Vulvar Cancer Surgery

Introduction

If you or someone close to you has been diagnosed with vulvar cancer, surgery is likely to be a central part of the treatment plan. This article is written for women who already have a diagnosis and are now trying to understand what the operation involves, how recovery typically unfolds, and what life looks like in the months and years afterwards.

Vulvar cancer is uncommon, and the surgery is tailored very closely to the individual tumour. Two patients with the “same” diagnosis can end up with quite different operations, depending on where the cancer sits, how deeply it has grown, and whether the lymph nodes in the groin are involved. The goal of this guide is to give you a clear, plain-language map of the options and the journey — so that the detailed conversation with your surgical team feels more navigable.

The treatment of vulvar cancer has shifted significantly over the last twenty years. Older operations were very extensive and left women with substantial physical and emotional after-effects. Current international guidelines from bodies such as the National Comprehensive Cancer Network (NCCN) and the European Society of Gynaecological Oncology (ESGO) favour the smallest operation that can remove the cancer safely, while still checking the lymph nodes properly. Understanding this shift can help you understand the choices your team is offering.

What Is Vulvar Cancer Surgery?

Vulvar cancer surgery is an operation to remove a cancer of the vulva — the external female genital area, which includes the labia majora, labia minora, clitoris, the opening of the vagina, and the perineum (the area between the vagina and the anus). The most common type of vulvar cancer is squamous cell carcinoma, which starts in the skin of the vulva. Other less common types include melanoma, basal cell carcinoma, Paget’s disease of the vulva, and adenocarcinoma of the Bartholin gland.

The operation has several aims:

• Remove the cancer completely, with a rim (margin) of healthy tissue around it.
• Check whether the cancer has spread to the lymph nodes in the groin, because this affects further treatment and prognosis.
• Preserve as much normal anatomy and function as the cancer allows.
• Provide tissue for the pathologist to confirm the type of cancer, its depth, and the status of the margins and lymph nodes.

In practice, “vulvar cancer surgery” is not a single operation but a family of procedures. The right combination is chosen based on the tumour size and location, how deeply it has invaded, whether the cancer is on one side or crosses the midline, the appearance of the groin lymph nodes on imaging, and your general health.

Why Is Vulvar Cancer Surgery Performed?

Surgery is the primary treatment for most early-stage vulvar cancers. For very small tumours that have not spread, surgery alone may be enough. For larger tumours or those that have reached the lymph nodes, surgery is usually combined with radiation therapy, sometimes with chemotherapy added.

The main reasons your team may recommend surgery include:

• Early-stage vulvar cancer (FIGO Stage I and II). The cancer is confined to the vulva, or has spread only to nearby structures such as the lower vagina or anus, and can be removed completely.
• Selected Stage III disease. Where the cancer has reached the groin lymph nodes but is still operable, surgery may be combined with radiation.
• Locally recurrent disease. If vulvar cancer returns in the same area after earlier treatment, further surgery is sometimes possible.
• Vulvar intraepithelial neoplasia (VIN) with high-grade or extensive changes. This is not cancer itself but a pre-cancerous condition that may be treated surgically to prevent progression.

For very advanced disease that has spread widely, surgery may not be the first step. Instead, the team may start with chemoradiation (chemotherapy combined with radiation) to shrink the cancer, and reconsider surgery afterwards.

Who Is a Candidate for Surgery?

Whether surgery is the right approach is a decision made by a multidisciplinary team — usually a gynaecologic oncologist (a surgeon who specialises in cancers of the female reproductive system), a radiation oncologist, a medical oncologist, a pathologist, and a radiologist. This group reviews your scans, biopsy results, and overall health before recommending a plan.

Factors the team considers include:

• Stage of the cancer. Staging follows the FIGO (International Federation of Gynecology and Obstetrics) system, which describes how big the cancer is, how deep it has grown, and whether it has spread to lymph nodes or distant organs.
• Tumour location. Cancers near the clitoris, urethra, or anus require careful planning to preserve function.
• Depth of invasion. Cancers that invade more than 1 mm into the tissue usually require lymph node assessment, while very superficial cancers may not.
• Lymph node status on imaging. MRI, CT, or PET-CT scans help estimate whether the groin nodes are involved.
• General health. Heart and lung fitness, diabetes control, nutritional status, and smoking history all affect surgical risk and wound healing.
• Personal preferences and priorities. Sexual function, body image, and the burden of follow-up are important parts of the decision.

Diagnosis and Pre-Surgical Evaluation

Before surgery, you will go through a structured cancer workup to confirm the diagnosis, define the stage, and plan the operation precisely.

