Radical vulvectomy

INTRODUCTION — Surgical procedures for the treatment of vulvar carcinoma have evolved considerably over the past several decades. Historically, the standard operation for the treatment of even a small invasive carcinoma of the vulva was radical vulvectomy with removal of the primary tumor, including a wide area of skin extending onto the medial thigh, groins, and lower abdomen, together with an en bloc resection of the inguinal and often pelvic lymph nodes [1]. This operation had a high morbidity rate with approximately 50 percent of wounds experiencing breakdown.

Increasing knowledge and understanding of the disease has allowed these surgical procedures to become more conservative and individualized. Such procedures are given a variety of names preceded by the word "radical," including hemivulvectomy, partial vulvectomy, anterior (horseshoe) vulvectomy, posterior (horseshoe) vulvectomy, local excision, and wide local excision. The fundamental aim of all these procedures is complete excision of the primary tumor with dissection down to the level of the deep fascia of the thigh and/or the periosteum of the pubis and inferior fascia of the urogenital diaphragm. The exact procedure used depends on the site, size, and histologic features of the tumor. In cases where the extent of tumor involvement would require resections that may lead to bladder and anal dysfunction, use of combined chemotherapy and radiation (chemoradiation) may reduce the volume and extent of the tumor and allow subsequent sphincter-sparing surgery to be performed.

Given the extensive nature of these procedures, the unavoidable distortion of the appearance of the perineal area, and potential for stoma formation, multidisciplinary collaboration and careful preoperative counseling are keystones in management.

Radical vulvectomy, including preoperative planning, operative technique, and postoperative care, is discussed here. Other related topics are discussed separately:

●(See "Vulvar cancer: Epidemiology, diagnosis, histopathology, and treatment", section on 'Bartholin gland carcinoma'.)

●(See "Squamous cell carcinoma of the vulva: Staging and surgical treatment".)

●(See "Squamous cell carcinoma of the vulva: Medical therapy and prognosis".)

●(See "Surgical management of primary cutaneous melanoma or melanoma at other unusual sites".)

PREOPERATIVE EVALUATION AND PREPARATION

Informed consent — Counseling of patients undergoing radical vulvar surgery includes the extensive nature of the dissection, the unavoidable distortion of the appearance of the perineal area, potential for stoma formation (in selected patients), and the potential effects on sexual function and body image.

Evaluation — The patient is evaluated for the ability to tolerate surgery and need for adjuvant therapy. (See "Squamous cell carcinoma of the vulva: Staging and surgical treatment", section on 'Pretreatment evaluation' and "Squamous cell carcinoma of the vulva: Medical therapy and prognosis", section on 'Patient selection'.)

Symptoms of urinary incontinence and anal sphincter weakness are carefully assessed and documented. Urinary or fecal incontinence may be an issue postoperatively, particularly with anterior or posterior radical vulvectomies, and may require additional surgical and/or medical management.

Prophylactic antibiotics — Antibiotics are given prior to radical vulvectomy to help prevent surgical site infection. This is discussed in detail separately. (See "Gynecologic surgery: Overview of preoperative evaluation and preparation", section on 'Antibiotic prophylaxis'.)

Thromboprophylaxis — Most patients undergoing radical vulvectomy are at moderate to high risk of venous thromboprophylaxis (eg, extensive pelvic dissection, delayed ambulation postoperatively) and require both mechanical (ie, intermittent compression devices) and pharmacologic (eg, subcutaneous prophylactic heparin) methods to minimize this risk. This is discussed in detail separately. (See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients".)

Role of bowel preparation — Bowel preparation is typically reserved for patients in whom a posterior dissection involving the anus or rectum is anticipated. Bowel preparation is typically not needed for other patients. (See "Gynecologic surgery: Overview of preoperative evaluation and preparation", section on 'Bowel preparation'.)

Surgical margins — The optimum tumor-free margin at surgery is 2 cm, though the exact margins are defined by the extent of the tumor.

While a 2 cm margin typically allows for a minimum pathologic margin of 8 mm [2], studies suggest that the extent of the pathologic tumor-free margin may not impact recurrence rates. Closer negative margins may be tolerated, especially when the tumor extends close to the clitoris or anus [3-7]. Nevertheless, the surgeon should aim for a 2 cm margin where feasible.

Anesthesia — General, epidural, or spinal anesthesia may be used based on patient-specific comorbidities, the anticipated extent of the excision, and preferences of the patient and surgeon.

