Defect Repair After Genital Malignant Tumor Surgery

Fig. 19.1
Case I. (a) The length of the residual penis was 1.5 cm before surgery. (b) The circular incision at the penile base. (c) The cavernous body was extended to 8 cm. (d) Design of scrotal skin flap. (e) The scrotal septal blood vessels were visible. (f) A hole was made at the root of the scrotum, which facilitated to take out the cavernous body. (g) The scrotal skin flap was translocated to the upper side of the cavernous body and was easy to wrap and suture the cavernous body. (h) The length of the reconstructed penis was 8 cm

Case II

The patients, aged 50, underwent partial penis resection due to penis cancer, the length of the residual penis was 2 cm, the stump was sutured to repair the wound, and the penile reconstruction was performed 6 years after surgery (Fig. 19.2).


Fig. 19.2
Case II. (a) The length of the residual penis was 2 cm before surgery. (b) The length of the erected penis was 5 cm. (c) The design of scrotal skin flap. (d) A 10 cm cavernous body was separated. (e) The cavernous body was transferred from the hole to the area under the skin flap. (f) The scrotal skin flap was used to wrap the extended cavernous body to suture and reconstruct the penis

This section describes several kinds of commonly used surgical methods for penile reconstruction [13]. Owing to various reasons, there are a limited number of patients undergoing penile reconstruction after penile cancer surgery in clinics. It is believed that along with the advance of society, people’s increasing requirement of sexual life, as well as the continuous improvement of penile reconstruction technology, the penile reconstruction will get more applications in patients with penile defect after penile cancer surgery.

3 Overview of Vulvar Cancer

Jing Wang 

Hunan Cancer Hospital/The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha Shi, Hunan Sheng, China



Jing Wang

3.1 Incidence Rate and Diagnosis

3.1.1 Incidence Rate

The vulvar cancer is a malignant tumor from the vulvar skin, mucous membrane, and its appendant organs and greater vestibular gland; the incidence rate accounts for 2–5% of the female genital tumors; the International Federation of Gynecology and Obstetrics (FIGO) reported that the incidence rate of vulvar cancer in Western women is 2–5/100,000.

Its etiology is not yet clear; it may be related to viral infection (human papillomavirus 16, 18, and 31 are more common), sexually transmitted diseases, low immunity, and chronic skin diseases (such as vulvar dystrophy). The vulvar cancer mostly occurs in postmenopausal women, and the average onset age is 52 years. The vulvar cancer is located in the body surface and can be diagnosed definitely based on medical history, symptoms, signs, and biopsy examination. The lesions can involve the vulva, perineum, or areas around the anus and can be divided into midline type and lateral type. The cancers in labia majora are most common, followed by the cancers in labia minora, clitoris, posterior commissure of the perineum, perineum, and urethra.

3.1.2 Pathological Diagnosis

The main pathological type is the squamous cell carcinoma, accounting for more than 80%, which is followed by the malignant melanoma (4.5%), basal cell carcinoma (2.5%), Paget’s disease (2.5%), adenocarcinoma (2.5%), and sarcoma (2%).

Currently, the clinical and pathological staging system for the vulvar cancer is the standard established by the International Federation of Gynecology and Obstetrics (FIGO) in 2009 (FIGO 2009).

3.2 Clinical Symptoms and Signs

The most common symptom of the vulvar cancer is localized itching, followed by vulvar mass, bleeding, pain, and increased secretions. In the vulvar skin or mucous membrane of the patients with early vulvar cancers, localized or diffused multifocal black-brown or brown maculopapules can be observed, or the mucous membrane in focus is rough and erosive, or there is thickening lichen sclerosus of the vulva with clefts. The primary tumor of the invasive vulvar cancer is mostly single limited mass or ulcerative mass. Seventy percent of tumors occur in the vulvar lips; the labia majora is most commonly seen, followed by the labia minora, clitoris, and perineum. Advanced tumors may invade the urethra and (or) bladder, anus and (or) the rectum, vagina, and pubic bone or ischium.

3.3 Applied Anatomy

In addition to local invasion, the vulvar cancer is metastasized mainly through the lymphatic tract, and the lymphatic metastasis pathway is consistent with the anatomical characteristics of lymphatic drainage in the vulvar area.

3.3.1 Regional Lymphatic Drainage

The lymphatic drainages from the labia majora and labia minora, clitoris, posterior commissure of the perineum, and perineum firstly enter into the superficial inguinal lymph nodes and then enter into the deep inguinal lymph nodes. All lymphatic drainages are aggregated into Cloquet’s lymph nodes and pass through this place to enter into the pelvic lymph nodes. In addition, the lymphatic vessels still have channels to enter into external iliac lymph nodes via the pubic symphysis or enter into obturator lymph nodes via the dorsal vein of the clitoris. When the lesions involve the urethra, bladder, vagina, or rectum, other lymphatic drainages can directly enter into the pelvic lymph nodes.

