Vulvectomy

A vulvectomy is performed to remove either part (or just skin) or whole of the vulva. The vulva includes the exterior part of the vagina, urethra, clitoris, labia minora and labia majora. 

Vulvectomy is usually performed to remove cancer cells from the vulva but it can also be done for various other conditions affecting the vulva, e.g., wart-like structures on the skin of the vulva. 

Vulvar cancer can occur in women of all ages; however, it is commonly seen in females above 60 years of age. Vulvar cancer can be treated with surgery, radiation or chemotherapy. This type of cancer forms gradually over the years and is commonly found on the outer vaginal lips (labia majora) and less frequently on inner vaginal lips (labia minora) or clitoris.

The type of vulvectomy performed depends on the tumour size or the area affected by the skin condition and the spread of the tumour to the nearby tissues and lymph nodes.

Doctors recommend this surgery for:

• Removal of vulvar tumour. A margin of healthy tissue may also be removed around the affected area
• Providing relief from the symptoms of vulvar cancer 
• Precancer of the vulva (vulvar intraepithelial neoplasia)
• Skin cancer (melanoma) of the vulva
• Cancer of the vulva
• Severe disease of the sweat glands in the groin (hidradenitis suppurativa)
• Severe skin disease (e.g., lichen sclerosus)

Signs or symptoms to watch for vulvar cancer are:

• Change in the appearance of the vulva, different from normal (colour of the skin for example)
• Constant itching or burning anywhere on the vulva
• Bleeding or discharge that is not related to menstruation
• An open sore (skin ulcer) that lasts for a month or more
• Painful bleeding or urination Read more: Painful urination causes
• A white, rough area on the vulva
• A lump (red, pink or white) with a wart-like or raw surface
• A mole on the vulva that changes its shape or colour
• A thick patch of skin that may be red, white, or dark
• Pain, tenderness, or soreness in the vulva

Sometimes, the symptoms may appear like other medical problems or conditions, so always consult your doctor for further investigation. If a biopsy shows the presence of vulvar cancer that is limited to the vulva, then vulvectomy may be recommended.

Any person with vulvar cancer/or a vulvar condition can undergo a vulvectomy if their doctor suggests that they are fit for it. However, it is important to know the stage of the vulvar cancer with biopsy or other tests to determine appropriate treatment including a vulvectomy. Vulvar cancer has the following stages: stage I, II, III, and IV. Although surgery is usually done for treating vulvar cancer, radiation and/or chemotherapy are also used when the cancer cannot be removed completely by surgery.

A doctor will do a physical examination and take your medical history and will also conduct a pelvic exam to check your uterus, ovaries, vagina, and cervix for any abnormality. The vagina and cervix may be checked with a speculum (a medical tool used to see inside the vagina). The doctor may also do an HPV test and a Pap smear test. However, a biopsy (a small amount of tissue is removed and examined under a microscope) is the most certain way to find out if the cancer is present.

The doctor may examine the vulva with magnification, which is called vulvoscopy. A hand-held magnifying glass or colposcope may be used to select the area for biopsy. A colposcope (an instrument with magnifying lenses) allows the doctor to view the surface of the vulva clearly and closely. Sometimes, the vulva may be wiped with a dye to find abnormal areas for biopsy. When such areas are located, and the area is small, it may be removed completely. This is known as an excisional biopsy. If the area is large, then a small piece of it is taken, which is called a punch biopsy.

Few other imaging tests such as the following may be required.

• Chest X-ray
• CT scan
• MRI scan
• PET scan

Besides, if the doctor suspects that cancer may have spread to adjacent organs, the following tests may be used to look inside the body for signs of cancer.

• Cytoscopy

In this test, a lighted tube is used to check the inside lining of the bladder. If any suspicious area is noted, then that area is biopsied. This test is done using local anaesthesia so that the area is numbed. Some people may require general anaesthesia (so that they are asleep during the procedure). 

• Proctoscopy

This test allows the doctor to check the inside of the rectum with the help of a thin, lighted tube. If any suspicious areas are found, then they are biopsied. 

