Vulvar Cancer Surgery
Operating on the vulva alone caused complications in 21.8 percent of women. Adding a full groin clearance took that figure to 54.2 percent in the same cohort.
About This Department
In a national cohort of 182 women treated for vulvar cancer, complications inside the first 30 days occurred in 21.8 percent of those who had surgery on the vulva alone, 39.6 percent of those who also had sentinel nodes taken, and 54.2 percent of those who had the groin lymph nodes cleared. The vulval part of the operation barely moved that number. The groin part more than doubled it, and that single pattern drives almost every decision described here, from how the nodes are assessed to how long the wounds take to heal and how long you should expect to stay in the country.
Free consultation
Find out whether your groins can be spared a full clearance
The review costs nothing and commits you to nothing. Send the biopsy report with the tumor type and depth of invasion, any MRI or CT of the pelvis and groins with the actual images, a photograph of the lesion if your own doctor has taken one, and a note of any previous vulval surgery or radiotherapy. A gynecologic oncologist will tell you which operation your case calls for and whether sentinel node biopsy is open to you.
The operations, and what each removes
Surgery for vulvar cancer stopped being one operation about forty years ago. The old approach removed the entire vulva together with both groins through a single butterfly-shaped incision, and it cured women at a heavy price in healing, swelling and sensation. What replaced it is a graded set of procedures, chosen to take out the cancer with a clear rim of normal tissue and nothing more.
- Wide local excision. The lesion and a rim of surrounding skin come out, leaving the rest of the vulva in place. Suitable for a small, single tumor, and the commonest operation performed today.
- Partial radical vulvectomy. A larger block of tissue, taken down to the deep layer, removing one side or one region of the vulva while sparing the rest.
- Total radical vulvectomy. The whole vulva, reserved now for extensive or multifocal disease, and much less common than it was.
- Groin node surgery. Sentinel node biopsy or full inguinofemoral lymphadenectomy, performed through separate incisions in the groin creases, away from the vulval wound.
Most women having treatment today have a combination, usually a wide local excision on the vulva with sentinel node biopsy in one or both groins. Whether the clitoris, the urethral opening or the anal margin can be preserved depends entirely on where the tumor sits, and that conversation belongs at the consultation, with the surgeon pointing at your own images.
Ask for the operation to be named. Precisely.
Margins, and the eight millimeter rule
Almost every guideline and almost every surgeon will mention eight millimeters. The figure refers to the width of healthy tissue between the edge of the cancer and the cut edge of the specimen, measured under the microscope after fixation, and the received wisdom holds that anything narrower raises the chance of the cancer coming back in the same place. Surgeons therefore aim for a centimeter of clearance in the operating theater, knowing the tissue shrinks in the pot.
The rule is shakier than it sounds.
What the margin evidence actually shows
According to PubMed, a meta-analysis of ten studies found that a tumor-free margin under 8 mm carried a higher risk of local recurrence, with a pooled risk ratio of 1.99. In the authors' own cohort of 148 women, no clear difference appeared between the narrow and the wide margin groups, and the only independent predictor of recurrence in the multivariable analysis was a margin with tumor actually reaching it (Nooij et al, 2016). The authors concluded that the 8 mm threshold deserves questioning as a prognostic marker.
Two things follow for a woman making a decision. A report describing a margin of five or six millimeters is not the disaster it can be made to sound, and it does not automatically mean returning to theater, because the evidence for re-excising a clear but narrow margin is weak. A margin with tumor at it is different, and that finding does lead to a discussion about further surgery or radiotherapy. Establish which of the two your report describes before agreeing to anything further.
The groin decides this operation
Vulvar cancer spreads first to the lymph nodes in the groin, and whether those nodes contain cancer is the single most powerful predictor of survival in this disease. Finding out used to mean removing every node from both groins, an operation that produced wound breakdown, repeated skin infections and permanent leg swelling in a substantial fraction of the women who underwent it. The whole modern effort has gone into learning who can safely avoid it.
Sentinel node biopsy
A radioactive tracer and a blue dye go into the skin around the tumor before surgery, travel the lymphatic channels the cancer would use, and mark the first node in each groin. The surgeon removes those nodes alone, through small incisions, and the pathologist examines them in far more detail than a routine node would receive.
What the evidence showed
PubMed indexes a multicentre study in which 403 women with tumors under 4 cm had the procedure across a multicentre study, and where the sentinel node was clear the groin clearance was omitted. Among 259 women with a single tumor site and a negative node, followed for a median of 35 months, six groin recurrences occurred, a rate of 2.3 percent, and three-year survival reached 97 percent. Groin wound breakdown fell from 34.0 to 11.7 percent, cellulitis from 21.3 to 4.5 percent, and leg swelling from 25.2 to 1.9 percent compared with women who went on to full clearance (Van der Zee et al, 2008).
