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 the pelvic lymph nodes . This operation had a high morbidity rate with approximately 50 percent of the wounds experiencing breakdown.
Surgical procedures for the treatment of carcinoma of the vulva have become more conservative and individualized to each patient. The fundamental basis of surgery for the primary tumor is now complete excision with a minimum 2 cm margin and dissection down to the deep fascia and to the periosteum of the pubic symphysis. Although adenocarcinoma of the vulva is treated in much the same fashion as squamous cell carcinoma, involvement of Bartholin gland is still thought to require total radical vulvectomy. The management of malignant melanoma remains controversial. (See "Disorders of Bartholin gland" and "Initial surgical management of melanoma of the skin and unusual sites".)
The exact procedure used depends upon the site, size, and histologic features of the tumor (picture 1). The clitoris may be preserved if the tumor is situated posteriorly on the vulva or lies 2 cm or more from the clitoris or closer in selected cases [2-4].
When a groin node dissection is planned it is usually performed first, unless the patient's medical condition is uncertain, in such patients it is best to excise the vulva tumor first in case the anesthetic has to be abandoned.
The extensive nature of some of the procedures, the unavoidable distortion of the appearance of the perineal area, and stoma formation can lead to major psychosexual problems for the patient. Preoperative counseling and postoperative support are vital parts of patient management.