SURGICAL TECHNIQUE — The focus for readership of this topic (gynecologic oncologists) will be on the extirpative technique of radical vulvectomy. The procedures of radical hemivulvectomy, radical partial vulvectomy, and radical local excision/resection are also incorporated in this description.

Vulvectomy procedure — The patient is placed in Allen stirrups with the hips abducted 45 degrees and flexed 45 to 90 degrees with care to minimize risk for femoral and common peroneal nerve injury. It is helpful to position the patient so that the perineum protrudes over the bottom of the operating table. A pad or cushion is placed under the sacrum. The electrosurgery return electrode (Bovie) pad is placed away from the thigh in case skin flaps need to be raised.

The skin is prepared to include all areas that may be required for skin flaps. The patient is examined carefully to identify the local disease distribution and then a marking pen is used to mark where the skin should be incised, both externally and within the vagina. The types of incisions used are individualized depending primarily on the site and size of the tumor (figure 1). A urethral catheter is inserted into the bladder. The skin incision is begun posteriorly and extended laterally on both sides, similar to the procedure for a simple vulvectomy, but the excision margins are wider, and the dissection is taken all the way through the subcutaneous fat to the deep fascia. (See "Vulvar wide local excision and simple vulvectomy", section on 'Procedure'.)

If frozen sections are required to ensure that the intended resection margins are clear of tumor, they are taken at this time and can be removed as small ellipses in the line of the incision. However, this is not routine practice, given increased operative time, cost, and the possibility of false-negative results. Only biopsies should be sent for frozen section, not the entire vulvectomy specimen.

The tissues are circumferentially separated from the deep fascia and pubic ramus with scalpel, scissors, or electrocautery until the intended posterior and lateral margins are reached, at which point the direction of dissection is central, toward the vaginal outlet, clitoral structures, and urethra. While circumferential tensioning of the specimen with the use of an Allis clamp is often employed to facilitate efficient separation of the specimen, care should be taken to minimize crush injury of the specimen margins so that a reliable pathologic assessment can be performed. Multiple strategies for maintaining hemostasis (eg, monopolar electrocautery, bipolar sealing devices, suture ligatures and clips) can be used and the choice is based on surgeon preference. For posterior dissections, branches of the pudendal artery should be anticipated as they are encountered posterolaterally. In posterior dissections, unintentional trauma to the anal sphincter can be avoided with the aid of a finger in the rectum to guide the dissection depth. If necessary, the outer capsule and anterior third of the anal sphincter can be removed with the specimen without significant risk for anal incontinence. In these cases, care must be taken to properly reinforce the sphincter with interrupted sutures prior to skin closure.

The dissection is carried medially and posteriorly toward the clitoral attachments by sweeping the specimen off the periosteum of the pubic bones, conserving the deep fascia until the clitoral attachments are reached (picture 1A-B). The suspensory ligament, which includes the neurovascular bundle of the clitoris, may be clamped, transected, and suture ligated.

The vaginal incision is then made circumferentially, ensuring that the required margin around the tumor is maintained. The tip of a scalpel or Kelly forceps is passed through the specimen in the midline to isolate the crura (picture 2 and picture 3). They are held with forceps, divided, and then suture ligated with absorbable sutures. The specimen is detached completely, and hemostasis is obtained with either electrocautery or suture ligatures. Venous sinuses around the urethra and vaginal margin may be difficult to control without use of a figure-of-eight suture. The specimen is sent for histology with the orientation marked.

Evaluation of lymph nodes — The inguinofemoral lymph nodes are the most important prognostic indicator in squamous cell carcinoma of the vulva [8]. As a result, proper performance of either a full inguinofemoral lymphadenectomy or sentinel lymph node biopsy (SLNB) for patients at increased risk for inguinal metastases is of utmost importance. The role of lymph node evaluation in patients with invasive vulvar melanoma is less clear. How to perform these procedures is detailed here; indications for these procedures, and the choice between them, are discussed separately. (See "Squamous cell carcinoma of the vulva: Staging and surgical treatment", section on 'Inguinofemoral lymph nodes' and "Surgical management of primary cutaneous melanoma or melanoma at other unusual sites".)

It is important to note that surgical volume for inguinofemoral lymph node dissection among gynecologic oncologists outside of specialized centers is low, making skill development and maintenance of this technique challenging. For this reason, low-volume surgeons are encouraged to perform this procedure with the assistance of another experienced surgeon who is comfortable with these techniques whenever feasible.

