Vulvectomy in India and UAE | Complete Patient Guide

• ELIGIBLE PATIENTS:

• Women diagnosed with vulvar squamous cell carcinoma (FIGO Stages I–IVA) confirmed by punch or excisional biopsy with histopathology

• Patients with vulvar intraepithelial neoplasia (VIN III / HSIL) refractory to topical imiquimod, laser ablation, or wide local excision with recurrent positive margins

• Women with Paget's disease of the vulva (extramammary) with or without underlying adenocarcinoma

• Patients with verrucous carcinoma or Bartholin gland carcinoma requiring radical local excision

• Women with severe, symptomatic lichen sclerosus with biopsy-confirmed atypia or early malignant transformation

• Recurrent or persistent vulvar melanoma requiring definitive surgical management

• REQUIRED PRE-OPERATIVE DIAGNOSTICS:

• Punch biopsy / wide local excision biopsy with full histopathological assessment (including depth of stromal invasion in mm — critical for FIGO IA vs. IB staging)

• MRI pelvis with gadolinium contrast (assess tumor extent, urethral/vaginal/anal involvement, and nodal disease)

• PET-CT (18F-FDG) for FIGO Stage IB and above to exclude inguinofemoral, pelvic, and distant nodal metastases

• High-resolution inguinal ultrasound ± fine needle aspiration cytology (FNAC) of suspicious groin nodes

• Colposcopy and cervical/vaginal biopsy if multicentric HPV-related disease is suspected

• Full blood count, comprehensive metabolic panel, coagulation screen (PT/aPTT/INR), HbA1c (diabetic patients have significantly elevated wound complication risk)

• Cardiopulmonary assessment including ECG and echocardiography for patients >60 years or with comorbidities

• Nutritional assessment (serum albumin, pre-albumin) — hypoalbuminemia is an independent predictor of wound breakdown in vulvectomy

• HPV genotyping and Pap smear / cervical screening

• RELATIVE OR ABSOLUTE CONTRAINDICATIONS:

• FIGO Stage IVB disease with unresectable distant metastases (systemic therapy preferred; surgery palliative only)

• Severe uncontrolled cardiopulmonary disease precluding general or regional anesthesia

• Active, uncontrolled coagulopathy or anticoagulation that cannot be bridged perioperatively

• Extremely poor performance status (ECOG 3–4) where surgical morbidity would outweigh oncologic benefit

• Active pelvic or perineal infection requiring resolution prior to elective resection

SURGICAL APPROACHES BY EXTENT OF DISEASE:

1. WIDE LOCAL EXCISION (WLE) — For FIGO Stage IA (stromal invasion ≤1 mm, lesion ≤2 cm): Excision with 1 cm clear margins; no lymph node surgery required. Lowest morbidity; outpatient or short-stay procedure.

2. RADICAL PARTIAL VULVECTOMY (HEMIVULVECTOMY) — For unilateral FIGO Stage IB–II lesions <4 cm: Resection of the involved hemi-vulva with 1–2 cm margins plus ipsilateral inguinofemoral sentinel lymph node biopsy (SLNB) using technetium-99m nanocolloid radioisotope mapping ± indocyanine green (ICG) near-infrared fluorescence guidance. SLNB has a false-negative rate of <3% in experienced hands and avoids the 25–40% lymphedema risk of full inguinofemoral lymphadenectomy (IFL). If sentinel nodes are positive on intraoperative frozen section, completion IFL is performed immediately.

3. RADICAL COMPLETE VULVECTOMY — For bilateral, midline, or >4 cm lesions (FIGO Stage II–IVA): En bloc resection of the entire vulva (labia majora and minora, clitoris, prepuce, perineal body) with bilateral inguinofemoral lymphadenectomy via separate groin incisions (the modern triple-incision technique, replacing the historically disfiguring butterfly incision, significantly reduces wound necrosis and infection rates). For very advanced disease (Stage IVA) involving the urethra, vagina, or rectum, pelvic exenteration (anterior, posterior, or total) may be required as part of a curative intent resection.

4. RECONSTRUCTIVE TECHNIQUES — Indicated when primary closure would cause urethral or introital stenosis, or when defect size exceeds 4–5 cm: - Rhomboid (Limberg) fasciocutaneous flap: Workhorse flap for lateral defects - Lotus petal flap (pudendal thigh fasciocutaneous flap): Preferred for posterior and perineal defects; preserves erogenous sensation - V-Y advancement flap: Reliable for medial thigh coverage - Gracilis myocutaneous flap: For large composite defects or after exenteration - Split-thickness skin grafting: Occasionally used for superficial defects

5. MINIMALLY INVASIVE & ROBOTIC-ASSISTED APPROACHES — Robotic-assisted laparoscopic pelvic lymphadenectomy (da Vinci Si/Xi system) is increasingly performed concurrently for pelvic node dissection in advanced cases, reducing blood loss, hospitalization, and recovery time compared to open pelvic surgery. Robotic platforms available at leading centers in India (Apollo, Fortis, Tata Memorial) and the UAE (Cleveland Clinic Abu Dhabi, American Hospital Dubai).