• Pelvic examination

Pelvic examination is done under anaesthesia. While the patient is under deep sleep, the doctor can do a thorough exam and can evaluate the spread of cancer to the internal organs of the pelvis.

The healthcare provider will tell you the type of vulvectomy that you would be going through. The type of operation depends on the stage of cancer. Before the surgery, you will have to sign a consent form that gives your approval for the procedure. You will be checked to see if you are fit for receiving an anaesthetic and making a good recovery after surgery will be checked. You may have to go through a few tests, such as:

• Blood tests for general health and to check kidney function. Read more: Kidney function test
• Breathing tests (lung function tests)
• An ECG to check your heart health
• An echocardiogram (test of the heart using sound waves)

The surgeon will inform you about the benefits of the surgery, possible complications or possibilities after the surgery. The nurse will check your overall health, blood pressure, weight, temperature and pulse. The dietician will suggest managing your diet, give tips on increasing nutrients and calories, and may provide nutritional supplements/drinks before the procedure. 

The following things should be done before going for the surgery.

• Quit smoking 6 to 8 weeks before the surgery. Smoking can lead to difficulty in breathing during the operation and slows down the healing process.
• You may be asked to stop the following medications before the surgery. 
  • Vitamin E, 10 days before the surgery as it may cause bleeding. 
  • Aspirin, herbal preparations, and other dietary supplements 7 days before the surgery. 
  • Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, naproxen, 2 days before the surgery as they can cause bleeding.
• Check with your healthcare provider if you can continue using multivitamins.
• Avoid eating anything after midnight before the surgery, including hard candy and gum. You may drink up to 12 ounces of water between midnight and until 2 hours before the surgery.
• You will need to clean your bowel, by taking laxatives, the night before the surgery.
• Take a shower at home before the surgery. After the shower, do not apply any cream, lotion, cologne, makeup, powder, deodorant or perfume.
• Remove all nail polish, metal objects, jewellery, hearing aids, contact lenses, dentures, or body piercings before going for the surgery.

Different types of vulvectomy are done based on the type and extent of the cancer:

• Skinning vulvectomy: In this, the upper layer of vulvar skin is removed.
• Modified radical vulvectomy: Here, a portion of the vulva is removed, and at times, the adjacent lymph nodes are also removed.
• Radical vulvectomy: Here, the whole vulva, along with nearby lymph nodes is removed.
• Simple vulvectomy: The entire vulva is removed, and sometimes the clitoris is also removed.

The surgery is performed in the following manner:

• Once you are in the hospital, you will be asked to change into a robe or hospital gown.
• You will be placed on a medical table and given either a general or spinal anaesthesia. It will keep you away from pain, and you may be numbed down the waist.
• Your pubic hair shall be removed. You will have to wear compression stockings to stop the formation of blood clots in the lungs and legs.
• A tube is placed into the windpipe through the mouth, which will help you breathe during the surgery.
• A Foley (urinary) catheter will be placed to drain urine from your bladder.
• The surgeon will either make one or more incisions (cuts) in your vulvar area.
• The surgeon will remove the tumour and whole or part of your vulva. A few lymph nodes will also be removed as needed.
• Next, the surgeon may close the incision with sutures (stitches). In a few cases, the surgeon may use a skin graft, which is a healthy skin from another area of the body, to cover the exposed parts of the vulva.
• The area operated will be covered with a dressing. If a skin graft is done, then the donor site (the site from which the skin has been taken) also needs to be covered.
• The breathing tube will be removed and you will be shifted to a recovery ward after surgery and kept under observation for some time.

Other surgical options such as laser surgery, wide local excision, inguinal lymph node dissection, or pelvic exenteration (removal of organs in the pelvic region) may be considered based on the extent of the cancer spread. Treatments like radiation therapy (uses radiation or high energy X-rays) or chemotherapy (uses drugs) may be given after surgery to destroy any cancer cells left. 