Inguinofemoral lymph node dissection — Inguinofemoral lymphadenectomy consists of removal of the inguinal (superficial) and femoral (deep) lymph nodes (figure 2 and figure 3) and can be performed unilaterally or bilaterally (figure 4). (See "Squamous cell carcinoma of the vulva: Staging and surgical treatment", section on 'Inguinofemoral lymph nodes'.)

Lymphadenectomy is usually performed prior to the vulvectomy procedure unless the patient's medical condition is frail. In such patients, it is best to begin with excision of the vulvar tumor in case the procedure has to be abandoned. If an inguinofemoral lymph node dissection alone is to be performed, the patient is placed supine with the legs abducted 30 degrees and externally rotated or in Allen stirrups to allow closer access for both the surgeon and assistants. The legs can be repositioned after the groin node dissection so that the hips and knees are flexed.

For patients with a clinically negative lymph node examination, the groin incision runs 2 cm below and parallel to the inguinal ligament which is drawn between the medial and cephalad prominence of the anterior superior iliac spine and the cephalad and lateral border of the pubic symphysis of the respective groin. The incisions starts 3 cm distal and medial to the anterior superior iliac spine and ends below the superficial inguinal ring (picture 4) and is typically 6 to 8 cm in length. The incision should be above the inguinal fold, if possible, to allow for improved wound healing. If there is concern for superficial inguinofemoral lymph node metastases, an elliptical skin incision can be made in the same line so that the overlying portion of skin can be excised with the nodes.

The incision is made through the full thickness of the skin and 2 to 3 mm of adipose tissue. Allis forceps or a self-retaining (eg, Weitlaner) retractor are applied to the skin and superficial adipose tissue to provide traction. Scissors, scalpel, monopolar cautery, or a bipolar sealing device are used to dissect through the subcutaneous adipose tissue laterally to expose the glistening fascia of the aponeurosis of the external oblique muscle 3 cm above the inguinal ligament (picture 5). Care must be taken not to dissect too close to the skin of the flaps because this will jeopardize the blood supply and may lead to flap necrosis. Scarpa (superficial) fascia, when prominent, can occasionally be mistaken for the external oblique aponeurosis, but does not have the glistening silver color. Once the external oblique aponeurosis is identified, the fatty tissue containing the inguinal nodes can be tractioned anteriorly and dissected off the inguinal fascia in a lateral to medial direction until the lower (medial) margin of the inguinal ligament, femoral triangle, and cribriform fascia are exposed.

The superficial inguinal nodal bundle is then elevated, and the dissection is continued posteriorly and caudally through the subcutaneous fat to the deep fascia of the thigh. Although the initial incision and dissection should span the entire length of the caudal flap, it is easier to identify the deep fascia at the lateral end. Once the deep fascia has been reached, dissection of the fatty bundle containing the inguinofemoral lymph nodes off the deep fascia is performed from lateral to medial (picture 6). Laterally, the circumflex iliac vessels need to be electrocauterized, but throughout the dissection care must be taken to control bleeding. A finger is passed beneath the round ligament as it exits from the superficial inguinal ring. Traction on the proximal end of the round ligament and the medial end of the inguinofemoral lymph node fatty bundle facilitates the dissection of tissues containing lymphatic vessels leaving the vulva (picture 7).

The fatty nodal bundle is grasped with forceps and elevated. Anteromedially the great saphenous vein (GSV) is identified ascending into the thigh from the medial side. The vein is typically left in situ but can be ligated and divided at the distal margin, if needed.

The tissues on the medial and caudal side of the GSV are dissected from the deep fascia. The proximal GSV in the nodal bundle is followed down to the saphenofemoral junction. Although the pulsation of the femoral artery is a good landmark for identifying the position of the common femoral vein, it is best approached by following down the medial side of the GSV. The proximal GSV is dissected free on all sides and suture ligated approximately 0.5 to 1 cm from the saphenofemoral junction, taking care not to narrow the common femoral vein. The specimen is removed, usually by dividing the lymphatic tissues entering the femoral canal.

The deep femoral nodes may have been removed with the specimen but if not, residual tissue is dissected from the anterior and medial surfaces of the femoral vein above the lower limit of the fossa ovalis (figure 3). Any fatty tissue in the femoral canal is excised. Lacerations of either the femoral vein or artery are repaired with either 4-0 or 5-0 nonabsorbable (polypropylene; Prolene) sutures. A divided inguinal ligament is repaired with 0 polyglactin or polypropylene to minimize risk of hernia formation.