Confirming the Diagnosis

The diagnosis of vulvar cancer is made on a biopsy — a small piece of the abnormal area is removed under local anaesthetic and examined under the microscope. The pathology report describes the cell type, the grade (how aggressive the cells look), and the depth of invasion. Your surgeon will rely heavily on this report when planning the operation.

Imaging

Imaging helps map the cancer and check for spread. You may have:

• MRI of the pelvis to show the cancer’s size, depth, and relationship to nearby structures such as the urethra, anus, and pubic bone.
• CT scan of the chest, abdomen, and pelvis to look for spread to lymph nodes or distant organs.
• PET-CT scan in selected cases, especially for larger tumours or suspected nodal involvement.
• Ultrasound of the groin sometimes used to look more closely at suspicious lymph nodes, occasionally with a needle biopsy.

Other Assessments

• Blood tests to check kidney and liver function, blood counts, and overall fitness for anaesthesia.
• Pelvic examination under anaesthesia in some cases, to map the cancer’s exact extent.
• Cervical and vaginal screening, because vulvar cancers linked to the human papillomavirus (HPV) can be associated with abnormalities elsewhere in the lower genital tract.
• Anaesthetic review, particularly important for older patients or those with other health conditions.

The Multidisciplinary Team Meeting

In most cancer centres, your case is presented at a multidisciplinary tumour board, where specialists agree on the recommended approach. This shared decision-making is considered standard practice in international gynaecologic oncology guidelines and helps ensure that your plan reflects the most current evidence.

Alternatives to Surgery

Although surgery is the cornerstone of treatment for most early vulvar cancers, it is not the only option in every situation. Understanding alternatives helps you have an informed conversation with your team.

Chemoradiation as Primary Treatment

For locally advanced cancers — particularly those involving the urethra, anus, or large parts of the vulva — combining chemotherapy with radiation therapy can shrink the cancer enough to either avoid very extensive surgery or make a smaller operation possible afterwards. This is sometimes called “organ-sparing” treatment because it can preserve structures such as the urethra and anal sphincter.

Radiation Therapy Alone

If surgery is not safe because of other medical conditions, radiation therapy by itself may be used to control the cancer.

Topical or Local Treatments for Pre-Cancer

For vulvar intraepithelial neoplasia (VIN) — the pre-cancerous condition — options other than surgery may include topical creams such as imiquimod, or laser ablation. These approaches do not provide a tissue sample for pathology, so they are not used for invasive cancer.

Clinical Trials

Vulvar cancer is rare, and trials of newer treatments — including immunotherapy for HPV-related cancers — are ongoing. Your oncology team can tell you whether any are relevant to your situation.

Surgical Approaches and Types of Vulvar Cancer Surgery

The operation is described in two parts: what is done to the vulva itself, and what is done to the lymph nodes in the groin. Reconstruction may be added to either.

Wide Local Excision

For small, early cancers, the surgeon removes the visible tumour along with a margin of healthy tissue around and beneath it — usually aiming for a margin of at least 1 cm. The rest of the vulva is left intact. This approach preserves as much normal appearance and function as possible.

Partial (Simple) Vulvectomy

A larger portion of the vulva is removed — for example, one labium majus or a section of the perineum — but not the whole vulva. This is used when the cancer is larger or in a position where wide local excision would not leave adequate margins.

Radical Vulvectomy

In a radical vulvectomy, the surgeon removes the cancer along with deeper tissue beneath it, down to the fascia (the firm layer over the underlying muscle). It may be radical local excision (removing only the cancer and surrounding tissue at full depth) or radical complete vulvectomy (removing most or all of the vulva). Current guidelines from NCCN and ESGO favour the more limited, tissue-sparing operations whenever possible, because removing the entire vulva is rarely necessary for modern early-stage disease.

Sentinel Lymph Node Biopsy

The sentinel lymph node is the first node, or small group of nodes, that drains lymph fluid from the area of the cancer. If cancer has spread to the lymph nodes, the sentinel node is statistically the most likely to be involved.

In this technique, a small amount of radioactive tracer, blue dye, or both is injected near the tumour before surgery. The dye or tracer travels through the lymph channels to the sentinel node, which the surgeon then locates and removes for examination. If the sentinel node is free of cancer, a full groin lymph node dissection can often be avoided.

Sentinel node biopsy is now recommended by major international guidelines as the preferred approach for selected patients — typically those with a single tumour smaller than 4 cm, no suspicious nodes on imaging, and depth of invasion greater than 1 mm. It significantly reduces the risk of long-term leg swelling (lymphoedema) compared with a full lymph node dissection.

