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 tumour without suspicious inguinal lymph nodes. It is standard treatment for these early-stage SCC of the vulva to be managed with a wide local excision (WLE) of the tumour in combination with uni- or bilateral inguinofemoral lymphadenectomy. 8 Radical vulvectomy and bilateral inguinal lymphadenectomy is the treatment of choice for other operable stages. Nodal status has shown a predominant role as a predictor of survival. The addition of bilateral inguinal lymphadenectomy at radical vulvectomy allows for improvement of overall survival reaching about 70%. 9 According to Hinton et al, about 80% of patients will experience morbidity. 8 There has been an observed decline in morbidity over the past two decades of between 1% and 2%. 10 The commonest morbidity is groin wound breakdown, occurring in 15-52% of patients, followed by cellulitis in 7-28%, lymphocyst formation in 15-20%, and lymphoedema in 6-65%. Chronic lymphoedema was the most debilitating consequence of inguinal lymphadenectomy, occurring in 27-28% of patients in a large GOG series. 11,12,13 Lymphoedema of the lower extremities is also a major problem in patients who have had inguinal and deep pelvic node dissection. 10 Varying degrees of lymphoedema of the lower extremities occurred in 69% of patients, and Rutledge and colleagues advocated for the post-operative use of antibiotics to prevent streptococcal lymphangitis, which is associated with increased lymphoedema. 10 The development of lymphocysts in the groin area is reported as a common complication that tends to resolve spontaneously. There are other methods used to avoid lymphocyst formation, including ligation of all the lymph-bearing tissue during the groin dissection and intermittent aseptic aspiration of the fluid. The use of neo-adjuvant radiation therapy, especially in patients with fixed inguinal nodes can result in vulval oedema and risk of breakdown after vulvectomy. 10 Gould et al demonstrated that patients developing early cellulitis were more likely to have early wound breakdown or early lymphocyst formation. 11 In addition, the type of procedure, postoperative prophylactic antibiotic use, need for adjuvant therapy, or duration of suction drainage did not significantly influence the incidence of early cellulitis. Node positivity is a potential risk factor associated with lymphocele formation after lymphadenectomy. There are however conflicting results that have been reported in different studies regarding lymphocele formation and its relationship to lymph node status. 14 Confalonieri et al, in a review of 284 women, reported as many as 234 that had a V-Y flap and 128, had Lotus petal flap (LPF). 15 The were postoperative complications 21.5% of women who had a V-Y flap and 13% of women who had a LPF. Post-reconstruction complications can be linked to several risk factors such as body type, chronic medical co-morbidities, immunosuppression, nutritional status, and previous radiation therapy. 15 The complications included wound partial or complete wound dehiscence, partial or complete necrosis, and reoperation. The commonest complication seen in up to 55% is complete or partial wound dehiscence. This study aimed to investigate the outcome of patients with vulva lesions managed surgically at Charlotte Maxeke Johannesburg Academic Hospital. MATERIALS AND METHODS The study aimed to review complications associated with surgical management of vulvar cancer in patients seen over a five year period between 2013 and 2017 at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH). Demographic data, medical history, theatre notes, and post-operative notes were extracted from the medical files. Categorical variables were summarized by frequency and percentages and illustrated using tables. Continuous variables were summarized by the means and standard deviation, medians, and interquartile ranges. Data analysis was carried out using SAS. The 5% significance level was used. Precision was managed by using 95% confidence intervals. Comparison of categorical variables was made using the Chi-squared or the Fisher’s exact tests, and comparisons of continuous variables were made using the student T-test or the Kruskal-Wallis test. The study was approved by the University of Witwatersrand Human Research Ethics Committee (WHREC) (Clearance certificate M190666). RESULTS One hundred and fourteen women with vulval pathology were planned for surgery during the study period. Thirty-six women were excluded for not meeting the inclusion criteria (22 had benign lesions on the final histopathological report, in 6, surgery was abandoned, and in 8, there were missing records). In total, data of 78 women who met the inclusion criteria were available for analysis. The mean age of women in this study was 44.07 years (SD±11.75). The median parity was two, with an inter- quartal range (IQR) of 1-3. The clinical presentation of the study participants is described in Table 1. Some women presented with a combination of symptomatology. Diagnoses were made through a biopsy specimen at a regional hospital in 43 (55.13%) women, 21 (26.92%) in tertiary hospitals, and 14 (17.95%) were done in other settings. The surgical margins were reported to be free in 60 (76.90%) women and involved in 14 (17.90%) women. There was no report on the margin status in 4 women (5.10%). Margins were considered positive when there was tumour involvement of the margins or when margins were less than 8 mm from the lesion. The interval between biopsy and surgery was a median of 158.00 days, (IQR 101.00 to 294.00 days). Sixteen (20.50%) women received neo-adjuvant chemo-radiation therapy due to the size of the vulval lesion. Complete vulvectomy was done in 46 (59.00%) women, hemi vulvectomy in 15 (19.20%), and wide local excision in 15 (19.20%). Thirty-four (43.60%) women had clitorectomy at the time of vulvectomy. There were 59 (75.60%) women who also had inguinal lymph node dissection, of which 2 (2.60%) had sentinel lymph node biopsy (SLNB). The dye used and the method of detection for SLNB was not specified. Seventy four (94.87) patients had squamous cell carcinoma. The histological subtypes and Surgico-pathological stages are shown in Tables 2 and 3 respectively. Fifty six (73.70%) women had primary repair and closure of the vulva wound at vulvectomy, and 14 (18.40%) required flaps for repair or wound closure. The method of repair was not documented in six (7.90%) women. The types of suture materials used during vulval wound repair were Vicryl ® in 46, (65.70%) women, nylon in 10 (14.30%), PDS in seven (10.00%), metal clips in four (5.70%), and other suturing materials in two (2.29%). There were no records of the type of suture material used in 19 (27.10%) women. Intra-operative complications included excessive African Journal of Obstetrics and Gynaecology | Volume 2 | Issue 1 | 2024 | 25