If the deep fascia has been extensively removed to expose much of the femoral artery and vein in the floor of the femoral triangle, and especially following preoperative radiation, a sartorius muscle flap can be swung across to protect the femoral vessels. The muscle forms the lateral boundary of the femoral triangle running from the medial condyle of the tibia to the anterior superior iliac spine. A finger is passed underneath the belly of the upper part of the muscle and, using electrosurgery (cutting mode), the muscle is divided close to the anterior superior iliac spine (figure 5). It is then swung across and sutured to the inguinal ligament just above the femoral vessels (figure 6).

Before closure, the skin flaps are checked to ensure that they are viable. If not, they need to be trimmed back to viable skin. A suction drain is brought out anterolaterally, cephalad to the groin, and secured. A layer of absorbable suture is typically used to close the subcutaneous layer utilizing Scarpa fascia as a landmark. The skin is closed with staples or interrupted vertical mattress sutures, ensuring that the skin edges are neatly apposed and everted. If a large defect is left, such as after radical resection of disease in the groin, the defect can be closed with a skin flap. (See 'Closure' below.)

Sentinel lymph node biopsy — Identification of the sentinel lymph node (SLN) is facilitated by a combination of vital dyes in conjunction with preoperative lymphoscintigraphy [9] or single photon emission computed tomography [10]. One to three hours before surgery, approximately 2 mCi of technetium 99m-labeled sulfur colloid in a volume of 1 cc is injected intradermally in four quadrants around the tumor in the radiology department [11]. Serial lymphoscintigraphs are taken until a technetium-avid SNL is identified within the inguinal lymph node basin. These images, when evaluated in relation to bony landmarks of the groin, facilitate initial localization of the inguinal incision and angle of dissection.

Intraoperatively, 1 to 3 mL of a vital blue dye (eg, 1% isosulfan blue) are injected intradermally around the tumor periphery using an insulin-type syringe and fine-gauge needle. The dye can usually be seen entering the lymphatics. The site of the groin incision is determined by use of a hand-held gamma probe angled both into the inguinal nodal basin and away from the vulva to avoid any confounding radioactivity emanating from the injected vulvar tumor. The SNL is identified based on its high count, usually at least 10 times the basal count (picture 8). A 2 to 4 cm incision is made over the localized area and parallel to the inguinal line. Groin adipose tissue is divided and separated from the underlying lymph node bundle until the radioactive ("hot") and isosulfan blue stained nodes are visualized, dissected free of its perforating lymphatic and vascular attachments, and sent to pathology for permanent analysis. Additional nodes identified as being possible sentinel nodes should be removed based on interpretation of the preoperative lymphoscintigram along with gamma probe and dye findings following removal of the initial node. In addition, any suspicious lymph nodes should be removed.

If the SNL is not detected, then a completed inguinofemoral lymph node dissection should be performed (see 'Inguinofemoral lymph node dissection' above). The node(s) can be sent for frozen section so that if it is positive for metastatic disease, the appropriate inguinofemoral lymph node dissection can be performed; however, this is controversial and is not always performed. If negative, the wounds are closed with subcuticular suture with or without a closed suction drain (picture 9).

ANCILLARY PROCEDURES FOR SELECTED TUMORS — In some patients, additional procedures may be required to ensure complete excision of the carcinoma.

Involving the urethra — If the tumor involves the urethra, the distal 1 to 1.5 cm of the urethra can typically be excised without significantly affecting urinary continence. The residual urethral mucosa should be included in the suture closure of the surrounding skin.

If more than the distal 1.5 cm of the urethra must be excised, the patient will likely experience complete urinary incontinence. Thus, such patients will often undergo primary radiation therapy. However, when surgery is performed, an anterior exenteration (ie, removal of the bladder, urethra, and anterior vagina) with urinary diversion is often performed along with the radical vulvectomy. (See "Exenteration for gynecologic cancer", section on 'Anterior exenteration'.)

Involving the vagina — The extent and localization of vaginal involvement dictate the amount of surgery required.

Patients with involvement of the lower lateral walls of the vagina can often be managed by resection and primary closure. In patients with tumor involving the anterior or posterior walls, care must be taken not to damage the bladder or rectum while achieving clear margins around the tumor. An exenterative procedure may be needed for those with extensive involvement of the anterior or posterior vagina. (See "Vaginectomy" and "Exenteration for gynecologic cancer".)

Involving the anus and rectum — Several procedures have been described for the excision of tumor involving the anus and rectum.