Where it does not apply
Sentinel biopsy suits a single tumor under 4 cm with groin nodes that look normal on imaging and feel normal on examination. Multifocal disease pushes the decision back toward full clearance, and so do a larger tumor, a node that looks suspicious on the scan, and a groin that has already been operated on or irradiated, since each of those makes the mapping less reliable in a different way. A unit offering sentinel biopsy outside those criteria is stretching the evidence past where it goes. Establish which criteria you meet.
This table scrolls sideways on a narrow screen. Swipe or drag to see every column.
| Extent of surgery | Complications within 30 days | Lasting leg swelling |
|---|---|---|
| Vulva only | 21.8 percent | Not attributable to groin surgery |
| Plus sentinel node biopsy | 39.6 percent | 3.8 percent |
| Plus full groin clearance | 54.2 percent | 38.6 percent |
Those figures come from a Swedish population-based cohort, so they describe ordinary practice instead of a trial's selected patients, and wound dehiscence in the groin ran at 8.3 percent after full clearance against nothing at all after sentinel biopsy (Rahm et al, 2022), also according to PubMed. Whichever hospital you choose, request one number above all others, which is how many sentinel node procedures for vulvar cancer it performs in a year.
When the sentinel node has cancer in it
Around one woman in five who has the procedure turns out to have cancer in a sentinel node, and the question then becomes whether the rest of the groin still has to come out or whether radiotherapy can do the same job with less damage. A large European study answered it, and the answer turns on a measurement of two millimeters.
The two millimeter line, and what a trial paid to find it
According to PubMed, 1535 women were registered and the sentinel node contained cancer in 322 of them, or 21.0 percent. Among 126 women whose deposit measured 2 mm or less and who received groin radiotherapy instead of surgery, isolated groin recurrence at two years ran at 1.6 percent. Among the women whose deposit measured more than 2 mm, radiotherapy produced a two-year isolated groin recurrence rate of 22 percent against 6.9 percent for those who had the groin cleared surgically (Oonk et al, 2021). The trial had opened with radiotherapy offered to every woman with a positive node, whatever its size. Read the last pair of numbers twice. Radiotherapy substituted for surgery in the wrong group tripled the chance of the cancer returning in the groin, and that finding emerged only because the trial had a stopping rule and used it. Less surgery is the right instinct in this disease, up to a threshold measured in millimeters, and past that threshold it costs lives.
So the size of the deposit belongs on your pathology report as a measurement in millimeters. Request it.
Closing the gap and rebuilding
A small excision closes directly, with the edges brought together and stitched, and the result settles into a line that becomes hard to find after a year. Larger removals leave a defect that will not close under its own tension, and forcing it shut guarantees the wound will open again in the second week. Reconstruction exists to prevent exactly that. The commonest technique brings healthy skin and fat from immediately alongside the defect, still attached to its own blood supply, and rotates or advances it into place. Flaps taken from the inner thigh, the lower abdomen or the buttock crease all appear in operative notes for this surgery, chosen for what the defect needs and what the woman's own anatomy offers. A plastic or reconstructive surgeon frequently scrubs alongside the gynecologic oncologist for the larger cases, and their presence is planned in advance from the imaging.
Reconstruction adds theater time. It also adds a second wound at the donor site. It buys a closure that heals, which counts for a great deal in this operation, and it also shapes the eventual appearance far more than the excision itself does. Anyone facing a larger removal should have that conversation before the day, with drawings, because the alternative is meeting the result for the first time in a mirror.
Theater day and the first nights
Where sentinel node biopsy forms part of the plan, the day does not start in theater at all. It runs in this order.
- Nuclear medicine first. A small dose of radioactive tracer goes into the skin around the tumor and images are taken to show where it travels.
- The blue dye follows once you are asleep, and between them the tracer and the dye mark the node the cancer would reach first.
- General anesthesia, with the legs supported.
- A urinary catheter for the first day or two, because passing urine over a fresh vulval wound is difficult at the start.
A wide local excision with sentinel biopsy takes about two hours. A radical vulvectomy with bilateral groin clearance and flap reconstruction can run to five or six, and drains are left in the groins afterward to collect the lymph fluid that would otherwise gather under the skin. Those drains stay in for days, sometimes for a week or more, and their output is what the team watches before removing them.
One or two nights covers a small excision with sentinel nodes. Five to ten nights is ordinary after groin clearance and reconstruction, and it is a stay the wounds dictate rather than the anesthetic.
