Other early postoperative complications include urinary tract infection, seromas in the femoral triangle, deep venous thrombosis, pulmonary embolism, myocardial infarction, hemorrhage, and, rarely, osteitis pubis. Anesthesia of the anterior thigh resulting from femoral nerve injury is common and usually resolves slowly.
One major late complication is chronic lymphedema, which occurs in about 30% of patients (32–34,138–140). Recurrent lymphangitis or cellulitis of the leg develops in about 10% of patients and usually responds to oral antibiotics. Urinary stress incontinence, with or without genital prolapse, occurs in about 10% of patients after radical vulvectomy and may require corrective surgery. Introital stenosis can lead to dyspareunia and may require a vertical relaxing incision, which is sutured transversely. An uncommon late complication is femoral hernia, which can be prevented intraoperatively by closure of the femoral canal with a suture from the inguinal ligament to Cooper’s ligament. Pubic osteomyelitis and rectovaginal or rectoperineal fistulas are rare late complications.
Other major long-term treatment complications associated with the extent of vulvar surgery include depression, altered body image, and sexual dysfunction (96,97). Modifications in the radical extent of the surgical approach and appropriate preoperative and postoperative counseling may help lessen some of the psychological trauma.
Role of Radiation Therapy
Radiation therapy traditionally had a limited role in the management of patients with vulvar cancer. In the orthovoltage era, local tissue tolerance was poor and vulvar necrosis was common, but with megavoltage therapy, tolerance improved significantly. Radiation therapy, frequently with concurrent chemotherapy, has an increasingly important role in the management of patients with vulvar cancer. It is important to remember that, with a rare exception, radiation therapy alone has little place in the primary management of vulvar cancer. It is indicated in conjunction with surgery.
The indications for radiation therapy for patients with primary vulvar cancer are evolving.
Radiation seems to be indicated in the following situations: 1.
Preoperatively, in patients with advanced disease who would otherwise require pelvic exenteration or suffer loss of anal or urethral sphincteric function.
2.
Preoperatively, in patients with fixed, unresectable groin nodes (141).
3.
Postoperatively, to treat the pelvic lymph nodes and groins of patients with multiple microscopically positive groin nodes, one or more macrometastasis (10 mm or larger), or any evidence of extracapsular spread.
Possible roles for radiation therapy include the following: 1.
Postoperatively, to help prevent local recurrences in patients with involved or close surgical margins (141–143).
2.
As primary therapy for patients with small primary tumors, particularly clitoral or periclitoral lesions in young and middle-aged women, for whom surgical resection would have significant psychological consequences (80).
No additional treatment is recommended if one microscopically positive groin node (5 mm or less tumor deposit) is found in a fully dissected groin. The prognosis for this group of patients is excellent, and only careful observation is required (57). If unilateral groin dissection was performed for a lateral lesion, there seems to be no indication for dissection of the other side, because contralateral lymph node involvement is likely only if there are multiple microscopic or any gross ipsilateral inguinal node metastases (57,60). For patients with a single groin node metastasis, a recent retrospective SEER database review suggests that adjuvant radiation may provide a therapeutic benefit, especially if the groin dissection was limited (144).