INTRODUCTION — Vulvar lesions are a common gynecologic problem. Lesions that are suspicious for malignancy or are premalignant may be excised in a conservative fashion, preserving as much of the vulvar architecture as possible. Treatment approaches also include ablative techniques, such as laser and pharmacologic therapy [1].
The techniques for vulvar wide local excision and simple or skinning vulvectomy are reviewed here. Diagnosis and treatment of vulvar lesions, precancer, and cancer are discussed separately. (See "Vulvar lesions: Diagnostic evaluation" and "Vulvar squamous intraepithelial lesions (vulvar intraepithelial neoplasia)" and "Squamous cell carcinoma of the vulva: Staging and surgical treatment".)
SURGICAL ANATOMY — The relevant anatomy includes the following vulvar and associated structures (figure 1):
●Labia majora
●Labia minora
●Clitoris and clitoral prepuce (hood)
●Urethral meatus
●Vaginal vestibule and introitus
●Paraurethral (eg, Skene) and greater vestibular (Bartholin) gland openings
●Mons pubis
●Perineum
Conservative excisional procedures of the vulva are limited to the superficial tissue layers. Deep vulvar anatomy is shown in the figure (figure 2).
PREOPERATIVE EVALUATION AND PREPARATION
Informed consent — Before undergoing a conservative vulvar excision, patients should be counseled about alternative treatment options. Some patients with vulvar intraepithelial neoplasia are candidates for medical treatment or ablative treatments. The least invasive treatment that will minimize risk of invasive disease should be chosen. (See "Vulvar squamous intraepithelial lesions (vulvar intraepithelial neoplasia)", section on 'Treatment'.)
Treatment planning and patient counseling should include the potential effects on sexual function and body image. Such effects appear to be minimal in patients who have undergone vulvar local excision with a margin of ≤1 cm, while some data suggest effects on sexual function with margins >1 cm [2,3]. The effect of simple or skinning vulvectomy on sexual function has not been well studied [4].
Patients should also be informed of the potential need for further surgery (such as for malignancy, positive margins or recurrent disease).
Evaluation — A routine preoperative medical history is taken, including: gynecologic history, medical comorbidities, medications, and allergies. A complete pelvic examination and focused general physical examination are performed, with particular attention to the vulva, vaginal introitus, perineum, anus, and inguinofemoral lymph nodes. Older patients or those with medical comorbidities may require preoperative medical consultation. (See "Overview of the principles of medical consultation and perioperative medicine".)
Imaging studies, or a laboratory evaluation (with the exception of a pregnancy test, if appropriate), are generally not required.
Biopsy of the vulvar lesion is required to determine the histology and appropriate treatment. Very small lesions can be simply excised at the time of biopsy.
Anesthesia — Local, regional, or general anesthesia may be used, depending upon the extent of the excision and preferences of the patient and surgeon.
Prophylactic antibiotics — There are no data regarding the risk of infection following conservative vulvar excision, but there is a potential for wound infection due to the presence of skin and vaginal pathogens. There are no guidelines regarding antibiotic prophylaxis of surgical site infection for these procedures. The American College of Obstetricians and Gynecologists advises the use of prophylactic antibiotics for vaginal colporrhaphy, for which the risks are likely similar to vulvar excision [5].
We suggest use of preoperative prophylactic antibiotics for wide local excision, simple vulvectomy, and skinning vulvectomy.
Thromboprophylaxis — The American College of Chest Physicians does not recommend thromboprophylaxis for minor surgery in low-risk patients, but early and frequent ambulation is advised [6].
Patients who undergo skinning vulvectomy require a period of postoperative bed rest or limited ambulation (see 'Postoperative care' below), and are good candidates for pharmacologic thromboprophylaxis during the postoperative period. Full options for thromboprophylaxis are discussed separately. (See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients", section on 'Selecting thromboprophylaxis'.)
