False-negative sentinel nodes were reported by others, but were thought to occur with low incidence in patients with clinically nonsuspicious nodes (44,134,135). Two recent studies of sentinel nodes in vulvar cancer, one single institution study of 56 patients and one multi-institution study of 127 patients with inclusion criteria similar to those in GROINSS-V, showed an unexpectedly high false-negative rate (27% and 7.7%, respectively), some of which may be attributable to insufficient experience of low-volume providers (128,136). This highlights one of the key concerns that any wide implantation of the sentinel node procedure beyond select expert centers might carry with it an unjustifiable rise in the frequency of groin recurrences.
The 2008 International Sentinel Node Society’s expert panel statement stresses the importance of a well-informed patient treated by a skilled multidisciplinary team of a gynecologic oncologist, a nuclear medicine specialist, and a pathologist with expertise in the sentinel lymph node technique (137). They recommended the following eligibility criteria for the performance of the sentinel node procedure: unifocal primary tumor of 4 cm or less in diameter with greater than 1 mm invasion; and absence of any obvious metastatic disease on physical examination or imaging studies, including the absence of suspicious groin nodes. Until data from prospective randomized controlled trials document comparable survival for patients undergoing the sentinel node procedure compared to full inguinofemoral lymphadenectomy, complete inguinofemoral lymphadenectomy remains indicated in all but stage Ia disease, given the high mortality of recurrence in an undissected groin. The sentinel node technique should be limited to carefully selected patients in expert centers, ideally on research protocols.
Despite the age and general medical condition of many elderly patients with vulvar cancer, surgery is usually remarkably well tolerated. Patients should be able to commence eating a low-residue diet on the first postoperative day. In the past, bed rest was advised for 3 to 5 days postoperatively to allow for immobilization of the wounds and to foster healing. Because radical local excisions are being performed with increasing frequency and groin lymphadenectomy is done through separate incisions, patients begin ambulation on postoperative day 1 or 2. Pneumatic calf compression or subcutaneous heparin should be given to help prevent deep venous thrombosis, and active leg movements are to be encouraged. Frequent dressing changes are performed to keep the vulvar wound dry. Meticulous perineal hygiene is maintained. Suction drainage of each side of the groin is continued until output is minimal to help decrease the incidence of groin seromas. It is not uncommon for suction drainage to continue for 10 or more days. The Foley catheter is removed when the patient is ambulatory. If there is significant periurethral swelling, prolonged bladder drainage may be advisable. If there is breakdown of the vulvar wound, sitz baths or whirlpool therapy is helpful, followed by drying of the perineum with a hair dryer.
The major immediate morbidity is related to groin wound infection, necrosis, and breakdown. This complication is reported in as many as 53% to 85% of patients having an en bloc operation (32,33). With the separate-incision approach, the incidence of wound breakdown can be reduced to about 44%; major breakdown occurs in about 14% of patients (34,78,138,139). With appropriate antibiotics, debridement, and wound dressings, the area will granulate and re-epithelialize over several weeks and may be managed with home nursing. Whirlpool therapy is effective for areas of extensive breakdown. The most common complications with the separate incision approach continues to be wound infection requiring antibiotic therapy and lymphocyst formation, both reported in about 40% of cases (139). Symptomatic lymphocysts should be managed by periodic sterile aspiration.