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 haemorrhage in 29 (38.70%) women, vessel injury in one (1.30%) woman, and in one (1.30%) woman the complication was not specified. There were no complications in 34 (45.30%) women, and there were no records on whether complications occurred or not in 11(14.70%) women. (Table 4.) Women were requested to post-operatively have restricted mobility as per unit protocol. Mobility was initiated on the first post-surgery day in 7 (9.00%) women, and on the second post-surgery day in 33 (42.30%) women. No records on post- operative mobilisation were available for 38 (48.70%) women. The difference in intra-operative complications in women with benign compared to malignant vulval lesions showed no statistical significance (p = 0.19). This study also found wound dehiscence and wound infection as the most common complications in both vulval wounds and groin wounds. However, the groin wounds also had an increased rate of lymphocyst formation, even though drains were routinely placed and kept for a minimum or three days. There was a statistically significant association between groin lymphocyst formation, groin sepsis, groin hematoma, and whether the lesion’s final pathology report was that of a benign or malignant lesion (p < 0.001). Lymphocyst formation was four times more likely to occur if the post- operative histology was that of an invasive malignancy. There was no statistical difference between post-operative vulval wound dehiscence and whether the lesion was malignant or benign (p=0.32) and post-operative vulval wound sepsis, and whether the lesion was malignant or benign (p=0.62). DISCUSSION In the United Kingdom, about 80% of patients with vulvar cancer are older than the age of 65 years. This disease has therefore been considered a disease of the elderly in Europe up until the last decade. Butt and Botha in 2017 reported that in South Africa women who present with vulvar cancer were 10 - 15 years younger than those presenting in high income countries (HICs). The mean age of the women in this study was 44.07 (SD±11.75) years. This is consistent with the findings of Butt and Botha’s study. This age difference, they postulated, has largely been attributed to the high prevalence of oncogenic HPV and HIV infections in the local community. 5 About 75% of women with vulvar cancer are reported to present with an ulcer or a vulval mass. 1 The findings in this study were similar, with ulcers and vulval lesions together accounting for 73% of clinical presentations and only 17% presenting with pain. A University of Stellenbosch study reported that over 63% of patients with vulva cancer sought alternative modalities before seeking help from a healthcare worker and those who attended with healthcare workers were treated with antibiotics, or creams before a definitive diagnosis was made. 17 Perhaps this is a contributor to their presenting with an obvious mass or ulcer. 17 HIV infection has been shown to increase the risk of both vulvar pre-cancer and cancer. Our community is particularly known for a high prevalence of HIV infection, with 22.71% of women aged between 15-49 years affected.16 The HIV infection rate in this study was 80.77% with 63 HIV positive women. However, this was a retrospective study. Currently, there is a larger population of HIV-positive women on treatment with viral suppression and reconstituted immune systems. It is hoped that in this cohort, the risk of vulva cancer and premalignant lesions will be low. A study by Graul 18 to determine the frequency of venous thromboembolism (VTE) in gynaecological oncology patients post-operatively, reported no VTE cases post-surgery in their study. In this study, in contrast, 5 (6.40%) women had pre-operative VTE, and 3 (3.80%) women developed VTE post-operatively. This could be related to reduced mobility in the study population in both the pre-operative and post- operative groups. Our unit protocol includes limited mobility in the first three days post-operative state to reduce wound breakdown. Perhaps this also contributed to the post- operative occurrence of DVT. More than a third (67%) of vulvar cancer patients present with squamous cell histological subtype. 6 When adeno- squamous carcinoma is included in this subtype, this may be as high as 90%. Subtypes such as melanoma are rare, with the largest incidence being about 10%. 19 Findings in this study were in keeping with this trend, however, with a higher than expected rate of rare histological subtypes such melanoma, and neuroendocrine malignancies. A cross-sectional study on predictors for wound complications, identified the increase in odds for wound complications in women, according to the extent of the surgery performed (hemi vulvectomy vs radical vulvectomy), and inguinofemoral lymphadenectomy. 20 Women in this study were treated with radical surgery that predisposes to wound infection risk. About a third of women had complete vulvectomy, and close to 54% had clitorectomy as well. Post-operative wound dehiscence and wound infection were the commonest complications in both vulva wounds and groin wounds. However, groin wounds also had an increased rate of lymphocyst formation, even though drains were routinely placed and kept for a minimum of three days. This was in keeping with recording literature on complications. 21 More than 50% of women in this study had a surgical advanced stage III disease and above (nodes positive), even though most of patients were a clinically presumed stage II at the time of surgery. However, there were more than 30% who had stage II disease, which was not in keeping with most literature. Perhaps this is due to the strict patient selection for surgery. CONCLUSION Vulval wounds are likely to develop sepsis and breakdown. The comorbidity of HIV infections increases the risk of sepsis and sepsis-related wound breakdown which was an expected complication finding in our study population which has a high HIV positive prevalence. It is not known if skin care or specific pre-surgery hygienic practices in these populations would perhaps reduce the sepsis and breakdown rate. We did not look into the organisms cultured at the sites of sepsis and hence it is not known if overgrowth of the vulva skin commensals could have played a role in the sepsis rate. REFERENCES ¢ ³ ¢ ´ ¡ ¡ ¢ ¥¢ ¥ ¡ African Journal of Obstetrics and Gynaecology | Volume 2 | Issue 1 | 2024 | 26