Patients undergoing local incision or simple vulvectomy are likely to be ambulatory, so wearing graduated compression stockings until discharge is generally sufficient unless the patient is at high risk for thromboembolism.
Other preoperative measures — Some surgeons treat postmenopausal patients who have atrophic vulvar and vaginal tissue with topical estrogen for two to six weeks prior to surgery. (See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Treatment", section on 'Vaginal estrogen therapy'.)
Bowel preparation is not generally indicated for patients undergoing wide local excision, simple vulvectomy, or skinning vulvectomy. (See "Overview of preoperative evaluation and preparation for gynecologic surgery", section on 'Bowel preparation'.)
OPERATIVE SET-UP — Vulvar excision is typically performed in an operating room. The patient is positioned in dorsal lithotomy and sterilely prepared and draped in the normal fashion.
WIDE LOCAL EXCISION — The use of the term "wide" is a misnomer because the extent of resection margin and depth of resection depend upon several factors, including the likelihood or presence of invasive cancer, and the size and location of the lesion.
Indications and contraindications — Conservative excisional procedures are performed for selected benign or premalignant conditions of the vulva, including:
●Vulvar squamous intraepithelial lesions (see "Vulvar squamous intraepithelial lesions (vulvar intraepithelial neoplasia)", section on 'Excision')
●Paget disease of the vulva (see "Vulvar cancer: Epidemiology, diagnosis, histopathology, and treatment", section on 'Paget disease of the vulva')
●Pigmented lesions and melanomas of limited size (see "Locoregional mucosal melanoma: Epidemiology, clinical diagnosis, and treatment", section on 'Vulvovaginal melanoma')
●Vulvar dermatologic conditions (see "Vulvar lesions: Differential diagnosis of vesicles, bullae, erosions, and ulcers")
●Severe perivulvar hidradenitis suppurativa (see "Surgical management of hidradenitis suppurativa", section on 'General considerations' and "Hidradenitis suppurativa: Management")
Occasionally a conservative procedure is used for diagnosis of a lesion suspicious for vulvar cancer (eg, a large lesion that appears malignant, but biopsies show only VIN). More radical surgery may then be performed if invasive disease is diagnosed.
Many patients are candidates for alternatives to excisional procedures, including treatment with laser ablation or pharmacologic therapy. In young patients with extensive lesions, nonexcisional therapy may give a better cosmetic result than excision.
It is important to note, however, that invasive cancer may be present in up to 22 percent of cases of VIN [7,8]. (See "Vulvar squamous intraepithelial lesions (vulvar intraepithelial neoplasia)", section on 'Treatment'.)
In patients with vulvar melanoma of limited size, surgical therapy may be conservative, rather than radical, excision. (See "Locoregional mucosal melanoma: Epidemiology, clinical diagnosis, and treatment", section on 'Vulvovaginal melanoma'.)
Conservative vulvar excision is rarely contraindicated for medical reasons. These procedures are minimally invasive and are well tolerated even by patients with medical comorbidities.
Procedure — When excising a totally benign lesion, the margin of normal skin around can be close, but for a malignant or potentially malignant lesion, margins are more important. In the case of a lesion that is suspicious for cancer (due to either documented severe VIN or by appearance), it can be excised circumferentially with the aim of achieving a 1 cm margin with the depth of excision extending into the underlying adipose tissue or to the deep fascia, depending on the circumstances. Small lateralized vulvar carcinomas can be excised in similar fashion but with resection taken down to the deep fascia. This form of wide local excision for cancer is sometimes termed "radical local excision." Margins in patients with vulvar carcinoma are discussed separately. (See "Vulvar cancer: Epidemiology, diagnosis, histopathology, and treatment", section on 'Treatment'.)
Depending on patient wishes, and bearing in mind the lesion diagnosis, the margin of resection may also vary according to anatomic location to avoid disruption of vulvar architecture and quality of life. For preinvasive disease, a margin of <1 cm may be taken in order to avoid damage to the clitoris or urethra or distortion of the vulva. If the margin taken is small and there is concern that the entire lesion will not have been excised, laser ablation of the surrounding skin may be performed.
