Saphenous vein sparing during inguinal lymphadenectomy to reduce morbidity in patients with vulvar carcinoma
Introduction
Vulvar cancer represents approximately 4% of all cancers of the female genital tract with an estimated 3870 new cases and 870 deaths this year [1]. After demonstrating marked improvement in survival in the 1940s with radical surgery, Taussig and Way standardized surgical treatment for resectable vulvar carcinoma to en bloc radical vulvectomy and bilateral inguinal and pelvic lymph node dissection [2], [3]. Unfortunately, operative mortality approached 20% and morbidity associated with this procedure was high, with 50 to 85% of patients experiencing wound breakdown or impaired healing and 69% of patients experiencing lymphedema [4].
A number of advances in the surgical management of vulvar carcinoma to reduce morbidity without affecting treatment outcomes have been made over the past 20 years [5], [6], [7], [8], [9]. It is now standard to only resect nodes if depth of invasion is greater than 1 mm [5], [10]. Ipsilateral lymphadenectomy has been found to be sufficient for lesions lateral to the midline. Other important changes include using separate incisions for the groin region, limited radical vulvar resection, pre-operative antibiotics, and the use of closed suction drains and optimization of preoperative medical management of the patients.
However, the technique of groin node dissection and its associated morbidity is still an area of contention. The classic description of inguinal lymphadenectomy includes resection of the saphenous vein to facilitate the process [11]. In 1988, Catalona et al. proposed preservation of the saphenous vein during inguinal lymphadenectomy to decrease postoperative morbidity in patients with carcinoma of the penis [12]. In 1993, Plaxe et al. proposed that this technique should be applied to inguinal lymphadenectomy in patients with carcinoma of the vulva [13].
In 2000, Zhang et al. demonstrated that preservation of the saphenous vein in inguinal lymphadenectomy decreased overall complication rate from 56 to 23% (P < 0.001) and chronic lymphedema decreased from 70 to 32% (P < 0.001) [14]. However, Lin et al. failed to show any decrease in chronic lymphedema with saphenous vein preservation, 17 vs. 13% [15]. Similarly, Hopkins and colleagues looked at this issue as part of a broader series and observed no difference [16]. Therefore, the object of our study was to compare short- and long-term morbidity associated with saphenous vein sparing versus ligation during inguinal lymphadenectomy for vulvar carcinoma. A secondary outcome was to compare the number of nodes dissected between the two groups, since this has not been previously reported.
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Materials and methods
IRB approval was obtained to conduct the study. Patients who underwent inguinal lymphadenectomy for surgical management of vulvar carcinoma from 1992 to 2003 at the Hospital of the University of Pennsylvania and at Pennsylvania Hospital were identified through a departmental database. Twenty-nine patients with carcinoma of the vulva who underwent inguinal lymphadenectomy were identified. A retrospective review of these charts was performed. Clincopathologic information was obtained from both
Results
A total of 29 patients were identified over the eleven year period. From this group, 49 inguinal node dissections were performed. Thirty-one (63.3%) had their saphenous vein ligated while 18 (36.7%) were spared. The demographics of these patients were analyzed and noted to be similar between the two groups. (Table 1) Number of nodes dissected was not statistically significant between the two groups. (Table 2) The patients in the two groups were comparable in the rates of indicators of medical
Discussion
The morbidity associated with groin dissection continues to remain significant despite the refinements in surgical technique over the past 30 years. The aggressive use of preoperative antibiotics, separate groin incisions and closed suction drains has reduced the overall complication rate; however, high rates of cellulitis, wound breakdown, and lymphedema are debilitating morbidities still associated with this procedure. Prior series report groin breakdown occurring in 15–25% of patients,
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2019, European Journal of Surgical OncologyCitation Excerpt :However, there remains an indication for a TLND in patients with macroscopic disease. Despite several modifications to the conventional open procedure, including relocating skin incisions, thicker skin flaps, preservation of the saphenous vein, and sartorius muscle transposition, complication rates have not substantially decreased [22–25]. In literature, complication rates up to 70% have been described for the open inguinal lymphadenectomy [1–7].