Wound healing, said plainly
Women say nobody warned them about this part, so here it is without softening. Wounds in the vulva and the groin sit in a warm, moist, mobile area crossed by urine and by the friction of walking, and they break down more often than wounds almost anywhere else on the body. In the Swedish cohort above, groin wound dehiscence followed 8.3 percent of full clearances, and separate series report considerably higher figures where the excision was large or a flap was used. A wound that opens in the second week is a recognized event with a management plan attached, and it is not a sign that the operation failed or that anyone did anything wrong.
What happens then is dressings, patience and time. An open groin or vulval wound is packed and dressed daily, heals from the base upwards over some weeks, and almost always closes without further surgery, which is the sentence to hold on to if it happens to you. District or community nursing does most of that work, which is precisely why an international patient needs it arranged at home before departure. A collection of lymph fluid under the groin skin, called a lymphocele, is the other common event. It feels like a soft swelling. Draining it with a needle once or twice usually settles the matter, and it rarely needs anything more than that. Infection is treated with antibiotics and is common enough that a prescription to take home is sensible.
Leg swelling, and how to limit it
Removing the groin nodes interrupts the drainage route for the whole leg on that side, and in the Swedish cohort lasting swelling followed 38.6 percent of full clearances against 3.8 percent of sentinel biopsies. Radiotherapy to the groin afterward makes it more likely again. The swelling can begin months or even years after the surgery, which catches women who thought they had escaped it.
Nothing cures it. Plenty controls it.
Compression garments fitted by a lymphedema specialist, manual lymphatic drainage, meticulous skin care to keep infections out, and early treatment of any cellulitis together keep most legs functional and comfortable, and the single most useful thing an international patient can do about any of it is to identify a lymphedema service near home before traveling, because the referral takes weeks in many health systems and the results are better where treatment starts early. Weeks matter here. Ask the surgical team to write the referral letter before you fly.
Sensation, sex and appearance
Vulval surgery changes how the area looks and how it feels, and consultations skate over this far too often. How much changes depends on what was removed and where. Excision of a small lesion on the labium majus may leave sensation almost untouched, while surgery close to the clitoris alters it substantially, and a total vulvectomy changes both appearance and sensation permanently. Numbness around the scars is usual at first and improves over months without ever fully returning to normal. Narrowing of the vaginal opening can follow a wide excision near it, and where that is a risk, a vaginal dilator program started once healing allows keeps the opening usable and is far easier than correcting the problem later. Intercourse waits until the wounds have healed, which for most women means six to eight weeks and longer where a wound broke down. Lubricant helps. Request it early. So does telling the surgical team which functions you most want protected, and telling them before the operation, since the extent of the excision is sometimes adjustable at the edges and the surgeon can only weigh what they know.
Specialist psychosexual support exists and works. Request the referral. Ask about vaginal dilators in the same conversation, before discharge rather than after it, because they are far easier to obtain and be shown how to use while you are still under the care of the team that operated on you.
Recovery, week by week
The recovery divides into three windows, and the middle one is the one that decides how long you stay.
Three windows, and the middle one matters most
The first week, when the wounds dominate
Sitting is uncomfortable. Washing with plain warm water and drying gently with cool air matters more than any product on any shelf, and a soft cushion together with a bottle of water to pour while passing urine will make the first days bearable. Both belong in the suitcase rather than on a list of things to buy on arrival.
Weeks two to four, when a wound opens if it is going to
The drains come out and walking extends. This is also the window in which a wound that is going to break down usually does, which is why a wound review belongs in the travel plan rather than left to chance.
Week four onwards, slower to watch and steadier
Sitting becomes comfortable again, and most women manage light work somewhere between four and eight weeks, depending on how extensive the surgery was and whether the wound stayed closed.
Three things need contacting someone about the same day. A wound that becomes hot, red and increasingly painful, whether that starts on the second day or in the fifth week. A leg that swells or aches on one side. And fever.
Traveling for the operation
Three to four weeks in the country is the realistic plan where the groins are being operated on, with two or three days at the front for imaging review, blood tests, anesthetic assessment and the consultation itself, five to ten nights for the admission where groin clearance or reconstruction is involved, and the balance for drain removal, wound review and a fitness-to-fly check. Where the surgery is a small excision with sentinel nodes alone, ten to fourteen days covers it. Book the return flight loosely, because this is the operation in the whole of gynecological oncology where a delayed departure is most likely, and a wound that opens in the second week is exactly the scenario that keeps someone an extra ten days.
