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342
C. Lam and M. M. Leitao
of fecal incontinence, particularly in patients
with previous irradiation. The digital rectal
examination is a rudimentary way to assess quality of anal tone. Fecal incontinence has been
evaluated using anorectal manometry, pudendal
nerve latency studies, and electromyography
[55]. The Wexner fecal incontinence scale is
likely the most widely used tool to assess for
presence of fecal incontinence and to measure
the severity of symptoms.
Prevention ofFunctional
Impairments After Radical
Vulvectomy
Radical vulvectomy by itself does not cause
incontinence, but according to a prospective
study of 21 patients who underwent a radical vulvectomy, removal of a portion of the urethra is a
risk factor for urinary incontinence, with estimated rates of severe/total urinary incontinence
ranging from 22% to 100% [85]. Appropriate
patient selection based on imaging and examination ndings, as well as adequate preoperative
and postoperative patient counseling, are recommended for all patients. Resection of the external
anal sphincter is a risk factor for postoperative
fecal incontinence. According to one retrospective study, two patients with resection of most of
the anus developed severe fecal incontinence
postoperatively, four of eight patients with partial
resection of the external anal sphincter developed
persistent postoperative fecal incontinence, and
no patients with preserved external anal sphincter
developed new-onset postoperative fecal incontinence [50]. Extensive perianal resection followed
by primary anal reconstruction using local skin
aps, such as unilateral or bilateral rhomboid
aps or local advancement aps, should be considered for preservation of fecal continence [9,
49]. Primary repair of the external anal sphincter
by anal sphincteroplasty, most commonly used in
the setting of obstetrical lacerations, can also be
considered at the time of radical vulvectomy to
preserve function of the external anal sphincter
and to prevent postoperative fecal incontinence.
Among the obstetric population, postoperative
results are felt to be better with delayed repair
rather than primary repair, which is likely due to
edematous tissues [35]; however, this may not
apply to oncologic procedures involving resection of the anal sphincter.
Although the primary aim of surgery is to
achieve local control of cancer or precancerous
lesions, as alluded to above, vulvar reconstruction has also become an area of interest for
improved outcomes for our patients.
Reconstructive surgery can provide aesthetic and
functional benets while maintaining the integrity of the oncologic resection with safe surgical
margins. In large defects, wound closure with
reconstructive aps is suggested to be superior to
direct wound closure for cosmetic and functional
purposes.
Various aps have been evaluated for reconstruction after extensive vulvovaginal carcinoma
surgery. Of 12 patients with gynecologic cancer
who underwent vulvovaginal surgery with simultaneous reconstruction, seven maintained satisfactory sexual function postoperatively. All of
these patients had been treated with the innervated pudendal-thigh ap [61]. In this study, the
gracilis myocutaneous ap was thought to be better suited for patients with a large defect after
excision procedure. In a systematic review of
various fascio-cutaneous aps for vulvovaginal
reconstruction, the lotus petal ap, which
includes the pudendal nerves in the pedicle, the
gluteal-fold fascio-cutaneous ap (Fig. 31.5),
which includes the cutaneous branches of the
internal pudendal nerve, the V-Y advancement
gluteal-fold ap (Fig. 31.6), which includes
branches of the cutaneous nerve from the femoral
and obturator nerves, and the medial thigh fasciocutaneous ap all support restoration of sensitivity in the area, and, therefore have the potential to
promote satisfactory sexual function after surgery [26]. One cross-sectional study assessing
quality of life and sexual function after vulvovaginal surgery with concurrent lotus petal ap
procedure demonstrated overall satisfaction in
sexual function in this patient population [44];
this nding has been conrmed in other studies
[93]. Additionally, compared to the V-Y advancement ap, the lotus petal ap was deemed to be
31 Inguinal Lymphadenectomy, Radical Vulvectomy
Fig. 31.5 Gluteus fasciocutaneous rotational ap. (Courtesy of Dr. Mario M.Leitao, Jr.)
343
Fig. 31.6 V-Y advancement ap (Courtesy of Dr. Mario M. Leitao, Jr.)
superior in terms of functional and cosmetic
results in patients who underwent vulvovaginal
oncologic surgery [20].
Several algorithms have been proposed to help
surgeons determine the best reconstructive plan
[92, 54, 31, 91, 34]. Further data of postoperative
outcomes, specically sexual function, are necessary to inform physicians and patients alike.
Postoperative sexual function after extensive
perineal excision may be particularly compro-
mised due to posterior introital scarring. Many
aps have been evaluated in the closure of perineal defects specically, including the inferior
gluteal ap, V-Y ap, lotus petal ap, and
rhomboid transposition ap [16, 45, 67, 93].
Repair of perineal defects after radical vulvar
surgery is best performed with skin aps versus
direct closure to reduce postoperative morbidity and provide better anatomical and functional
results [62].