Inguinofemoral Lymphadenectomy (Groin Lymph Node Dissection)

If the sentinel node contains cancer, or if the tumour is large, or if a sentinel node procedure is not suitable, the surgeon removes a larger group of lymph nodes from the groin — the inguinal (superficial) and femoral (deep) nodes. This may be done on one or both sides, depending on whether the tumour is on one side of the vulva or crosses the midline.

Groin lymph node dissection is a thorough cancer operation but carries a higher risk of wound problems, fluid collections (seromas), and lymphoedema than sentinel node biopsy.

Reconstruction

When a large area of vulvar tissue is removed, the surgeon may use reconstructive techniques to close the wound and restore appearance and function. Options include:

• Direct closure, where the edges of the wound are simply brought together.
• Local skin flaps, where nearby skin is moved to cover the defect.
• Myocutaneous flaps, where skin and underlying muscle from a more distant area — such as the inner thigh — are used to rebuild the vulva.

Reconstruction is planned jointly by the gynaecologic oncology and plastic or reconstructive surgery teams.

A Note on Open, Laparoscopic, and Robotic Surgery

Vulvar surgery itself is an open operation, because the vulva is on the body’s surface. Laparoscopic (keyhole) and robotic techniques may be used to help assess deeper pelvic lymph nodes in selected advanced cases, but most of the operation on the vulva is done through traditional open incisions.

Preparing for Vulvar Cancer Surgery

Good preparation can make a real difference to how surgery and recovery go.

Medical Preparation

• Review of all current medications. Some — particularly blood thinners and certain diabetes drugs — may need to be paused before surgery.
• Optimisation of conditions such as diabetes, high blood pressure, anaemia, or heart disease.
• Stopping smoking is strongly encouraged, ideally several weeks before surgery, because smoking significantly impairs wound healing in vulvar operations.
• Nutritional review — eating well in the weeks before surgery helps wound healing.

Practical Preparation

• You will be told when to stop eating and drinking before the operation.
• You may be asked to shower with an antiseptic wash the night before and morning of surgery.
• Hair around the surgical area is usually clipped, not shaved, just before the operation.
• Compression stockings or injections to reduce the risk of blood clots are usually started around the time of surgery.

Emotional Preparation

A vulvar cancer operation touches an intimate part of the body and can raise concerns about femininity, sexuality, and partner relationships. Many cancer centres offer access to a clinical psychologist, counsellor, or specialist nurse before surgery. Talking through your concerns — including questions about sexual function and reconstruction — with the surgical team in advance is encouraged by current gynaecologic oncology practice.

What Happens During Surgery

The exact steps depend on the operation planned, but a typical day in hospital looks roughly like this.

Admission and Anaesthesia

You are admitted to hospital, usually on the morning of surgery or the day before. The anaesthetist reviews your history and explains the anaesthetic plan. Most vulvar cancer operations are done under general anaesthesia. A nerve block or spinal injection may be added to help with pain control afterwards.

Positioning and Surgical Field

You are positioned with your legs supported, similar to a gynaecologic examination position. The skin is cleaned with antiseptic and sterile drapes are placed.

The Vulvar Part of the Operation

The surgeon marks the planned incisions, then removes the cancer with a margin of healthy tissue around and beneath it. The removed tissue is sent to the pathology lab. If reconstruction is planned, flaps are designed and moved into place.

The Lymph Node Part of the Operation

If a sentinel node biopsy is being done, the radioactive tracer or blue dye injected earlier guides the surgeon to the relevant node, which is removed through a small incision in the groin. If a full inguinofemoral lymphadenectomy is being done, longer incisions are made in the groin and the lymph nodes are carefully dissected from the surrounding blood vessels.

Drains and Closure

Small soft tubes (drains) are often placed under the skin in the groin area to remove fluid that collects in the first days after surgery. The wounds are closed with stitches, usually dissolvable, sometimes covered with a dressing.

Duration

A wide local excision with sentinel node biopsy may take around two hours. A radical vulvectomy with bilateral groin dissection and reconstruction can take four to six hours or more.

Recovery and Healing

In Hospital

Most patients stay in hospital for between two and seven days. During this time the focus is on:

• Controlling pain, usually with a combination of paracetamol, anti-inflammatory medicines, and stronger painkillers in the first days.
• Wound care — keeping the area clean and dry, gentle rinsing after passing urine, and careful inspection of the wounds and any flaps.
• Managing the urinary catheter, which is usually placed during surgery and removed after a few days.
• Caring for drains in the groin, which are usually removed once the fluid output drops.
• Getting you moving safely, starting with sitting up and short walks, to reduce the risk of blood clots and chest infections.
• Preventing constipation, because straining can be uncomfortable on a vulvar wound.

