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BACKGROUND

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Radical vulvectomy has 2 major variations: en bloc radical vulvectomy and bilateral inguinal lymphadenectomy and the technique with separate vulvar and groin incisions. Historically, all cases of vulvar cancer were treated by the classic en bloc radical vulvectomy popularized by Taussig and Way in the 1940s and 1960s.1,2,3 This procedure demonstrated superior outcomes compared with simple vulvectomy and, as a result, became the therapeutic approach for virtually all cancers of the vulva. Advances in the understanding of disease etiology, natural history, and prognostic factors precipitated changes in practice focusing more on individualization of care and paralleled the more contemporary realization that it is possible to adhere to the important principles of wide excision of the primary tumor and diagnostic/therapeutic removal of groin lymph nodes without performing radical vulvectomy with bilateral inguinal lymphadenectomy on all patients.4,5,6 In addition, recent advances in irradiation therapy combined with sensitizing chemotherapy have greatly reduced the requirement for radical vulvectomy as primary treatment of locally advanced vulvar cancer.7 Today, radical vulvectomy using separate groin incisions or radical wide excision is the preferred technique for most cases of locally advanced disease not amenable to treatment with chemoradiation, because this approach is associated with less risk of wound breakdown and overall morbidity.

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INDICATIONS AND CLINICAL APPLICATIONS

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The surgical management of vulvar cancer has evolved over the past 3 decades. Contemporary surgical treatment principles include tailoring the radicality of resection of the primary lesion (eg, wide radical excision), more conservative techniques for assessing regional lymph nodes (eg, unilateral lymphadenectomy, sentinel node biopsy), and the liberal use of reconstructive surgical techniques to restore anatomy and function. The main indication for radical vulvectomy is invasive squamous carcinoma of the vulva stages II to IVA: non-lateralized T2 lesions (> 2 cm in maximal diameter), T3 lesions (adjacent spread to the lower urethra, vagina, or anus), and T4 lesions (spread to the upper urethra, bladder or rectal mucosa, or pubic bone) not amenable to radical wide excision or combined chemoradiation. Additional indications may include extensive Paget’s disease of the vulva with an underlying adenocarcinoma, advanced adenocarcinoma of the Bartholin’s gland with infiltration of vulvar soft tissues, locally advanced vulvar melanoma (without evidence of regional or distant spread), and extensive verrucous carcinoma of the vulva (generally not treated with radiation therapy, which may aggravate the disease and lead to dedifferentiation). Extensive hydradenitis suppurativa not amenable to more conservative resection may also be managed by radical vulvectomy, although there is no requirement for formal node dissection.

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The wide radical excision of the vulva procedure arose from the move toward individualized treatment for patients with vulvar cancer. In properly selected patients, radical wide excision has been associated with similar recurrence and survival outcomes as radical vulvectomy while offering a substantial reduction in morbidity and improved quality of life and self-image. Radical wide excision as an alternative to radical ...

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