344
C. Lam and M. M. Leitao
Management ofFunctional
Impairments After Radical
Vulvectomy
Urinary incontinence related to anatomical distortions from radical vulvectomy warrants a different treatment approach. Urethral resection is
sometimes necessary in the surgical treatment of
locally advanced vulvar cancer, which leads to a
pathology similar to type III stress urinary incontinence related to intrinsic sphincter deciency.
Management options for urinary incontinence
due to radical vulvectomy with urethrectomy are
similar to those used to treat intrinsic sphincter
deciency. This includes articial sphincter
implantation, pubovaginal sling, midurethral
tension- free vaginal tape, or bulking agent injection. One unique treatment modality is transurethral Macroplastique implantation, which was
shown to be safe and effective in oncologic
patients with total urinary incontinence after radical vulvar surgery [76].
Urethral eversion can be seen specically
after a radical vulvectomy. It is important to perform a thorough physical examination to rule this
out, as urethral eversion is a cause of urinary
incontinence and general difculty with micturition can be managed surgically. In one case
report, a patient who underwent radical vulvectomy with direct wound closure presented with
severe pain due to urethral orice eversion one
year after primary surgery; the patient subsequently underwent a secondary vulvar reconstruction using bilateral gluteal-fold aps three
years after primary surgery [86]. Although primary reconstruction is ideal, this case report supports the feasibility of secondary reconstruction
should it be necessary.
Fecal incontinence after radical vulvectomy is
most commonly observed in patients with anal
sphincter resection or damage. Conservative
measures should be attempted rst; these include
dietary adjustments, ber supplementation or
other bulking agents, constipating agents, anal
plugs, and biofeedback therapy [28]. Avoiding
food and drink that cause loose stool or increasing the intake of constipating agents are key
dietary adjustments that have been shown to be
effective in some cases of fecal incontinence.
Fiber and bulking agents, such as psyllium,
methyl cellulose, and synthetic polycarbophil,
can change stool consistency to decrease symptoms of fecal incontinence [12, 102]. Loperamide
increases anal resting pressure, impairs the rectoanal inhibitory reex, and increases transit time
in the small and large intestines, and has been
well-documented to have efcacy in cases of
fecal incontinence associated with loose stool
[43, 63, 69, 71, 84, 88]. Pelvic oor rehabilitation
plays a crucial role in the management of anal
incontinence, often in conjunction with surgical
procedures such as sphincteroplasty [75].
Pudendal nerve terminal motor latencies can
be used to assess pudendal neuropathy. Once
standard evaluation has been completed, if the
determined etiology of fecal incontinence is not
pudendal neuropathy, sphincteroplasty may be an
option to restore anal continence, depending on
the availability of the anal sphincter muscle. If
there is inadequate sphincter muscle due to resection, encirclement procedures using synthetic
materials or muscle transfer techniques can be
employed. Implantation of a stimulating electrode can be helpful in certain clinical scenarios,
particularly when using a gracilis neosphincter or
articial sphincter [55]. Sacral nerve stimulation
and posterior tibial nerve modulation are neuromodulatory techniques that can decrease incontinence episodes, and there does not seem to be a
difference in efcacy between the two methods
[103]. Antegrade colonic irrigation through an
appendicostomy was rst described in children
but has been shown to have some long-term efcacy in adults [65, 77]. Fecal diversion can be
pursued if all other options are exhausted, or if
the patient desires this option or is not a candidate for other therapeutic options.
General emotional support in the preoperative
and postoperative phases has been shown to be
necessary for patients who undergo surgical
treatment for vulvar cancer [7]. With depression
and anxiety affecting up to one-third of all
patients with vulvar cancer, the complex correlation between psychosocial status and sexual dys-
31 Inguinal Lymphadenectomy, Radical Vulvectomy
345
function cannot be ignored [68]. Preoperative
relational dissatisfaction is more common in
patients with vulvar malignancy and can continue
or even worsen postoperatively, regardless of the
extent of surgical excision [8, 68]. Depending on
the type of sexual dysfunction the patient presents with, psychotherapy can be tailored to t
their needs.
In addition to psychosocial risk factors, anatomic distortions can also contribute to sexual
dysfunction in patients with vulvar cancer.