The shape of the excision should be elliptical, running in the longest axis parallel to neighboring structures. Thus, for lesions on the labia majora, the ellipse would run anterior-posterior. Lesions close to the vaginal introitus are often better excised with the ellipse running around the line of the introitus. Marking the intended incision with a pen is helpful in planning the extent and axis. Estimation of histologic margins must take into account tissue shrinkage during fixation.
The defect may be reapproximated with interrupted or running synthetic absorbable suture. A small suction drain may be placed.
Postoperative care — Postoperative care consists of keeping the wound clean and dry.
Complications — There are no data regarding the incidence of complications following vulvar wide local excision, but in our experience, they are rare. Potential complications include infection, excessive bleeding, hematoma, and scarring.
SIMPLE VULVECTOMY — Simple, or total, vulvectomy refers to removal of the entire vulva together, usually including some subcutaneous tissue [9]. The perineal tissues are removed, if indicated. The clitoris is removed only if this is mandated by the extent of disease and ablation is not possible. Partial or hemivulvectomy can sometimes be performed to tailor the surgery to the disease and patient, maintain body image, and preserve sexual function.
Indications — A simple vulvectomy is performed for benign or premalignant conditions of the vulva that are extensive or multifocal and are not amenable to removal with local excision alone. The procedure is typically reserved for older patients in whom preservation of vulvar contour and sexual function is not paramount.
Procedure
Vulvectomy — A bladder catheter is placed. The incision is planned leaving as much skin of the vaginal vestibule surrounding the urethra as possible (1 cm or more) to facilitate closure and avoid distortion of the urethral meatus. The line of resection laterally depends upon the extent of disease, but may include all of the labia majora. The clitoris is spared, if possible. The internal and external resection margins are marked prior to incisions being made (figure 3).
The posterior incision is made first. The incision is made across the skin of the perineum and then laterally up to the level of the urethra. Stretching the vulvar skin to create a flat surface facilitates making the incision.
The posterior edge of the specimen is grasped with forceps allowing the operator to elevate the skin and stretch it out using two fingers placed behind the flap (figure 4). Dissecting scissors, scalpel, or electrocautery is then used to carefully separate the skin from the underlying perineal tissues to a level beyond the intended vaginal margin. Mobilization of the lower vagina above the intended resection margin will facilitate closure. Care must be taken to avoid damaging the rectum during dissection.
The incision is then extended anteriorly and laterally on both sides. The lateral skin edges of the specimen are grasped with forceps and sharp dissection is performed (using curved Mayo scissors or a scalpel, or electrosurgery if the lesion is benign), staying within the subcutaneous fat and aiming for the resection margin in the vagina. It is not necessary to resect deeply. An assistant should be ready with hemostats and an electrosurgical instrument to control bleeding.
The specimen is then detached from the distal vagina laterally and posteriorly. Scissors are used to cut radially through the specimen to the vaginal margin, and the specimen is separated on both sides to a point level with, but lateral to, the upper part of the urethral meatus (figure 5).
If excision of the clitoris is planned, the dissection is taken down from above toward the clitoral attachments. The suspensory ligament is divided and ligated. The scalpel is used to incise the skin across the vestibule above and lateral to the urethral meatus, joining with the internal incision around the distal vagina. The tip of the scalpel or the Kelly forceps is then passed through the specimen in the midline to isolate the crura of the clitoris and to allow the crura to be held on each side with forceps, divided, and underrun with 0 polyglactin sutures. The specimen is then completely detached and hemostasis is obtained with an electrosurgical instrument. Bleeding from venous sinuses around the urethra and vaginal margin may be controlled with a running 2-0 polyglactin suture.
