incision are delineated using a marking pencil. The most

Vulvar Injuries

Figure 2

1 Outlines of area to be excised

2 Hymenal ring

3 Lesion

4 Normal skin

5 Subcutaneous fat

6 Ligated pudendal vessels

7 Fascia of the urogenital diaphragm important aspects are to obtain a 1-2 cm tumor-free margin and to provide the best cosmetic closure. To that end, the surgery is strictly tailored to the lesion.

To perform a total radical vulvectomy, lateral skin incisions are made along the labiocrural crease. The incision should extend anteriorly over the pubis and posteriorly across the perineum, anterior to the rectum. A second incision is then made circumferentially around the vaginal introitus. This incision is usually made along the hymenal ring; however, it may be made higher to incorporate the distal urethra or vagina to achieve an adequate surgical margin (Figure 1).

An en bloc dissection is performed which extends down to the fascia lata and the inferior fascia of the urogenital diaphragm. Care must be taken to ligate the pudendal vessels which enter the vulva at the four

Ischiocavernosus

Figure 3

1 Perineal membrane

2 Vaginal orifice

3 Urethral orifice

4 Ischiocavernosus muscle

5 Bulbospongiosus muscle

6 Internal pudendal vessels, ligated

7 Superficial transverse perineal muscle o'clock and eight o'clock positions. The posterior extent of the dissection involves the tissue in the ischiorectal fossa (Figure 2). The total radical vulvectomy results in the removal of the bulbocavernosus, ischiocavernosus and superficial transverse perineal muscles (Figure 3). Lesions involving the clitoris may require a more extensive excision of the mons. Those involving the perineum may require dissection into the thigh or partial resection of the anus.

Lesion Clitoris

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  • concordia pisano
    What nerves supply the vulva?
    8 years ago

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