Vulval lesion excision at Exeter Hospital

What is vulval lesion excision?

Vulval lesion excision removes an area of abnormal skin on the vulva, along with a border of healthy tissue around it. It's also called a wide local excision, or sometimes a simple vulvectomy, and is used to treat pre-cancerous changes, recurrent lesions, or early vulval cancer.

What conditions does it treat?

This operation is generally used for:

• pre-cancerous changes in the vulval skin, sometimes called vulval intraepithelial neoplasia (VIN) or vulval dysplasia
• a lesion that has come back after previous treatment
• early, small vulval cancer.

Where the abnormal cells are higher grade, there's a higher chance of finding a small area of hidden invasive cancer in the tissue removed, which is part of why the tissue is always examined closely afterwards.

What are the benefits of having a vulval lesion excision?

The main benefit is removing pre-cancerous or early cancerous cells before they can progress further, whilst only taking a narrow border of healthy tissue around them.

Compared with more extensive vulval surgery, this approach aims to preserve as much of the vulva's normal appearance and function as possible, since the aim is always to remove the abnormal tissue while keeping any change to how things look and feel to a minimum.

Are there different types of surgical approaches?

A simple excision, sometimes called a simple vulvectomy, is used for pre-cancerous lesions and aims for a margin of healthy tissue around 0.5 to 1cm. Where early vulval cancer is confirmed, a larger operation called a radical partial vulvectomy may be needed instead, removing deeper layers of tissue with a wider margin of around 2cm; this margin may be limited if the lesion is close to structures such as the clitoris, urethra or anus.

Depending on where the lesion is and how deep it goes, your surgeon may also recommend removing some nearby lymph nodes at the same time, to check whether the disease has spread.

What happens before the operation?

You'll be invited to a pre-operative assessment before your surgery, which checks your fitness for a general anaesthetic and gives you the chance to ask questions.

• Continue your usual medications unless you're told otherwise
• Stop smoking for 6 weeks before your operation; this is strongly advised
• Tell the team about any problems that occurred during previous operations or anaesthetics, and any allergies
• Bring an overnight bag, in case you need to stay in hospital
• Sign a consent form once you've had the chance to ask any questions about the surgery, and feel happy to proceed.

What happens during the procedure?

The operation itself is generally quick, reported as around 30 minutes to an hour depending on the source, though you should expect to be in theatre and recovery for 3 to 4 hours in total. In general, it follows these steps:

1. You're given a general anaesthetic, so you're asleep throughout.
2. A cannula is placed in a vein in your arm or hand for fluids and medication, and a urinary catheter may be inserted once you're asleep, depending on where the lesion is.
3. Your surgeon cuts around the lesion and removes it along with the planned margin of healthy tissue.
4. The wound is closed with dissolvable stitches; a tissue flap may be used to reconstruct a larger wound.
5. A local anaesthetic injection at the end helps numb the area for the first 24 to 48 hours.

What does recovery look like?

You'll wake up in the recovery area and may not remember much until you're back on the ward. Pain relief is given during surgery and continued afterwards as needed. Most people are discharged the same day or within about 3 days, depending on the surgery and how they're recovering; occasionally a urinary catheter stays in for a short period, with a plan made for its removal before you go home.

At home, some discomfort is normal and taking pain relief regularly works best. You may feel weak or tired for a few days, and it's normal to feel tingling or pulling around the wound as it heals. Shower the area with lukewarm water and dry with a soft, non-shedding cloth or a cool hairdryer at least 3 times a day, or every time after using the toilet. If stinging when passing urine is a problem, pouring a warm jug of water over the area while sitting on the toilet can help.

Dissolvable stitches can feel tight and may be trimmed by a district nurse after about a week if needed. A brownish discharge is normal at first; contact your GP or specialist nurse if it becomes heavier, foul-smelling, or if you have bright red bleeding.

Most people take around 4 to 6 weeks to heal fully and return to work within 2 to 6 weeks, depending on the size and depth of the wound, general health, and the type of job. It's common for part of the wound to open slightly during healing; this usually isn't serious and heals on its own from the base upward without needing to be re-stitched.

When recovering, gradually increase your activity and walking, but avoid swimming until any bleeding has stopped and the wound has fully healed. If you are unsure about the healing, please seek healthcare advice.

What are the risks and complications?

As with any operation, there are risks to be aware of. Your surgical team will talk you through these, but the ones reported most often include:

• wound separation or delayed healing, the most common complication, more likely with higher-grade abnormal cells, a larger area removed, or a lesion on the perineum
• infection, reported in around 1 in 15 cases in one study
• bleeding, or a collection of blood under the skin (haematoma)
• a blood clot in the leg (deep vein thrombosis) or lungs (pulmonary embolism)
• injury to nearby structures, such as nerves, blood vessels, the anal sphincter, or the urethra
• a positive margin, where abnormal cells are still found at the edge of the tissue removed; reported in around half of cases involving high-grade dysplasia in one study, sometimes needing further surgery or treatment
• general anaesthetic risks.