In order to assist the pathologist with postoperative assessment and processing, it is helpful to place an orientation suture in an area of normal tissue at the periphery of the specimen (usually at the 12 o'clock position) and to draw a diagram on the pathology form marking the sites of disease, if these are not clearly apparent.
Closure — An assessment is made of how best to reapproximate the tissue edges. The patient's legs may be adducted to reduce tension on the repair. If it appears the edges may be under too much tension when brought together, the lateral and posterior vagina and skin edges may be further undermined. When undermining vulvar skin, care must be taken to leave sufficient subcutaneous tissue attached to prevent devascularization. It is best to start by freeing up the lateral and posterior vaginal edges. Local skin flaps may be required. Small open areas may be allowed to granulate.
We use undyed 3-0 polyglactin for closure. Closure is started by inserting a stay suture to approximate the skin immediately above the urethral meatus. The approximation of the skin edges is done later. Prior to each stitch being placed around the introitus, it should be assured that the closure is being performed evenly and that a difficult to close area will not be left until the last, when it may be too late to correct without revising sutures.
A suction drain may be brought out on one or both sides of the perineum and sutured to the skin. When suction is applied, leakage of air may occur around the incision, and extra sutures may need to be inserted. Leakage often only stops when the patient's legs are brought together at the end of the procedure.
Postoperative care — The bladder catheter is left in place for between 5 and 10 days until the wound edges are healing with no sign of breakdown. A longer period of catheterization may be necessary in patients who are chronically incontinent in order to allow the wound to fully heal in a dry environment. In our practice, we allow the patient to be out of bed, to sit in a chair, and to mobilize at an early stage. Thromboprophylaxis in the form of graduated compression stockings is employed until discharge, unless the patient is at high risk for thromboembolism when low molecular weight heparin is used in addition. (See 'Thromboprophylaxis' above.)
Perineal hygiene with sitz baths and gentle cleansing with saline rinse are encouraged, followed by carefully drying the area with a dryer. Exposure to the air is helpful, so underwear is discouraged and the patient reclines with knees apart whenever possible. The suture tails may be trimmed after a few days if they are causing irritation, while the sutures themselves are left in place until the wound is fully healed and, only at this time, persisting sutures may be removed if they are causing discomfort or irritation.
Complications — In our experience, hematoma formation is rarely a problem, provided the suction drains are functioning. Infection is usually noted early after the surgery and should be treated with antibiotics and continued perineal hygiene. Small separations of the wound edges may occur and can be left to heal spontaneously. Wide separation is unusual but can also generally be left to heal by secondary intention. Stricture of the introitus is not usually a problem following this procedure.
SKINNING VULVECTOMY — Skinning vulvectomy refers to a procedure in which the vulvar skin is removed and replaced with a split-thickness skin graft. The vulvar skin is removed along a relatively avascular plane beneath the epidermis, while preserving the subcutaneous tissue [10-13]. This procedure preserves the contours of the vulva, which are derived from the underlying subcutaneous fat and fascia. A partial resection with a graft is possible in selected patients [14].
Indications — Skinning vulvectomy is rarely indicated and is reserved for extensive vulvar intraepithelial lesions that are either multifocal or large and confluent. It is used in the small proportion of patients in whom prior treatments such as topical treatments, laser ablation, or smaller excisions have failed to control disease. (See "Vulvar squamous intraepithelial lesions (vulvar intraepithelial neoplasia)".)
Procedure — The excision margins are marked with a pen (figure 6) and the skin is incised down and through the dermis to the superficial fascia overlying the fat pads, but no deeper. Use of this depth preserves the contours of the vulva. Keeping tension on either side of the incision facilitates this procedure.
The skin edges are grasped and elevated with forceps and the skin is dissected off the subcutaneous tissues, keeping close to the underside of the dermis (figure 7 and figure 8). If the disease is present on the clitoris and clitoral hood, these structures can be preserved and treated with laser ablation.