• Laser surgery – This technique uses a powerful beam of light to destroy abnormal cells. The beam of light can be directed to a specific part of the body without making a large cut. This method can be used only in non-invasive diseases of the vulva. 
• Wide local excision – Here the cancer cells and a margin of surrounding normal or healthy tissue (1-2 cm) are removed.
• Inguinal lymph node dissection – Inguinal lymph nodes are present in the groin and their removal is an important step of the staging and prognosis of vulvar cancer. It is done for any vulvar tumour that is more than 2 cm or that has grown inside the underlying tissue of vulva by over 1 mm.
• Pelvic exenteration – It is an extensive surgery done to remove the lower colon, rectum and bladder along with the cervix, vagina, ovaries and nearby lymph nodes. Artificial openings are then made for urine and stool to pass out from the body into a collection bag.

It may take around 1 to 2 hours to complete the procedure. When you wake up, you may find tubes, bandages and drains around the vulvar area. You may have an intravenous line in your arm or hand to provide you with fluids, a pain pump (pump used to deliver pain medicine to you as required), and compression boots on the calves to help in blood circulation.

The time required to stay in the hospital depends on the type of surgery. You may go home the same day or a few days later for a less extensive surgery.

You may be allowed to go home with the drains. The nurse will teach you how to take care of the incisions at home. You will be given a small bottle with a squirt tip (peri-bottle, squeeze bottle) for cleaning the incisions around the vulva and perineum and will be shown how to use it.

At home, you will have to keep the following things in mind:

• You will be prescribed medicines for nausea and pain. These medicines along with self-care measures will also help ease swelling.
• Your regular medications will be restarted.
• Sexual and physical activity may be restricted at this time.
• You will need bed rest and will be asked to keep your legs together. After bed rest, you should avoid climbing stairs and limit walking. All of this will help in wound healing.
• For 3 to 4 weeks after surgery, you may only be able to sit on a doughnut (soft inflatable plastic ring) cushion or a soft pillow only. If the surgery was a major one, then you may not be able to sit until 8 weeks. However, you will be able to stand or lie down.
• You may eat a regular diet just like before surgery, unless advised by your doctor. Eat vegetables, fruits and whole grains. Try to eat a balanced diet with more calories and proteins to help you heal, and drink plenty of fluids. Avoid alcohol or caffeine.

Here are a few points to keep your incisions clean, and few tips to keep you comfortable while your wound heals.

• Wash your vulvar and anal region with warm water using peri-bottle each time you pass urine or have a bowel movement.
• Take a shower every day with soap and water. 
• Use a hand spray shower or a sitz bath (sitting in a warm water bath that covers the buttocks and hips) at least 2 times each day. 
• Pat dry your incisions with a clean towel. Avoid rubbing your incisions.
• Use loose-fitting clothing.
• Use ice packs to the affected area and leave the area open to air during the night.

If you have periods after your surgery, use 100% cotton pads when possible. Do not use synthetic panty liners or pads to absorb the blood.

When to see the doctor?

Call the doctor immediately if you have any of the following symptoms:

• Fever above 100.4°F (38°C)
• Severe pain (in which pain killer medicines do not seem to help)
• Bleeding that requires pad changing every hour
• Heavy vaginal discharge with a bad odour
• Chest pain or difficulty breathing
• Pain, redness, or swelling in the legs
• Fluid or blood that leaks from the incision or if the wound opens up
• Painful urination
• Nausea and vomiting
• Swelling around the area of incision

The risks associated with vulvectomy are:

• Wound problems like delayed healing, fluid-filled cyst formation, infections or graft site failure
• Swelling of the legs (lymphoedema)
• Urinary tract infections
• Narrow vaginal opening, painful intercourse or decrease in sexual pleasure
• Change in how the vulva looks, decreased libido, genital numbness (temporary)
• Change in the urine stream with extensive surgery, e.g., the urine stream may go to one side 
• Fatigue and discomfort
• Infection and scarring
• A blood clot in the lung or legs
• Bleeding
• Separation of wound edges
• Changes in body image and sexual function
• Blood blisters under the skin (hematoma)
• Need for additional surgery to remove more tissue

You will visit your surgeon around 2 to 4 weeks after the surgery. The surgeon will check the incisions and remove any remaining sutures, staples or drains. Thereafter, you will need to follow up regularly with your doctor to check for recurrence of the cancer.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.