Vulvar Cancer: Surgery

Surgery is the most common treatment for vulvar cancer. The goal of surgery is to remove the cancer (cancerous lesions) from the vulva while trying to leave as much normal tissue as possible. This helps reduce changes to your sex life and the way your bowels and bladder work. Another goal is to remove lymph nodes from the groin to check them for cancer. Sometimes surgery includes removing nearby tissue or organs.

You should be treated by a gynecologic oncologist. This is a specialist with extra training to diagnose, do surgery, and manage gynecologic cancers.

Types of vulvar surgery

These are some of the most common types of surgery for vulvar cancer:

Local excision

If you have a precancerous sore (lesion) or early-stage vulvar cancer (Stage 0 carcinoma in situ or Stage 1A), the surgeon may remove the cancer and some normal skin around it. This surgery is sometimes called wide local excision.

Laser surgery

This type of surgery uses a laser beam to cut out or kill abnormal cells. Laser surgery is sometimes used instead of wide local excision to treat precancerous lesions or Stage 0 (carcinoma in situ) vulvar cancers. It isn’t used to treat invasive cancer.

Vulvectomy

For this surgery, your healthcare provider removes part (partial vulvectomy) or all (total vulvectomy) of your vulva. The extent of surgery depends on the size of the tumor, where it is on the vulva, and how much of the vulva is affected. It also depends on the traits of the tumor and if the surgeon can remove enough normal tissue around the tumor.

Sometimes the entire vulva must be removed (the inner and outer labia and tissue just under the skin). This is called a simple vulvectomy. In some cases, the surgeon removes all of the vulva, including the deep tissues, and your clitoris (called a complete radical vulvectomy). It depends on where the cancer is in the vulva. In most cases, your surgeon can save the clitoris and remove part of the vulval along with the deep tissue (a partial radical vulvectomy).

Your surgeon will also think about how the area will look after surgery and how surgery will affect your quality of life. You may need a skin graft or skin flap if a lot of tissue is removed (reconstructive surgery). Talk with your healthcare provider about this so you know where the grafted skin and tissues will come from and how it will be done.

Lymph node surgery

This surgery may be called an inguinal lymph node dissection. Vulvar cancer often spreads to lymph nodes in the groin. So the surgeon may remove lymph nodes from your groin to check for signs of cancer. In most cases, the surgeon only removes the lymph nodes in the groin on the side of your body that has the tumor. If the tumor is near the center, lymph nodes might be taken out from both sides.

Lymph nodes might even be removed in women with small tumors. Ask your healthcare provider if sentinel lymph node biopsy (SLNB) is a choice for you. This involves finding the first lymph node that drains the area with the cancer. This node is taken out and tested during the surgery. If there are no cancer cells in it, no more nodes are removed. SLNB allows the surgeon to remove fewer lymph nodes for accurate staging. This reduces the chance of side effects that can happen when a lot of lymph nodes are removed.

Pelvic exenteration

If the cancer has spread outside your vulva to nearby organs, you may need a more complex, life-changing surgery. Your vagina, cervix, uterus, lower colon, rectum, or bladder may need to be removed. The extent of the surgery depends on where the cancer has spread. This surgery is called a pelvic exenteration. It's rarely needed for vulvar cancer. There are other choices for treatment when the cancer is so extensive. 

Risks of vulvar cancer surgery

All surgery has risks. The risks of vulvar surgery include:

• Heavy bleeding

• Wound healing problems

• Infection

• Blood clots

• Chronic leg swelling (lymphedema), if many lymph nodes were removed

• A collection of fluid where the lymph nodes were removed (seroma)

• Changes in sexual pleasure and desire

• Urinary tract infections

• Change in the urinary stream (urine may come out to the side or may spray)

Your risks depend on your overall health, what type of surgery you need, and other factors. Talk with your healthcare provider about which risks apply most to you.

Getting ready for your surgery

Your healthcare team will talk with you about the surgery choices that are best for you. You may want to bring a family member or close friend with you to appointments. Write down questions you want to ask about your surgery. Make sure to ask:

• What type of surgery will be done

• What will be done and what will be removed during surgery

• The risks and side effects of the surgery

• If there will be changes in how your body works after surgery

• When you can return to your normal activities

• If the surgery will leave scars and what they will look like

• If surgery will affect your sex life

Before surgery, tell your healthcare team if you’re taking any medicines. This includes prescription medicines, over-the-counter medicines, vitamins, herbs, and other supplements. Tell them if you use any form of marijuana or any illegal drugs. This is to make sure you’re not taking anything that could affect the surgery or the anesthesia. After you’ve talked about all the details with the surgeon, you’ll sign a consent form that says that the healthcare provider can do the surgery.

You’ll also meet the anesthesiologist or nurse anesthetist. You can ask questions about the anesthesia and how it will affect you. Just before your surgery, an anesthesiologist or a nurse anesthetist will give you medicines so that you fall asleep and don’t feel pain. In some cases the surgery can be done under a spinal anesthesia. This means the medicines are put into your lower back to make your lower body numb during the surgery.

What to expect after surgery

You may have to stay in the hospital for a few days. This depends on the type of surgery you had. For the first few days after surgery, you’ll likely have pain from the incision. Your pain can be controlled with medicine. Talk with your healthcare provider or nurse about your choices for pain relief. Some people don’t want to take pain medicine. But doing so can help you heal. If you don’t control pain well, you may not want to cough, turn over often, or get out of bed. You need to do this as you recover from surgery.

You’ll likely have a urinary catheter for a few days. This a tube put through your urethra and into your bladder so that your urine goes into a bag outside your body. You may go home with the catheter for a few weeks until you heal.

You may feel tired or weak for a while. The amount of time it takes to recover from surgery is different for each person.

The side effects you have after surgery depend mainly on the extent of your surgery. If your healthcare provider removes a large area of skin during surgery, you may need a skin graft or skin flap from another part of your body. This helps the vulvar wound to heal. But it also gives you another wound at the site the skin was removed for the graft or flap. Other side effects can include the following:

• Discomfort or pain. You’ll likely have some pain after surgery. After you heal, you might find that if you wear tight jeans or pants, you have some discomfort in the genital area. This is because some padding of vulvar tissue is now missing.

• Wound infection. The location and type of surgery increases the risk for wound infection. If you have a fever, redness or pain that gets worse, or discharge, tell your healthcare provider right away.

• Sexual changes. Depending on how much tissue is removed during surgery, you may have some numbness or trouble reaching orgasm. These changes may or may not go away.

• Genital or leg swelling. This is a side effect of lymph node removal. It's called lymphedema. The fewer lymph nodes removed, the less likely you will have this side effect. Talk with your healthcare provider about this risk. There are things you can do to help prevent it. Once it starts, it can be very hard to treat.

Talk with your healthcare provider about ways to cope with these side effects. Most can be treated, and some can be prevented. Be sure you know what to watch for and when you need to call your provider. Make sure you know what number to call if you have problems after office hours or on weekends or holidays.