BlueCross BlueShield of Tennessee Medical Policy Manual

Vulvectomy

DESCRIPTION

The vulva is the outer part of female genitals. Vulvectomy refers to a surgical procedure in which the vulva is partially or completely removed.  A simple, partial vulvectomy removes only the affected area and an edge (or margin) of tissue around the lesion, which is called “getting a clear margin.” The most extensive surgery is called a radical complete vulvectomy, done only for known cancerous lesions. This includes the inner and outer lips of the vulva, the clitoris, and often the lymph nodes that drain lymph fluid from the vulva. The vagina, uterus, and ovaries remain intact.

A wide variety of lesions occur on the vulva. Some of the disorders causing these lesions are limited to the vulva, while others also involve skin or mucocutaneous membranes elsewhere on the body. Typically they are benign and treated topically. Dermatologic lesion such as lichen sclerosus et atrophicus (LSA), which causes the vulvar skin to become very thin, scaly and itchy; have a very small risk of developing into cancer (4%).

Papillomas (more commonly known as warts) are not cancers. However, certain types of human papilloma viruses (HPV) have been linked to about half of vulvar cancers. In individuals with a lesion suspicious for vulvar cancer or intraepithelial neoplasia, a conservative procedure can be used with a more radical procedure performed if invasive disease is diagnosed.

On rare occasion a benign lesion may require a surgical margin because it is difficult to distinguish from cancerous tissue. Cases of extramammary Paget’s disease, and trichoblastoma (benign tumor of the hair follicle), resistant plasma cell vulvitis (i.e. Zoon’s vulvitis) have been documented as being treated with partial vulvectomies.

POLICY

See also:  Human Papillomavirus (HPV) Vaccine

MEDICAL APPROPRIATENESS

IMPORTANT REMINDERS

SOURCES

Abramov, Y., Elchalal, U., Abramov, D., Goldfarb, A., and Schenker, J. (1996, March) Surgical treatment of vulvar lichen sclerosus: a review. Obstetrics & Gynecology Journal. 51(3):193-9. Abstract retrieved November 4, 2016 from PubMed database.

American Cancer Society. (2016, February). Cancer reference information. Detailed guide: vulvar cancer. Retrieved October 31, 2016 from: http://www.cancer.org

American College of Obstetricians and Gynecologists. (2016, October). ACOG Committee Opinion. Number 675. Management of vulvar intraepithelial neoplasia. Retrieved October 31, 2016 from: http://www.acog.org.

American College of Radiology. (2012) ACR appropriateness criteria® management of loco-regionally advanced squamous cell carcinoma of the vulva. Retrieved November 26, 2014 from http://www.guideline.gov (NGC # 009680).

Anton, C., Vicentini da Costa Luiz, A., Carvalho, F., Baracat,E., and CarvalhoI, J. (2011) Clinical treatment of vulvar Paget’s disease: a case report. Clinics. 66(6):1109-1111. (Level 4 evidence)

British Association for Sexual Health (2014) National guideline on the management of vulval conditions. Retrieved October 28, 2016 from: http://www.guideline.gov  (NGC # 010238)

Chan, M. and Zimarowski. (2012, March) Vulvar dermatoses: a histopathologic review and classification of 183 cases. Journal of Cutaneous Pathology. 42: 510–518. (Level 4 evidence)

European Academy of Dermatology and Venereology (2015) Evidence-based (S3) Guideline on (anogenital) Lichen sclerosus. Journal of European Academy of Dermatology and Venereology. 29, e1-e43.

Gurumurthy, M., Cairnes, M., and Cruickshank, M. (2010, January) Case series of Zoon vulvitis. Journal of Lower Genitourinary Tract Disorders; 14(1):56-8. Abstract retrieved November 4, 2016 from PubMed database.

Jia, Y., Wu, J., Xu, M., Tang, L., Li, C., Luo, M., et. al. (2014) Clinical responses to focused ultrasound applied to women with vulval intraepithelial neoplasia. Journal of Ultrasound Medicine; 33:1903-1908. (Level 4 evidence)

National Comprehensive Cancer Network® (2016, October) NCCN clinical practice guidelines in oncology (NCCN guidelines®) vulvar cancer (squamous cell carcinoma) version 1.2017. Retrieved October 28, 2016 from: www.nccn.org.

Neri, I., Patrizi, A., Marzaduri, S., Marini, R. and Negosanti, M. (1995) Vulvitis plasmacellularis: two new cases. Genitourinary Medicine; 71:311-313. (Level 4 evidence)

Pina, A. , Sauthier, P., and Rahimi, K. (2015, January) Vulvar trichoblastoma: case report and literature review. Journal of Lower Genitourinary Tract Disorders. 19(1):e10-2. Abstract retrieved October 28, 2016 from PubMed database.

Shetty, K. J., Prasad, H. L., & Rai, S. (2012). Primary amelanotic melanoma of vulva in a young, lactating female. Indian Journal of Surgical Oncology, 3 (1), 36-7. (Level 4 evidence)

Xu, L,. Luo, R., Sun, X., He, J., and Zhang, Y. (2013) Prognostic analysis of early-stage squamous cell carcinoma of the vulva. World Journal of Surgical Oncology. 11:20. (Level 4 evidence)

ORIGINAL EFFECTIVE DATE:  10/11/2008

MOST RECENT REVIEW DATE:  3/23/2017

ID_BT

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