The First Two Weeks at Home

• Rest is important, but short, gentle walks several times a day help circulation and reduce clot risk.
• Wounds are typically washed gently with water; harsh soaps and scrubbing are avoided.
• Loose clothing and cotton underwear — or no underwear at home — reduce friction on the wound.
• Sitting on a soft cushion can help.
• Some swelling, bruising, and a feeling of tightness are normal as healing progresses.

Weeks Three to Six

• Stitches dissolve or, if non-dissolvable, are removed at a clinic visit.
• Light activities such as desk work, cooking, and short outings usually become possible.
• Heavy lifting, cycling, and strenuous exercise are still avoided.
• If a flap reconstruction was done, healing of the flap is monitored closely.

Six to Twelve Weeks

• Most patients can return to normal walking, work, and daily life, depending on the job and the extent of surgery.
• Sexual activity is usually resumed only after the surgical team confirms that healing is complete.
• Final assessment of healing, scar appearance, and any ongoing symptoms takes place.

Pathology results from the removed tissue and lymph nodes are usually discussed at a follow-up appointment within a few weeks of surgery. These results determine whether further treatment — such as radiation therapy — is recommended.

Risks and Complications

All cancer operations carry risks. Your surgical team will discuss the specific risks relevant to your operation as part of consent. The main categories are below.

General Surgical Risks

• Bleeding during or after surgery.
• Infection of the wound, the urinary tract, or the chest.
• Blood clots in the legs or lungs.
• Reactions to anaesthesia.

Wound-Related Complications

Wound healing problems are the most common short-term complication of vulvar surgery, particularly when large areas are removed or when groin dissection is done. They include:

• Wound breakdown, where parts of the wound separate before healing is complete.
• Wound infection.
• Skin flap problems, including delayed healing or partial flap loss.

Smoking, diabetes, obesity, and previous radiation increase these risks. Careful surgical technique, early mobilisation, and good wound care all help.

Lymph Node Surgery Complications

• Seroma — a collection of clear fluid in the groin, which sometimes needs to be drained.
• Lymphocele — a similar fluid collection lined by lymphatic tissue.
• Lymphoedema — chronic swelling of one or both legs because of disrupted lymphatic drainage. This is more common after full inguinofemoral lymphadenectomy than after sentinel node biopsy, and may benefit from specialist lymphoedema therapy.
• Numbness in the inner thigh from injury to small sensory nerves.

Longer-Term Effects

• Changes in the appearance of the vulva.
• Changes in sensation, including reduced clitoral sensation depending on the operation.
• Effects on sexual function — from physical changes, scar tissue, or dryness.
• Urinary changes — some women find that the direction of urine flow alters after surgery.
• Psychological and emotional effects, including changes in body image and mood.

Modern surgical planning, including the use of sentinel node biopsy and tissue-sparing operations, aims to reduce these effects without compromising cancer control.

Adjuvant Treatment After Surgery

For some patients, surgery alone is enough. For others, the pathology results show features that increase the risk of the cancer coming back, and further treatment is recommended.

Radiation Therapy

Radiation therapy to the vulva, groin, or pelvis may be recommended when:

• One or more groin lymph nodes contain cancer.
• The surgical margins are close to, or involve, the cancer and cannot be re-excised.
• The tumour has certain high-risk features such as large size or lymphovascular spread.

Radiation is typically given over several weeks in short daily sessions.

Chemotherapy

Chemotherapy is often combined with radiation (chemoradiation) when nodes are heavily involved or the disease is more advanced, because the combination is more effective than radiation alone in many situations.

Immunotherapy and Newer Treatments

For recurrent or metastatic vulvar cancer, immunotherapy and other targeted approaches are increasingly studied, particularly for HPV-related disease. Whether any of these are appropriate is a discussion to have with your medical oncologist.

Life After Vulvar Cancer Surgery

Follow-Up and Surveillance

After treatment, regular follow-up helps detect any recurrence early. A typical schedule, broadly consistent with international guidelines, is:

• Every three to four months during the first two years.
• Every six months in years three to five.
• Yearly thereafter.

Visits usually include a careful examination of the vulva, perineum, and groin, with imaging only if symptoms or examination findings raise concern. You will be asked about new lumps, bleeding, pain, or skin changes.

