CPT® Code 56640

1. Indications

The radical vulvectomy with inguinofemoral, iliac, and pelvic lymphadenectomy is indicated for the treatment of invasive carcinoma of the vulva. This procedure is typically performed when there is a confirmed diagnosis of malignancy that necessitates the complete excision of vulvar structures to ensure that all cancerous tissues are removed. The presence of invasive cancer that extends beyond the superficial layers of the vulva and may involve surrounding lymphatic structures is a critical factor in determining the need for this extensive surgical intervention.

• Invasive Carcinoma The primary indication for this procedure is the presence of invasive carcinoma affecting the vulva, requiring comprehensive surgical intervention to remove all affected tissues.

2. Procedure

The procedure begins with the marking of excision margins to ensure that an adequate amount of healthy tissue is included in the surgical resection. The incision is initiated above the labial folds in the mons pubis, where the skin is incised down to the level of subcutaneous fat. Deep dissection is then performed, continuing down to the perineal fascia and potentially into the periosteum of the pubic symphysis if necessary. The incision is extended laterally along the labia majora and across the posterior fourchette. As the dissection progresses, the pudendal arteries and veins are identified, clamped, and tied bilaterally to control bleeding. Care is taken to protect the urethral orifice while extending the incision from the meatus around the vaginal introitus. The rectum is also safeguarded as the incision is carried inferiorly. The final areas to be transected include the fat pad in the mons pubis and the vascular plexus surrounding the clitoris, which is clamped and tied prior to transection to manage hemorrhage. After the radical vulvectomy is completed, the surgical defect is repaired, ensuring that the vaginal mucosa is undermined and mobilized to prevent contracture of the introitus. A catheter is placed in the urethral meatus, and the periurethral mucosa is sutured to the skin to secure the area.

• Step 1: Mark excision margins to include healthy tissue surrounding the malignancy.
• Step 2: Initiate the incision above the labial folds in the mons pubis, incising through the skin to the subcutaneous fat.
• Step 3: Perform deep dissection down to the perineal fascia and potentially into the periosteum of the pubic symphysis.
• Step 4: Extend the incision laterally along the labia majora and across the posterior fourchette.
• Step 5: Identify, clamp, and tie the pudendal arteries and veins bilaterally as encountered.
• Step 6: Protect the urethral orifice while extending the incision from the meatus around the vaginal introitus.
• Step 7: Safeguard the rectum as the incision is carried inferiorly.
• Step 8: Transect the fat pad in the mons pubis and the vascular plexus surrounding the clitoris, clamping and tying to control bleeding.
• Step 9: Repair the surgical defect, undermining and mobilizing the vaginal mucosa to prevent contracture.
• Step 10: Place a catheter in the urethral meatus and suture the periurethral mucosa to the skin.

In conjunction with the radical vulvectomy, inguinofemoral lymphadenectomy is performed first when indicated. A skin incision is made just below and parallel to the groin crease, allowing access to the inguinal region. The incision is carried through the membranes covering the inguinal vein and artery to expose the inguinofemoral lymph nodes, which are then excised. If a bilateral lymphadenectomy is required, the procedure is repeated on the contralateral side. Following the radical vulvectomy and inguinofemoral lymphadenectomy, an abdominal incision is made to access the iliac and pelvic lymph nodes. The involved lymph nodes, which may include external and common iliac nodes, hypogastric nodes, and/or obturator nodes, are carefully dissected free from surrounding tissues and removed to ensure comprehensive management of potential metastasis.

3. Post-Procedure

Post-procedure care following a radical vulvectomy with inguinofemoral, iliac, and pelvic lymphadenectomy includes monitoring for complications such as infection, bleeding, and proper healing of the surgical site. Patients may require pain management and should be advised on wound care to promote healing. Follow-up appointments are essential to assess recovery and to monitor for any signs of recurrence of malignancy. Additionally, patients may need support for any psychological or emotional impacts resulting from the extensive nature of the surgery and its effects on body image and sexual function.