Types of surgery for vulval cancer

Surgery is the main treatment for vulval cancer. The type of surgery you have depends on different factors such as how big the cancer is and how much of your vulva is affected.

Deciding what surgery you need

A team of doctors and other healthcare professionals recommend the best treatment and care for you. They are called a multidisciplinary team (MDT). 

There are different types of surgery for vulval cancer. The type of surgery you have depends on different factors such as:

• where the cancer is on your vulva and how far it has spread

• the depth of the cancer. This is because your surgeon must remove all the cancer together with a border of healthy tissue around it

• whether the cancer has spread to the lymph nodes in your groin

• your personal wishes and feelings

• your general health

Your surgeon aims to remove all of the cancer while keeping as much healthy skin as possible. Removing all the cancer is the most important factor in trying to cure the cancer. Some women with vulval cancer only need surgery to cure their cancer. 

Types of surgery

You might have a wide local excision. This is when the surgeon removes an area of your vulva. For larger cancers, your surgeon might need to remove a larger part of your vulva. This is called a partial vulvectomy.

Rarely you might need to have your whole vulva removed. This is called a vulvectomy or a radical vulvectomy. 

Your surgeon also checks your lymph nodes . They may remove them if they contain cancer cells. 

Wide local excision

A wide local excision means that the surgeon removes the area containing the cancer, along with a border of healthy tissue around it. The border of healthy tissue is called the margin. It's important that the margin of healthy tissue does not contain cancer cells. This lowers the risk of the cancer coming back.

Your surgeon might also remove some nearby lymph nodes during this surgery.

Removing part of the vulva (partial vulvectomy)

The surgeon removes some but not all of the vulva. Depending on where your cancer is, they may also have to remove other parts. This includes:

• the clitoris
• the lymph nodes in one or both sides of your groin

The first diagram below shows a partial vulvectomy where the cancer is on one side of the vulva.

The next diagram shows a partial vulvectomy where the cancer is at the top of the vulva.

The last diagram shows a partial vulvectomy where the cancer is in the lower part of the vulva.

Removing the whole vulva (radical vulvectomy)

Surgery to remove the whole vulva is called a radical vulvectomy or vulvectomy. The surgeon removes the whole vulva, including the inner and outer lips of the vulva. You may also have the clitoris removed.

The most common type of vulvectomy operation is called a 3 in 1, or triple incision. This means that your surgeon does:

• one cut to remove the vulva itself
• 2 cuts (one on each side) to remove the lymph nodes

Removing and checking lymph nodes for cancer

Lymph nodes are part of a system of tubes and glands in the body that filters fluid and fights infection. There are lymph nodes all over our body, including in the groin area. 

It is important for doctors to know if the cancer has spread to the lymph nodes. This helps them decide if you need more treatment. 

For very early vulval cancer, it is unlikely that there are cancer cells in the lymph nodes. So you don't need to have the lymph nodes removed. This is usually stage 1A.

If your cancer is stage 1B or greater, your surgeon usually removes some lymph nodes during surgery. 

Removing lymph nodes in the groin

The lymph nodes in the groin are usually the first place where cancer cells spread from the vulva. So your surgeon may recommend you have the lymph nodes in the groin area removed. This is a lymph node dissection or lymphadenectomy. Your surgeon does this at the same time you have your vulval operation.

Removing the lymph nodes in the groin reduces the risk of the cancer coming back. It also gives the doctor information about the stage of your cancer. This helps them decide whether you need more treatment.

Your surgeon may remove the lymph nodes on one or both sides of your groin. This depends on how big the cancer is and where it is. 

Checking the sentinel node for cancer cells

Removing all the groin lymph nodes has side effects. It can affect fluid drainage in your legs and cause a condition called lymphoedema. So on some occasions, doctors may check for cancer cells in the sentinel nodes.

The sentinel node is the first node that fluid drains from the vulva. This means it’s the first lymph node the cancer could spread to. If this node does not contain cancer, it’s unlikely that further lymph nodes contain cancer cells.