When the lesion just encroaches on the anus, or there is a suspicion of encroachment, the anterior third of the anus and anal sphincter can be excised without major impact on continence [12]. The external anal sphincter is repaired with multiple interrupted 0 polyglactin sutures. For extra support of the sphincter mechanism, the distal limbs of the puborectalis may be plicated together anterior to the anus. The skin can be closed with rhomboid flaps [13].

In many cases, partial resection of the anus would be oncologically insufficient to achieve an adequate margin and thus, such patients will often undergo primary chemoradiation therapy. When surgery is performed, anovulvectomy [14,15], anoproctectomy [16], or posterior exenteration can be used. Anoproctectomy differs from anovulvectomy in that a more extensive perianal/perirectal dissection is needed to encompass the distal rectum. Both procedures involve fecal diversion with either an end or loop colostomy (see "Overview of surgical ostomy for fecal diversion"). These procedures, however, are rarely indicated in settings where radiotherapy is an option. When performed, they should be done in a multidisciplinary setting and managed or comanaged with plastic and colorectal surgeons experienced in vulvar and perineal techniques.

Involving the bony pelvis — In cases of central tumor involvement, excision of the central part of the pubic symphysis or parts of the ischial pubic rami can be performed with the Gigli saw or an equivalent instrument [17]. Orthopedic consultation should be obtained preoperatively given the concern for postoperative pelvic instability.

CLOSURE — Closure after radical vulvectomy is discussed here briefly, and the description of surgical technique is intentionally limited.

Primary closure — Following mobilization of the circumferential soft tissue, the wound can often be closed primarily without resorting to special techniques. Care is taken to oppose the skin above the urethral meatus to the residual skin of the mons pubis. Marker sutures may be placed to assess the way in which the edges will come together. Closure of posterior lesions often requires mobilization of the posterior and posterolateral vaginal mucosa from the rectovaginal septum and perineal body for tension-free approximation of the skin.

For large wounds, or those utilizing musculocutaneous transposition flaps, a suction drain with wide holes may be inserted on one or both sides and brought out through the perineum (picture 10). Paraffin gauze is placed over the wounds and covered by a gauze dressing held in place by medical mesh underwear.

Closure of larger skin defects — Methods available for closure of larger skin defects should be carefully considered during preoperative planning. Many gynecologic oncologists perform simple fasciocutaneous advancement flaps, including rhomboid flaps and V-Y advancement flaps [13,18]. Other, more complex closures, such as anterolateral thigh, lotus pedicle, rectus abdominis, and anterior obturator perforator flaps are often managed or comanaged with plastic surgeons experienced in vulvar and perineal techniques [19-22]. The selection of the most appropriate closure technique for the specific defect is based on a number of factors and is beyond the scope of this topic.

Uncommonly, some wounds are deemed infeasible for closure based on patient factors (eg, medical comorbid conditions, surgical risk) and require packing with povidone iodine-soaked gauze and regular fibrinous debridement. Such patients require considerable skilled postoperative nursing care while the wound is allowed to granulate.

POSTOPERATIVE CARE — Postoperatively, the patients can start mobilizing the day after surgery. Use of pneumatic calf compression, active leg movements, and pharmacologic thromboprophylaxis minimize the risk of deep venous thrombosis and embolism. (See 'Thromboprophylaxis' above.)

A urethral catheter is removed when the patient is ambulatory; a longer period of catheterization may be necessary in patients who are chronically incontinent to allow the wound to heal in a relatively dry environment. The wound is inspected daily to ensure continued healing and to detect early signs of infection. The perineum is cleansed with sterile saline after the first 48 hours and dried with a hair dryer. Sitz baths are begun a few days later.

For patients in whom the anal sphincter or rectum was repaired, a low-residue diet is advised to avoid excessive stretch of the perianal sutures during defecation. Patients who undergo anovulvectomy with sigmoid colostomy typically experience intermittent discharge of small amounts of mucus from the rectum into the perineum. Occasionally, the mucus may be retained in the residual rectum and requires release either digitally or by dilation of the perineal opening.

For patients in whom lymphadenectomy was performed, a suction drain is placed to allow time for the incision to heal and the underlying soft tissue edges to approximate and heal. The drain can be removed once the wound edges have healed, and after a daily log of lymph drainage tapers (surgeon preference, but usually when drainage of serous fluid has decreased to <20 to 25 mL per day for two consecutive days). The wound is kept dry and inspected for signs of necrosis or infection.

