Risk Factors for Postoperative Complications After Vulvar Surgery

Discussion

The most commonly performed therapeutic strategies in vulvar cancer patients include chemotherapy, radiotherapy and surgery; however, due to the low incidence of the disease large randomized trials are still missing, while the most appropriate therapeutic strategy represents a real challenge (6). Although the actual trend is to perform minimal surgical procedures in association with chemo-radiation, in certain cases radical surgery might be the best option of therapeutic intervention (3).

In cases treated by surgery with curative intent it has been widely demonstrated that the most important prognostic factors for the long-term outcomes are represented by the stage at diagnosis, the status of the resectional margins and of the retrieved lymph nodes, the five year survival rates decreasing from 78% in the International Federation of Obstetrics and Gynecology (FIGO) stage I to 13% in FIGO stage IV disease (7). However, it seems that the stage at diagnosis also influences the risk of postoperative complications. This aspect can be explained by the fact that larger tumors necessitate more extended local or regional resections.

As for the type of incision that should be performed in such cases, “the butterfly incision” providing an en bloc vulvectomy and inguinal lymph node dissection seemed to be associated with significant postoperative complications and has now been mainly replaced by the “triple incision technique”, which allows for the vulvar resection and inguinal lymph node dissection through separate incisions (8, 9). However, the type of incision should be tailored to each patient in order to achieve negative resection margins and, at the same time, the excision should not be too wide so as to protect from exposing the wound dehiscence which can lead to prolonged, impaired healing. When it comes to the extent of the tumor free resection margins, this subject is strongly debated; certain authors support the notion that a width of 8 mm is enough, while other studies consider that the safety value of this parameter is at 10 mm (6). An interesting study by de Hullu et al., have focused on the influence of the resection margins on the long term outcomes of vulvar cancer patients, where it was demonstrated that no patient with microscopical resectional margins of at least 8 mm developed local recurrence; however, half the patients with macroscopic negative margins of at least 1 cm presented in fact positive microscopic margins at 8 mm (10). In this study the authors advised on macroscopic resection margins of 2 cm in order to minimize the risk of positive microscopic margins (10).

When it comes to the cases in which radical excision is not enough to provide radical resection, these cases are considered as locally advanced and might necessitate performing more extensive procedures, such as exenterative procedures (11). In such cases, neoadjuvant radio-chemotherapy might be considered in order to diminish the extent of visceral sacrifice, which represents another important problem for vulvar cancer patients and improve their quality of life (12). Therefore, multiple studies have been conducted on this theme and demonstrated that the higher the number of aggressive and extensive surgical procedures are proportionally associated with lower levels of quality of life. In the study conducted by Gunther et al., the authors included 199 patients submitted to surgery for vulvar cancer, who demonstrated that local excision was more frequently associated with a better quality of life, including a better social, emotional and cognitive functioning when compared to patients treated with radical vulvectomy (13). Moreover, the extent of lymph node dissection was also correlated with other postoperative complications, such as insomnia and lymphedema. However, it should be emphasized that the status of the resection margins and of the number of retrieved lymph nodes remain the most important prognostic factors with regard to the local and distant recurrence rates. Therefore, a tailored treatment for each patient, especially at younger ages, remains crucial.

In order to maximize the effect of surgery and minimize the risk of postoperative complications, a careful selection of the candidates for surgery is important. Similar to other solid tumors, it seems that in vulvar cancer the preoperative levels of serum albumin significantly influence the short-term outcomes (12, 13). More specifically, a lower level of preoperative albumin caused by malnutrition and albumin synthesis suppression as a consequence of a systemic inflammatory response is responsible for a higher rate of postoperative morbidity (14-17). In a recent study conducted by Bekos et al. in 2019, the authors included 103 patients submitted to vulvar cancer surgery, nine of whom presented with preoperative hypoalbuminemia (18). Among these patients, the rates of postoperative complications were higher when compared to patients with a normal nutritional status. Moreover, the authors underlined the fact that lower preoperative serum albumin levels were associated with significantly poorer rates of overall survival in both univariate and multivariate analyses, and thus, demonstrating the importance of this parameter (18). In another study that also investigated the influence of the preoperative serum levels of albumin on the postoperative outcomes, the authors demonstrated that hypoalbuminemia is significantly associated with the risk of wound complication even after adjusting for age, body mass index, preoperative hematocrit or association of diabetes (19).

Another factor that appears to influence the risk of systemic complications after surgery for vulvar cancer is represented by the length of hospital stay. Prolonged hospitalization might predispose these patients to the development of systemic complications and advocate for early discharge with suction drains in situ. Early removal of drainage tubes (within the first 3 postoperative days) seem to predispose to the apparition of local complications, such as wound dehiscence, wound infection and lymphocyst formation; on the other hand, a prolonged hospital stay (until the drainage can be removed) seems to increase the risk of postoperative complications, such as pulmonary complications; therefore, certain authors recommend early postoperative discharge with in situ drainage tubes in order to prevent the development of further complications (20).

An interesting study on postoperative complications and readmission rates following vulvar surgery was conducted by Dorney et al. The study included 363 patients submitted to surgery for vulvar cancer and demonstrated that the risk of readmission as well as the postoperative outcomes were significantly influenced by the presence of comorbidities, the type of surgical procedure, the nodal assessment, the initial hospital stay and discharge to a post-acute care facility (21). Interestingly, contrary to our results, in this study the previous history of radiation therapy did not significantly influence the risk of postoperative complications.

Vulvar surgery is still associated with important risks of postoperative complications, the rates of morbidity being significantly influenced by the stage at diagnosis, the extent of surgery, the associated preoperative comorbidities and the poor nutritional status. We suggest that an attentive selection of patients for this invasive procedure is mandatory so to lower the rates of postoperative complications.