A split-thickness skin graft is taken from the inner thigh and meshed in order to increase the area that can be covered and prevent clot and exudate accumulating under the graft. It is important to obtain good hemostasis before the graft is applied. The undersurface of the graft is applied to the defect and the edges secured to the wound edges using 3-0 polyglactin over dental rolls (figure 9). Paraffin gauze is laid over the graft and cotton dressings are secured over the top to maintain apposition. A few sutures are left long on each side to use for tying down the dressing at the end of the procedure. Paraffin gauze and dressings are placed over the donor site on the thigh, which is then wrapped in a crepe bandage. Excess skin is refrigerated in case the first graft does not take completely.
A bladder catheter is placed at the end of the procedure and left in place until the graft has taken, approximately seven days.
Postoperative care — Activity for the first seven days is restricted to bed rest or sitting in chair. Thromboprophylaxis is employed. (See 'Thromboprophylaxis' above.)
The vulvar dressings are inspected daily, but not taken down for five days unless there are signs of infection. On the fifth postoperative day, analgesia is given and then the dressings are removed. General anesthesia is necessary for some patients. If the dressings are adherent to the graft and adjacent skin, they should be treated with warm saline to facilitate removal.
If the graft has taken at this stage, the wound can be left open. It should be kept clean with saline rinse or sitz bath and kept dry with a hair dryer. If the skin graft has not taken, it should be debrided followed by application of the stored extra skin.
The donor site (inner thigh) dressing is left in place for two weeks, unless it shows signs of infection.
Complications — Skinning vulvectomy is a safe procedure. Combined data from several studies show complications in 7 of 103 patients (6.8 percent) following skinning vulvectomy, including: graft sloughing, partial (one patient) or complete (one patient); fever (three patients); and dyspareunia related to slow healing of the introital area and introital narrowing (two patients) [11-14].
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Vulvar cancer and vaginal cancer".)
SUMMARY AND RECOMMENDATIONS
●Conservative excisional procedures are most often performed for biopsy and treatment of benign or premalignant conditions of the vulva, including vulvar intraepithelial neoplasia (VIN), Paget disease, or dermatologic conditions. (See 'Indications and contraindications' above.)
●We suggest use of prophylactic antibiotics for simple, skinning vulvectomy, and wide local excision (Grade 2C). (See 'Prophylactic antibiotics' above.)
●Patients who undergo skinning vulvectomy require a period of bed rest and limited ambulation, and we suggest thromboprophylaxis for these patients during the postoperative period (Grade 2C). Graduated compression stocking are adequate for most patients undergoing excision or simple vulvectomy who are ambulatory. (See 'Thromboprophylaxis' above.)
●Local excision is generally performed when one or two focal lesions are present. The extent of the margin depends upon diagnosis, the potential for invasive disease, and the anatomic location of the lesion. The depth of the excision is full thickness of the skin along with some underlying subcutaneous adipose tissue in cases where invasive cancer is a possibility. (See 'Wide local excision' above.)
●Simple vulvectomy refers to removal of the entire vulva together with perineal skin and usually includes some subcutaneous tissue. (See 'Simple vulvectomy' above.)
●A simple vulvectomy may be performed for extensive benign conditions of the vulva, such as intractable symptomatic lichen sclerosus. It may also be indicated in extensive Paget disease and in older patients with severe widespread VIN. (See 'Indications' above.)
●Complications of simple vulvectomy include hematoma formation, infection, and wound separation. (See 'Complications' above.)
●Skinning vulvectomy refers to a procedure in which the vulvar skin only is removed, to retain the normal contours of the vulva, and replaced with a split-thickness skin graft. This procedure is rarely performed and is reserved for extensive VIN lesions that are either multifocal or large and confluent in patients who have failed other treatments. (See 'Skinning vulvectomy' above.)
●Complications of skinning vulvectomy include graft sloughing, infection, or scarring. Scarring around the introitus may cause dyspareunia, which can be treated by gradual dilation or revision. (See 'Complications' above.)
