Sparing of saphenous vein during inguinal lymphadenectomy for vulval malignancies

doi:10.1016/j.ygyno.2007.02.011

Gynecologic Oncology

Volume 105, Issue 3, June 2007, Pages 722-726

https://doi.org/10.1016/j.ygyno.2007.02.011 Get rights and content

Abstract

Objective

This work was set out to investigate the effect of saphenous vein preservation during inguinal lymphadenectomy for patients with vulval malignancies.

Methods

64 patients with vulval malignancies were allocated into two groups depending on their clinical stages, with one of them (31 patients included) being subjected to sparing of saphenous vein and the other to saphenous vein ligated surgery while treated with inguinal lymphadenectomy. The operative time, blood loss, 5-year survival rate, short- and long-term postoperative complications, 5-year survival rate and groin recurrence were selected as the monitored parameters, through which the above two groups were compared with each other using t test, χ² and life table analysis.

Results

(1) The median operative time for bilateral inguinal lymphadenectomy was 155 min (130–170 min) in the sparing group, compared to 140 min (120–170 min) in the excision group (P > 0.05). The median intraoperative blood loss was 295 mL (100–450 mL) in the sparing group, and 270 mL (150–390 mL) in the excision group (P > 0.05). (2) Short-term lower extremity lymphedema occurred with 27 patients (43.5%) in the sparing group and 44 patients (66.7%) in the excision group (P < 0.01). Still, short-term lower extremity phlebitis was observed with 7 patients (11.3%) in the sparing group while 17 developed phlebitis (25.8%) in the excision group (P < 0.05). However, there was no statistical difference in postoperative fever, acute cellulites, seroma, or lymphocyst formation. (3) Long-term complication occurrence rate decreased by about 50% in patients subjected to saphenous vein sparing surgery compared with those to ligated surgery, while there was no remarkable difference between two groups in the occurrence rates of phlebitis and deep venous thrombosis (P > 0.05). (4) The overall 5-year survival rate was 67.3%, with 66.7% and 68.0% for the excision group and the sparing group, respectively (P > 0.05).

Conclusion

The application of saphenous vein preservation technique during inguinal lymphadenectomy for patients with vulval malignancies could significantly decrease the occurrence rate of postoperative complications without compromising outcomes and should be widely put into clinical practice.

Section snippets

Background

Inguinal lymphadenectomy plays an important role in the cure of patients with inguinal metastasis from vulval cancer or prophylactic inguinal lymphadenectomy. Unfortunately, this treatment is often associated with multiple postoperative complications usually classified into minor-wound infection, seroma formation requiring drainage, skin necrosis, low extremity pain, and sense abnormity, and major-deep venous thrombosis, persistent seroma formation, flap necrosis requiring skin graft, low

Clinical materials

There were 89 patients with vulval malignancies enrolled in our hospital from Jan of 1989 to Dec of 2005, and 22 of them were referred from outside institutions for their recurrence or further surgery. 64 of the above 89 patients were subjected to radical vulvectomy combined with bilateral inguinal lymphadenectomy using separate groin incisions. These 64 patients were from 36 to 75 years old with the median age being 59, and 34 of them were more than 60 years old. The distribution of FIGO

Operative time duration and intraoperative blood loss

The median operative time for bilateral inguinal lymphadenectomy was 155 min (130–170 min) in the sparing group, similar to that in the excision group, 140 min (120–170 min) (P > 0.05). Besides, the estimated median blood loss was 295 ml (100–50 ml) in the sparing group, also similar to that in the excision group, 270 ml (150–90 ml) (P > 0.05), and no statistical difference was observed.

Wound healing

Primary wound healing was noted in 17 (27.4%) groin incisions in the sparing group vs. 11 (16.7%) in the excision

Discussion

The primary therapeutic approach to cure vulval malignancies is surgery, whose operative procedure for individual case depends closely on the size and location of the lesion, stage of the disease, general condition and age of the patient, as well as the condition of the surrounding tissue and possible continuance of sexual life. The routinely operative modality was radical vulvectomy with bilateral dissection of the groin nodes recommended by Tanssig and Way [2], [3], and the surgical treatment

Acknowledgments

We would like to thank Dr. Beihua Kong from Qilu Hospital of Shandong Medical University and J. Howard from Shandong University of China for their critical reading of the manuscript.

References (14)

M.P. Hopkins et al.
A comparison of staging systems for squamous cell carcinoma of the vulva
Gynecol Oncol.
(1992)
K.K. Dhar et al.
Changes in the management of vulval cancer
Best Pract. Res. Clin. Obstet. Gynaecol.
(2003)
W.J. Catalona
Modified inguinal lymphadenectomy for carcinoma of the penis with sparing of saphenous veins: technique and preliminary results
J. Urol.
(1988)
R. Rouzier et al.
Inguinofemoral dissection for carcinoma of the vulva: effect of modifications of extent and technique on morbidity and survival
J. Am. Coll. Surg.
(2003)
T.S. Dardarian et al.
Saphenous vein sparing during inguinal lymphadenectomy to reduce morbidity in patients with vulvar carcinoma
Gynecol. Oncol.
(2006)
F.J. Taussig
Cancer of the vulva: an analysis of 155 cases
Am. J. Obstet. Gynecol.
(1940)
S. Way
The anatomy of the lymphatic drainage to the vulva and its influence on the radical operation for carcinoma
Ann. R. Coll. Surg. Engl.
(1948)

There are more references available in the full text version of this article.

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Sparing of saphenous vein during inguinal lymphadenectomy for vulval malignancies

Abstract

Objective

Methods

Results

Conclusion

Section snippets

Background

Clinical materials

Operative time duration and intraoperative blood loss

Wound healing

Discussion

Acknowledgments

Gynecol Oncol.

Best Pract. Res. Clin. Obstet. Gynaecol.

J. Urol.

J. Am. Coll. Surg.

Gynecol. Oncol.

Cancer of the vulva: an analysis of 155 cases

Am. J. Obstet. Gynecol.

The anatomy of the lymphatic drainage to the vulva and its influence on the radical operation for carcinoma

Ann. R. Coll. Surg. Engl.