AFJOG

ORIGINAL RESEARCH African Journal of Obstetrics and Gynaecology | Volume 2 | Issue 1 | 2024 | Complications following Surgical Management of Vulvar Cancer in a South African teaching hospital ABSTRACT Introduction: In the current surgical management of invasive vulvar cancers, a triple-incision technique is used which entails a separate incision for the primary vulval lesion and one for each groin. The commonest morbidities recorded are groin wound breakdown, cellulitis, lymphocyst formation , and lymphedema. Chronic lymphoedema is reportedly the most debilitating consequence of inguinal lymphadenectomy. Methods: This study retrospectively reviewed complications associated with surgical management consisting of wide local excision, vulvectomy, and vulvectomy with lymphadenectomy of vulvar cancer in patients seen over a five year period from 2013 to 2017 at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH). The study employed quantitative techniques with a 5% significance level. Results: Of 114 files identified, data of 78 women were available for analysis. The mean age of women in our study was 44.07 years (SD±11.75). About 75% of women with vulvar cancer presented with an ulcer or a vulvar mass. In this study, ulcers and vulval lesions together accounted for 73% of clinical presentations with 17% presenting with pain. Procedures performed included radical vulvectomy on 46 (59.00%), hemi vulvectomy on 15 (19.20%), a wide local excision on 15 (19.20%) and 34 (43.60%) women had clitorectomy at the time of vulvectomy. Fifty nine (75.60%) women also had inguinal lymph adenectomy done, and two (2.60%) had sentinel lymph node biopsy. Fifty six (73.70%) women had primary repair and closure of the wound at vulvectomy, and 14 (18.40%) required a reconstruction flap. Intra-operative complications included haemorrhage in 29 (38.70%) women, vessel injury in one (1.30%), and other in one (1.30%) women respectively. There were no complications in 34 (45.30%) women. Wound breakdown and sepsis were the commonest post-operative complications in both vulval wounds and groin wounds. More than 50% of cases had surgical advanced stage III disease and above even though most of the patients were clinically presumed stage II at the time of surgery. There was an association between groin lymphocyst formation, groin sepsis, groin haematoma, and the final pathology report of a benign or malignant lesion. There was no statistical association between post-operative vulval wound complications and whether the lesion was malignant or benign. Conclusion: Vulval wounds have a high risk of developing sepsis and breakdown. The comorbidity of HIV infections increases the risk of sepsis and sepsis-related wound breakdown. The routine use of drains on groin wounds did not prevent lymphocyst formation. It is not known if skin care or specific pre-operative hygienic practices in these populations would perhaps reduce the sepsis and wound breakdown rate. Keywords: Vulva Cancer, Vulvectomy, Wound Breakdown, Wound Sepsis, Lymphocyst formation, Vulvectomy Complications. Funding: This study was not funded, nor did it receive any grants. Conflict of Interest: The authors declare that they have no conflict of interest. INTRODUCTION Vulvar cancer is rare, and according to Smith, 1 it constitutes about 3-5% of all gynaecological cancers. It ranks as the fourth most common gynaecologic cancer and as the 20th most common female cancer. 2,3 It arises from a range of skin conditions that are pre-malignant, and this is via two major pathways. These include human papillomavirus (HPV) dependent lesions with precancerous vulva intraepithelial neoplasia (VIN) and non-HPV dependent lesions such as lichen sclerosus, which is associated with mutations in TP53, extramammary Paget’s disease, and lichen planus. 4 Non-HPV- dependent vulvar cancer is associated with a worse prognosis thanHPV-associated vulvar cancer. However, its carcinogenesis has not been fully clarified. 4 About 75% of patients will present with an ulcer or a vulval mass. 1 The remainder will have incidental findings such as vulval pruritus, pain, irritation, vaginal discharge or bleeding. A combination of these signs and symptoms is not uncommon. Historically, vulvar cancer is considered a disease of the elderly, with 80% of patients older than 65 years in the UK. A South African study in 2017 found that women who present with vulvar cancer are 10 - 15 years younger than those presenting in high-income countries (HICs). 5 This change is related to the presence of HIV infection. 5 Fu et al in their study of characteristics and outcomes for patients with advanced vaginal or vulva cancer, found that 67% of these patients presented with squamous cell carcinoma, 86% had good functional status, with an Eastern cooperative oncology group (ECOG) performance status of 0 or 1, and median overall survival (OS) of 5.6 months. 6 Obese patients were found to have a median OS of 13.2 months, longer than those who were not obese (4.4 months; 3.1-5.7; p = 0.04). 6 Surgery is the mainstay of treatment. In the current surgical management of invasive vulvar cancers, a triple-incision technique is used. This entails making a separate incision for the primary vulval lesion and one for each groin. Some developments resulted in changes in the management of these cancers to reduce postoperative morbidity. An example is the application of techniques such as sentinel lymph node biopsy and chemo-radiation. 7 Many patients with vulvar squamous cell carcinoma (SCC) have early-stage disease with cT1 (<2 cm) or cT2 (>2 cm) KA Kgomo, 1, 3 L Mbodi, 2, 3 YAdam 1, 3 1 Department of Obstetrics and Gynaecology, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa 2 Department of Obstetrics and Gynaecology, Gynaecologic Oncology Unit, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa 3 Department of Obstetrics and Gynaecology, Gynaecological Oncology Unit of the University of the Witwatersrand, Johannesburg, South Africa CORRESPONDENCE: Dr Koena Allen Kgomo| Email: koena.kgomo@wits.ac.za Complications following Surgical Management of Vulvar Cancer in a South African teaching hospital African Journal of Obstetrics and Gynaecology | Volume 2 | Issue 1 | 2024 | 24