Introital stenosis is one such example that can
occur after vulvectomy. As in the case of urethral
eversion, introital stenosis can also be managed
surgically if conservative treatment with dilators
is not sufcient to provide adequate relief of
symptoms. A case report demonstrated the lotus
petal ap was a safe and effective technique for
reconstruction in the case of severe introital stenosis after primary vulvovaginal surgery with
direct wound closure [15]. Given the crucial role
of the clitoris in sexual function, clitoral-sparing
surgical procedures have been evaluated for
safety and efcacy in the management of vulvar
carcinomas. One retrospective study examining
clitoral- sparing modied vulvectomies found no
loco- regional recurrences [17]. In fact, when
compared to complete radical vulvectomy, modied radical vulvectomy is generally associated
with the same rate of recurrence and decreased
risk of sexual dysfunction [27, 30, 96]. One retrospective study, however, demonstrated an
increased risk of loco- regional recurrence after
wide local excision compared to radical vulvectomy, suggesting that less radical surgery was
associated with a higher risk of recurrence.
Although, in this study, there was no difference
in survival between the two groups, which suggests that such loco-regional recurrences can be
successfully salvaged [24]. Thus, clitoral-sparing surgery can preserve sexual function while
maintaining oncologic integrity of the excisional
procedure.
Physiological changes, present both preoperatively and potentially enhanced postoperatively,
including anorgasmia, difculty in lubrication,
and pain, can contribute to sexual dysfunction
and should be addressed as indicated [68].
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Pelvic andParaaortic
Lymphadenectomy
MitchelHoman, MurrayShames,
andBernardH.Bochner
32
Introduction
Removal of pelvic and/or paraaortic lymph
nodes is an integral part of surgery for gynecologic and urologic cancers. For gynecologic
malignancies paraaortic lymph nodes are divided
into infra- and supramesenteric relative to the
bifurcation of the aorta, inferior mesenteric
artery (IMA), and left renal vein (Fig.32.1). For
women with high- risk bladder cancer undergoing a radical cystectomy, the pelvic lymphadenectomy is routinely performed and is divided
into limited, extended and super-extended with
the proximal limit of dissection at the common
iliac bifurcation, aortic bifurcation, or the base
of the IMA respectively [1]. Lymphadenectomy
may be performed by open or laparoscopic
surgery.
Major complications related to pelvic and
paraaortic lymphadenectomy (PPLND) include
vascular injury, lymphedema, nerve injury, ureteral injury, compromise of blood supply to the
intestinal tract, injury to the duodenum, arterial
embolization, lymphocyst and chylous ascites.
M. Hoffman (*)
Department of Gynecologic Oncology, Moftt
Cancer Center, USF Morsani College of Medicine,
Tampa, FL, USA
e-mail: mitchel.hoffman@moftt.org
M. Shames
Department of Surgery, Division of Vascular Surgery,
USF Morsani College of Medicine, Tampa, FL, USA
e-mail: mshames@usf.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Hoffman et al. (eds.), Major Complications of Female Pelvic Surgery,
https://doi.org/10.1007/978-3-031-66772-5_32
B. H. Bochner
Urology Service, Department of Surgery, Memorial
Sloan Kettering Cancer Center, New York, NY, USA
e-mail: bochnerb@mskcc.org
351
352
iliac node
e
Fig. 32.1 Anatomy of
the lymphatic system as
it relates to pelvic and
paraaortic
lymphadenectomy. The
relationships of the
major vasculature,
urinary tract and
obturator nerves are
shown
M. Homan et al.
Periaortic nodes
Common
Anatomy of the pelvic and paraaortic lymph nodes
Vascular Injury
Background
Risk factors for major vascular injury include
obesity, obliteration of the retroperitoneum or pelvic planes (prior surgery, radiation therapy),
tumor involvement of the vasculature either via
direct extension or involved regional lymph
nodes, aberrant anatomy, and utilization of an
energy device that may impact tissue beyond what
is intended [2]. Although uncommon, major vascular injury is the most serious and life- threatening
complication of PPLND [3]. Therefore, much of
this chapter will focus on vascular injury during
the performance of a PPLND.
Prevention
The internal iliac venous plexus is complex, relatively delicate, and not easily visualized. This
iliac node
Superior external
Internal iliac nod
Inferior external
iliac node
Obturator node
Deep femoral
nodes
plexus progressively coalesces into the short
internal iliac vein. Several venous branches to the
internal iliac vein travel in an anterior/posterior
plane as they arise from the gluteal compartment.
Injury to the more cephalad and coalescing portion of this plexus is more likely to result in substantial hemorrhage that may be difcult to
control due to the caliber, anatomic complexity,
thin walls, and relative surgical inaccessibility.
Control of bleeding is best done prophylactically.
The plexus is mainly at risk during the dissection
of internal iliac and obturator lymph nodes.
Prevention of injury to this plexus begins with
appropriate development of the relatively avascular paravesical space, exposing the obturator
fossa. When reasonable based on clinical ndings, the surgeon should limit dissection to
remain supercial to the obturator nerve, with
caution moving the cephalad toward the venous
conuence. If deeper dissection is needed, a layered approach to dissection of the obturator fossa
is optimal [4]. A split and roll technique can be
used to free the lymphatic tissues anterior to the