COMPLICATIONS — Radical vulvectomy has a high morbidity rate. In one series including 101 patients with vulvar carcinoma treated with modified radical vulvectomy and complete inguinofemoral lymphadenectomy, complications occurred in 76 percent of patients and included [23]:

●Lymphocyst formation (40 percent).

However, rates of clinically significant lymphocyst formation are lower, and it is not unusual for a large volume of lymph fluid to be observed in the closed suction drains; this will invariably taper with time. It is of utmost importance to ensure the drains are functioning properly. Persistent lymphocyst, however, is uncommon as the wound typically becomes adherent to the underlying tissues, obliterating the cavity that allows the fluid to collect. For symptomatic patients, aspiration of cyst fluid may be attempted. (See "Complications of gynecologic surgery", section on 'lymphedema and lymphocyst'.)

●Infection (39 percent).

Infection can occur early or chronically. Signs of infection should prompt culture of the affected tissue and early antibiotic use.

Infection is more common in those with lymphedema [24]. Urinary tract infection may also occur.

●Lymphedema (28 percent).

Chronic lymphedema may occur, particularly if lymph node dissection was performed in association with radiation therapy, and may be associated with recurrent bouts of infection (lymphangitis). While infections can be treated with elevation and antibiotics, the edema may be less responsive to therapy. The patient can try compression stockings and elevation and may benefit from treatment at a lymphedema center.

Use of a fibrin sealant at time of surgery does not appear to decrease rates of lymphedema. In a randomized trial including 137 patients undergoing surgical management of vulvar cancer, use of fibrin sealant followed by sutured closure compared with sutured closure alone resulted in similar rates of lower extremity lymphedema [24].

●Wound breakdown (17 percent); historically this rate was much higher (>50 percent) [1].

Superficial wound separation usually heals by secondary intention. Hematomas/seromas, although unusual if adequate drainage is maintained, may require evacuation.

Skin flaps may necrose partially or completely, particularly after radiation treatment. Necrosed tissue should be excised, and the wound should be allowed to granulate. Localized loss of sensation of the skin in the thigh area may also occur.

●Other – Other complications include thromboembolism, osteitis pubis, stenosis of the vaginal introitus, and pelvic organ prolapse. These complications are discussed in related UpToDate content.

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

●Definition – Radical vulvectomy is performed for the treatment of vulvar carcinoma and involves complete excision of the primary tumor with dissection down to the level of the deep fascia of the thigh and/or the periosteum of the pubis and inferior fascia of the urogenital diaphragm. Modifications to radical vulvectomy have focused on limiting the extent of tissue removal and reducing the need for complete inguinal node dissections to reduce morbidity. The exact procedure used depends on the site, size, and histologic features of the tumor (figure 1). (See 'Introduction' above.)

●Informed consent – Counseling of patients undergoing radical vulvar surgery includes the extensive nature of the dissection, the unavoidable distortion of the appearance of the perineal area, potential for stoma formation (in selected patients), and the potential effects on sexual function and body image. (See 'Informed consent' above.)

●Surgical margins – The optimum tumor-free margin at surgery is 2 cm, though the exact margins are defined by the extent of the tumor. (See 'Surgical margins' above.)

●Evaluation of lymph nodes – The inguinofemoral lymph nodes are the most important prognostic indicator in squamous cell carcinoma of the vulva. As a result, proper performance of either a full inguinofemoral lymphadenectomy or sentinel lymph node biopsy (SLNB) for patients at increased risk for inguinal metastases is of utmost importance. How to choose between these procedures is discussed separately. (See 'Evaluation of lymph nodes' above and "Squamous cell carcinoma of the vulva: Staging and surgical treatment", section on 'Inguinofemoral lymph nodes'.)

●Ancillary procedures – Ancillary procedures may include distal urethrectomy, vaginectomy, anovulvectomy, posterior exenteration, sigmoid colostomy, and pubic symphysectomy. Use of combined chemotherapy and radiation (chemoradiation) may limit the extent of surgery by reducing the volume and extent of the tumor. (See 'Ancillary procedures for selected tumors' above and 'Introduction' above.)

●Large defects – Fasciocutaneous or musculocutaneous transposition flaps may be necessary to close large defects on the vulva and perineum. (See 'Closure of larger skin defects' above.)

●Complications – Complications are common and include lymphocyst formation, infection, lymphedema, wound breakdown, vaginal stenosis, and pelvic organ prolapse. (See 'Complications' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges C William Helm, MD, MBBChir, FRCS, MRCOG, who contributed to earlier versions of this topic review.