This table scrolls sideways on a narrow screen. Swipe or drag to see every column.
| Small excision with sentinel nodes | Groin clearance or reconstruction | |
|---|---|---|
| In the country | Ten to fourteen days | Three to four weeks |
| Before surgery | Two or three days for imaging review, blood tests, anesthetic assessment and the consultation | The same two or three days |
| The admission | One or two nights | Five to ten nights |
| Afterward | A wound review and a fitness-to-fly check | Drain removal, wound review and a fitness-to-fly check, with room for a wound that opens |
| The return flight | Bookable with reasonable confidence | Book it loosely. This is the operation in gynecological oncology where a delayed departure is most likely |
Arrange three things before you fly. Community or district nursing at home able to dress an open wound. A named lymphedema service, with the referral letter already written. And a plan for who reviews the pathology report, which will issue after you have left.
Bring a companion. Sitting, walking and dressing are all harder than expected through the first fortnight, and a second pair of hands turns an ordeal into an inconvenience.
What drives the cost
Quotes for this surgery separate mainly on how much groin work is involved and whether the defect needs reconstructing, since those two decisions govern theater time, the number of surgeons scrubbed, the length of stay and the likelihood of a complication that extends it. Sentinel node biopsy adds the nuclear medicine tracer, the imaging session and the gamma probe, and the detailed pathology that follows a sentinel node costs more than a routine node examination because the tissue is cut and stained at multiple levels. Reconstruction adds theater hours and frequently a second surgeon. Published packages in this market ordinarily cover surgeon and anesthesiologist fees, theater time, a defined number of nights, pre-operative imaging and blood work, histopathology, and transfers with interpreting, while flights, accommodation beyond the stated nights, radiotherapy afterward, and treatment of a wound complication sit outside them.
Read this exclusion twice
Treatment of a wound complication sits outside almost every package
That exclusion carries more weight here than in any other gynecological cancer operation, because wound breakdown after groin surgery is ordinary rather than rare. Ask what an extra ten days of dressings, nursing and inpatient nights would cost before you accept a figure, not after a wound opens in the second week.
Before accepting a quote, establish what an additional inpatient night costs and how many the figure assumes, whether sentinel node mapping and its pathology sit inside the total, what happens financially if reconstruction proves necessary once the excision is done, and whether dressings and district nursing during a longer stay are covered. Only a surgeon who has seen your biopsy report and your imaging can answer any of it, and that review costs nothing.
Back home, and the follow-up
Carry the operative note, the full histopathology with the margin distance in millimeters and the size of any nodal deposit in millimeters, a copy of the imaging, and a written statement of what the treating team recommends next. Those two measurements decide whether anything else is needed. A report giving them as words instead of figures should go back for correction. Once you are home, follow-up for vulvar cancer runs on examination, because recurrences appear on the skin where they can be seen and felt. Review every three to four months for the first two years is the usual pattern, and it needs a clinician willing to examine the vulva properly at each visit. Scans are arranged when something is found, and no sooner. Recurrence on the vulva is treatable, frequently with further surgery, and it is found early when someone is looking. Report any new lump, ulcer, itch or color change without waiting for the next appointment.
What the operating team can still do from a distance
Remote follow-up with the operating surgeon earns its keep in the first months, particularly for judging whether a slow-healing wound is on track, and a clear photograph sent to the team who did the surgery settles in a day what would otherwise cost a week of worry.
Frequently asked questions
Will the whole vulva be removed?
Do my groin lymph nodes have to come out?
My margin was under 8 mm. Do I need more surgery?
If a sentinel node is positive, can radiotherapy replace groin surgery?
How likely is the wound to open?
Why should I book the return flight loosely?
References
- Van der Zee AGJ, Oonk MH, De Hullu JA, et al. Sentinel node dissection is safe in the treatment of early-stage vulvar cancer. J Clin Oncol. 2008;26(6):884-889.
- Oonk MHM, Slomovitz B, Baldwin PJW, van Doorn HC, van der Velden J, et al. Radiotherapy versus inguinofemoral lymphadenectomy as treatment for vulvar cancer patients with micrometastases in the sentinel node. Results of GROINSS-V II. J Clin Oncol. 2021;39(32):3623-3632.
- Nooij LS, van der Slot MA, Dekkers OM, et al. Tumor-free margins in vulvar squamous cell carcinoma. Does distance really matter? Eur J Cancer. 2016;65:139-149.
- Rahm C, Adok C, Dahm-Kähler P, Stenström Bohlin K. Complications and risk factors in vulvar cancer surgery. A population-based study. Eur J Surg Oncol. 2022;48(6):1400-1406.
Written by the Biruni Hospital medical editorial team.
Reviewed by Dr Yunus Emre Yavuz, Gynecologic Oncology.
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