6. ADJUVANT AND MULTIMODAL THERAPIES: - External beam radiotherapy (EBRT) to groins ± pelvis: Indicated for ≥2 positive inguinal nodes, extracapsular nodal extension, or positive/close surgical margins (standard dose: 45–50 Gy in 25 fractions with concurrent cisplatin-based sensitization in high-risk patients) - Concurrent chemoradiation (cisplatin 40 mg/m² weekly): For unresectable or borderline resectable disease as primary treatment or in neoadjuvant setting to downsize before surgery - Immunotherapy (pembrolizumab): Emerging data for PD-L1-positive recurrent/metastatic vulvar SCC; available within clinical trials at leading Indian and UAE oncology centers - PARP inhibitors and targeted agents: Under investigation for BRCA-mutated cases or those with specific molecular alterations identified on next-generation sequencing (NGS) tumor profiling

PHASE 1 — REMOTE PRE-CONSULTATION (Weeks 1–2, from home country):

• Patient submits medical records, biopsy reports, imaging (MRI/PET-CT), and pathology slides to GAF Healthcare's oncology coordination team

• Virtual multidisciplinary tumor board (MDT) review with the designated gynecologic oncologist in India or UAE within 48–72 hours

• Personalized treatment plan, cost estimate, and hospital recommendation provided

• GAF Healthcare initiates e-Medical Visa application (India) or confirms entry requirements (UAE)

PHASE 2 — PRE-OPERATIVE WORKUP ON ARRIVAL (Days 1–3):

• Arrival and transfer to hospital or partner accommodation

• In-person consultation with gynecologic oncologist and reconstructive plastic surgeon

• Repeat or confirmatory imaging if prior films are >6 weeks old or of insufficient quality

• Anesthesiology assessment; optimization of comorbidities (glycemic control, nutritional support if albumin <3.5 g/dL)

• Sentinel lymph node mapping injection (technetium-99m nanocolloid) performed 18–24 hours before surgery if SLNB planned

• Patient consent, surgical marking, bowel preparation if exenteration is possible

PHASE 3 — SURGICAL PROCEDURE (Day 4):

• General anesthesia with neuraxial (epidural) component for superior postoperative analgesia

• Radical vulvectomy performed per preoperative plan (duration 2–6 hours depending on extent)

• Intraoperative frozen section of sentinel nodes; decision for completion lymphadenectomy made in real time

• Reconstructive flap or primary closure as indicated

• Closed-suction drains placed in groin wounds bilaterally

• ICU or high-dependency unit (HDU) monitoring for 12–24 hours post-procedure

PHASE 4 — IN-HOSPITAL RECOVERY (Days 4–10):

• Urinary catheter remains in situ for 5–7 days to protect the suture line

• Daily wound care with antiseptic irrigation; compression dressings

• Groin drains removed when output <30 mL/24 hours (typically day 5–7)

• Early physiotherapy: gentle ambulation from day 2, deep breathing exercises, lower limb compression stockings and pneumatic compression devices to prevent DVT

• Nutritional support: high-protein diet (1.5 g/kg/day); nasogastric or supplemental feeding if intake inadequate

• Pathology results (permanent sections) available within 5–7 days; oncologist reviews margins and nodal status

• Multidisciplinary review: radiation oncology and medical oncology consulted if adjuvant therapy indicated

• Discharge planning initiated: wound care education, lymphedema prevention counseling, outpatient follow-up schedule

PHASE 5 — OUTPATIENT RECOVERY IN DESTINATION COUNTRY (Weeks 2–6):

• Wound review at 2-week and 4-week post-op clinic visits

• Suture/staple removal (typically day 14–21)

• Commencement of adjuvant radiotherapy if indicated (5–6 week course; patients who require this will need an extended stay of 8–10 weeks total)

• Pelvic floor physiotherapy and psychosexual counseling initiated

• Lymphedema specialist assessment; manual lymphatic drainage (MLD) and compression garment fitting if groin dissection performed

• FIT-TO-FLY MILESTONE: Patient may travel by air after 4–6 weeks if wound fully healed, no active infection, ambulating independently, and no active DVT risk (confirmed by clinical assessment ± Doppler ultrasound)

PHASE 6 — HOME COUNTRY FOLLOW-UP:

• GAF Healthcare provides a complete discharge summary, histopathology report, operative notes, and adjuvant therapy plan for the patient's home oncologist

• Telemedicine follow-up with the treating gynecologic oncologist at 3 months, 6 months, and 12 months

• Standard surveillance: clinical examination every 3–6 months for 2 years, then annually; imaging as clinically indicated