Checking the sentinel node for cancer cells is called a sentinel node biopsy. You have it at the same time as surgery to remove the cancer.

You might have a sentinel node biopsy if:

• your cancer is smaller than 4cm
• you only have one area of cancer in the vulva
• the cancer has grown more than 1mm into the skin and tissues underneath. This is called stromal invasion

To have a sentinel node biopsy, your doctor first needs to find the sentinel node. They inject a dye or a small amount of a weak radioactive chemical (called a tracer) into the area around the cancer. The dye or radioactive tracer follows the route of the fluid that drains from the vulva to the lymph nodes. The first lymph node that the dye or tracer reaches is the sentinel node. 

The surgeon then removes this and sends it to the laboratory where a specialist doctor checks it for cancer cells.

If it doesn't contain cancer cells, there is a good chance that the cancer has not spread. You will not need surgery to remove the rest of the lymph nodes.

You will need further treatment if there are cancer cells in one or more sentinel nodes. You might have surgery to remove all the remaining lymph nodes. You may also have radiotherapy to the groin area.

Pelvic exenteration

Vulval cancer can sometimes spread from the vulva to other parts of the body such as the bowel, bladder or womb. This is advanced or metastatic vulval cancer.

For advanced vulval cancer, your treatment team may suggest that you have a radical vulvectomy and a pelvic exenteration. A pelvic exenteration is a big operation. Your surgeon removes one or more of the following:

• lymph nodes in the pelvis or groin
• the lower part of your bowel
• back passage
• bladder
• womb – the body of the womb (uterus) or neck of the womb (cervix) or both
• vagina

Having a pelvic exenteration is rare for vulval cancer. Your surgeon will only consider this if you are fit enough to make a good recovery. Doctors might suggest you have chemotherapy and radiotherapy instead of a pelvic exenteration. 

Vulval reconstruction

Vulval reconstruction means creating a new vulva after you have had surgery. The aim is to make sure your vulva will look similar to what it was before the operation. 

After removing the cancer, your surgeon may be able to stitch the remaining skin back together. Or you may need a skin flap or skin graft to repair the area, but your surgeon will avoid doing this if they can.

A skin flap is an area of healthy skin with its blood supply, which is moved from close by to cover the area where the skin has been removed.

Skin grafting is used less often than a skin flap. Grafting means your surgeon takes some healthy skin from another part of your body and stitches it over the site of the operation. The healthy skin is most often taken from your inner thigh. This is called the donor site. The donor site will heal on its own over a few weeks.

Other treatments you might have

Your doctor may suggest you have radiotherapy after surgery to try to kill any remaining cancer cells. This is called adjuvant treatment. It helps to lower the risk of the cancer coming back. You may have radiotherapy on its own or in combination with chemotherapy (chemoradiotherapy).

Your doctors may also suggest you have treatment before surgery. This is neo adjuvant treatment. The treatment might shrink the cancer and make it easier to remove. It may mean that you can have a smaller operation. 

Coping with vulval cancer surgery

Vulval surgery is probably one of the more difficult types of surgery to cope with emotionally and physically. It is one of the most private parts of a woman's body and plays a very big role in sexual life. It's normal to feel anxious and upset when you find out about the type of surgery you need. It may help you to cope better if you understand exactly what is going to happen. 

Most hospitals have a clinical nurse specialist (CNS) that supports women having this type of treatment. This nurse is there to answer your questions or just talk about how you are feeling.

There should be information available for you to take home with you. Ask your surgeon or clinical nurse specialist for a booklet or printed web pages that you can read through yourself. This will help you to work out what questions you need to ask next time you go to the hospital. 

You might find it useful to talk to someone about the effect that surgery will have on your everyday life. Ask your doctor or nurse what support is available in your area. You could ask about counselling if you think this might help.

Problems after surgery

You may have physical and psychological side effects after surgery for vulval cancer. This includes changes to your sex life and numbness in the vulval area.