Sexual Health and Intimacy

Vulvar cancer surgery can change how the vulva looks and feels, and may affect sexual response, lubrication, and confidence. Most gynaecologic oncology services now consider sexual health a core part of follow-up. Helpful supports may include:

• Vaginal moisturisers and lubricants.
• Pelvic floor physiotherapy.
• Open communication with a partner about what feels comfortable.
• Specialist counselling, including psychosexual therapy where available.

If you have not been offered support in this area, it is reasonable to ask for it.

Lymphoedema Care

If you develop leg swelling, early referral to a lymphoedema therapist is helpful. Care may include skin care, specific exercises, manual lymphatic drainage, and compression garments. Recognising and treating cellulitis (skin infection) promptly is important, as cellulitis can worsen lymphoedema.

Emotional Recovery

Anxiety about recurrence, changes in body image, and feelings of grief or loss are common after vulvar cancer treatment. These feelings often improve with time but may need support — through your medical team, a psychologist, a cancer support group, or a counsellor. Some women find peer support from others who have been through similar treatment particularly valuable.

Healthy Habits

• Stopping smoking reduces the risk of cancer recurrence and improves long-term health.
• Maintaining a healthy weight supports lymphatic function and general recovery.
• Up-to-date cervical screening and attention to any new skin changes elsewhere in the lower genital tract remain important, particularly for HPV-related cancers.

Outcomes and Prognosis

The outlook after vulvar cancer surgery depends on several factors — the stage of the cancer, the status of the lymph nodes, the completeness of removal, and your general health. In general, outcomes are most favourable when the cancer is confined to the vulva and the lymph nodes are not involved, and become less favourable as nodal involvement and spread increase. Squamous cell carcinoma, the most common type, tends to behave differently from less common types such as melanoma.

Specific survival numbers vary between studies and populations, and they describe groups of patients rather than individuals. Your own outlook is best discussed with your oncology team, who can interpret your pathology and imaging in detail. What is clear from international experience is that early diagnosis, complete surgical removal, careful lymph node assessment, and appropriate adjuvant treatment together give the best chance of long-term cancer control.

Frequently Asked Questions

How painful is recovery from vulvar cancer surgery?

Pain is usually most noticeable in the first days after surgery and is managed with a combination of medicines. By two weeks, most patients have moved to simpler painkillers. Discomfort with sitting and walking is common in the early weeks and improves as the wound heals.

Will I always need my lymph nodes removed?

Not necessarily. For very superficial cancers (depth of invasion 1 mm or less), lymph node assessment may not be needed. For most other early cancers, a sentinel lymph node biopsy can replace full lymph node dissection if specific criteria are met. Full dissection is reserved for situations where the sentinel node is not suitable or contains cancer.

Can vulvar cancer come back after surgery?

Yes, recurrence is possible — either in the vulva, in the groin nodes, or, less commonly, at a distant site. Risk depends on stage, margins, and node status. Regular follow-up exists to detect recurrence early, when further treatment is most likely to be effective.

Will surgery change how I look and feel sexually?

Vulvar surgery can change the appearance of the vulva and may affect sensation, lubrication, and sexual response, particularly when larger operations are needed. Smaller, tissue-sparing operations and reconstructive techniques aim to limit these effects. Many women resume satisfying sexual lives after recovery, sometimes with the help of pelvic floor physiotherapy, lubricants, or counselling.

How soon can I travel after surgery?

This is a clinical decision based on how the wounds are healing, drain status, and the risk of blood clots from long journeys. Many patients need to remain near their surgical team for two to three weeks for wound checks and drain removal before longer travel is considered safe. Your surgeon will give specific guidance for your situation.

Do I need to stop hormone therapy or other medicines?

Some medicines — particularly blood thinners and some hormone treatments — may need to be adjusted before and after surgery. Bring a full list of your medications to your pre-operative appointment so your team can advise you.

Will I need radiation or chemotherapy after surgery?

Not everyone does. The decision is based on the final pathology, particularly margin status and lymph node involvement. If the team recommends further treatment, they will explain the reasons and the expected benefits and side effects.

Conclusion

Vulvar cancer surgery has changed significantly over the past two decades. Operations are more tailored, more tissue-sparing, and more focused on quality of life than they used to be, while still aiming to remove the cancer completely. The combination of careful staging, sentinel lymph node biopsy where appropriate, modern reconstructive techniques, and individualised adjuvant treatment now allows many women to achieve good long-term outcomes alongside meaningful preservation of function and well-being.

Every plan is built around the specific cancer, the specific person, and a careful conversation with the multidisciplinary team. Knowing the shape of the journey — the staging, the options, the operation, the recovery, and the longer-term follow-up — can help that conversation feel less daunting and more like a series of informed choices made together with your doctors.