3.3.2 The Relevant Factors of Lymph Node Metastasis

The lymph node metastases are related to the size and location of the cancer focus, the relationship with neighboring organs, tissue differential degree, tumor infiltration depth, the presence or absence of lymphatic and vascular invasion, and the clinical stage.

3.3.3 Preoperative Evaluation of the Lymph Node Metastasis

  1. 1.

    Clinically attentions should be paid to palpable and fixed lymph nodes which are gathered into groups; these lymph nodes are generally positive.


  2. 2.

    The imageological examinations such as CT, MRI, or PET-CT can only be used as reference.


  3. 3.

    The sentinel lymph nodes (SLN) are the level I lymph nodes of the primary tumor lymphatic drainage; the pathological state of this group of lymph nodes can guide the need for extensive lymphadenectomy. The concept was firstly proposed in the study of penile cancer by Cabanas in 1976; in 1979, Disaia put forward SLN in vulvar cancer and considered that the inguinal lymph nodes firstly receive the lymphatic drainage from the vulva.


  4. 4.

    Detection method:

    1. (1)

      Bioactive dyes such as methylene blue and isosulfan blue.


    2. (2)

      Radioactive tracers such as 99m Tc sulfur colloid (99mTc-SC) and 99m Tc-human serum albumin (99mTc-HSA).


    3. (3)

      Radionuclide colloid injection: The bioactive dye and radionuclide colloid injection are combinedly used as the most commonly used method; the detection rate is high.



  5. 5.

    The clinical significance of SLN rationally determines the surgical ranges of the secondary vulvar lesions (groin and pelvic lymph nodes) and reduces the surgical traumas and complications. But because the lymph node metastasis has a jumping phenomenon, negative SLN cannot exclude the possibility of lymph node metastasis; at present, the priority is given to clinical studies.


3.4 Treatment Plan

3.4.1 Surgical Treatment

The vulvar cancer is mainly treated with surgery:

  1. 1.

    The classic radical resection of vulvar cancer, namely, the Way surgical method (1940), is the extensive vulvar resection (including the mons pubis, the labia majora and labia minora, the perineum, part of the vagina or part of the lower urethra, and the subcutaneous adipose tissue in corresponding parts; the depth reaches to the layers of fascia and myolemma) plus bilateral inguinal lymphadenectomy or pelvic lymphadenectomy. This surgical method is applicable to the following high-risk patients:

    1. (1)

      The focus is midline type.


    2. (2)

      The lymph nodes are suspected positive and N1 and N2.


    3. (3)

      The focus is highly differentiated (G1), with a depth of > 5 mm; moderately differentiated (G2), with a depth of 2 mm; poorly differentiated (G3), with an unlimited depth.


    4. (4)

      There is cancer cell infiltration in lymphatic vessel clearance.



  2. 2.

    Changes in surgical method’s individualization of vulvar cancer surgery:

    1. (1)

      The limited tumor can be treated with modified partial vulvectomy.


    2. (2)

      T1 stage, the invasive depth ≤ 1 mm, and the groin lymph node (GN) dissection are not performed.


    3. (3)

      Unilateral lesion (T0): The unilateral GN dissection is performed; if the pathological result is negative, the contralateral GN dissection is not performed.


    4. (4)

      Modified groin surgery (the fascia lata and great saphenous vein are retained).


    5. (5)

      The routine pelvic lymph node dissection is not performed, even if there are multiple positive GNs; the pelvic lymph node dissection can also be canceled; instead, the radiotherapy is carried out in areas of GNs and pelvic lymph nodes.


    6. (6)

      The advanced patients receive preoperative radiotherapy and chemotherapy and don’t undergo pelvic organ resection.



3.4.2 Radiotherapy

Because of poor tolerance to radiotherapy, the vulvar tissue cannot be treated preferably by radiotherapy even though it is sensitive to radiotherapy pathologically to a certain extent. At present, the radiotherapy is generally used as the palliative treatment or the supplement of the surgical treatment, for example, the postoperative radiotherapies on the inguinal area and the area outside the pelvic cavity in patients with inguinal lymph node metastases are carried out to reduce the possibility of recurrence and metastasis, and the patients with huge masses invading the adjacent organs undergo preoperative radiotherapy or adjuvant chemotherapy to shrink the tumor to increase the resection rate and preserve the corresponding viscera function to improve the quality of life. In European countries with mature radiotherapy technologies, the radiotherapy interpolated among tissues is performed; it is reported that the effect is good, but it is limitedly carried out in China.

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Mar 19, 2018 | Posted by in Reconstructive surgery | Comments Off on Defect Repair After Genital Malignant Tumor Surgery

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