Vulvar cancer is uncommon, accounts for approximately 3% to 5% of gynecologic cancers, and has an incidence of 0.6% of all cancers in women [1], and this disease classically affects older women with an average age of onset of 65 to 70 years. Radical vulvectomy with en bloc resection of the inguinofemoral lymphadenectomy was the standard treatment for invasive cancer patients, but the postoperative morbidity of this procedure was high, and prolonged hospitalization was common [23]. In 1960, Way [4] introduced the technique of sartorius transposition following inguinofemoral lymphadenectomy to protect the femoral vessels in the event of wound breakdown and to reduce the risk of secondary hemorrhage. This procedure has been shown to reduce infections in vascular grafts in the groin. However, Judson et al. [5] in 2004 performed a prospective, randomized study and failed to show any decrease in the incidences of wound cellulitis, wound breakdown, lymphedema, or rehospitalization in the sartorius transposition group. Without doubt, sartorius transposition procedure can cause unnecessary damage to the skeleton muscle, which can result in ischemia and incision necrosis following the operation, and seriously affect the quality of life (QOL) of the patients. In order to improve the operation process and reduce the postoperative complications, we conducted a matched case-control study using the sartorius tendon transposition method compared with those of conventional sartorius transposition method following inguinofemoral lymphadenectomy in vulvar carcinoma patients to assess the outcomes.

In terms of age, BMI, International Federation of Gynecology and Obstetrics (FIGO) staging, histology and grade, the patients in the sartorius transposition and tendon transposition group were comparable. The median age and BMI were 57.5 and 57.0 years, 24.5 and 23.3 kg/m² at the sartorius transposition group and tendon transposition group (p=0.889 and p=0.320). No significant differences were found at FIGO stage histology grade between the two group (p=0.932, p=0.701, and p=0.493, respectively). The data for both groups are shown in Table 1.

Taussig (1940) [7] and Way (1948) [4] presented a standard operation for cancer of the vulva (i.e., radical vulvar resection and inguinal lymph node dissection), and the 5-year survival rate of the patients who underwent this procedure was approximately 70%. Since then, this radical surgery became the most common treatment for vulvar carcinoma patients. However, this procedure is often accompanied with physical and psychological adverse effects that seriously affect the patient's QOL, and the high rate of postoperative groin wound morbidity that is observed reflects the continued need for improvements in the surgical technique for inguinal-femoral lymphadenectomy and the postoperative care of these patients [89]. In an attempt to reduce severe complications, changes to surgical therapy have been continuously reported [1011121314].

The use of muscular flaps to improve the healing time of wounds is commonplace in plastic and reconstructive surgery, especially the well-vascularized tissue for chronically infected regions. As a treatment for vulvar carcinoma, sartorius transposition was first introduced by Way [4] in 1960. This procedure was originally introduced to protect the femoral blood vessels in cases of wound breakdown. In 1997, Paley et al. [15] reported that groin wound complications, such as wound breakdown and cellulitis, are significant reduced by the use of the sartorius transposition method following inguinal-femoral lymphadenectomy. Based on their findings, these authors inferred that the morbidity that follows groin dissection likely arises from anatomical or surgical factors rather than microbial factors. However, Judson et al. [5] subsequently performed a prospective, randomized study and found no statistically significant differences in the incidences of wound cellulitis, wound breakdown, lymphedema, or rehospitalization in the sartorius transposition group. This author found that this method does not reduce postoperative wound morbidity [5]. This procedure undoubtedly requires the freeing of the upper portion of the sartorius and the suturing of this portion to the inguinal ligament to cover the surface of the femoral vessels for protection, which will certainly cause unnecessary damage [16]. The functions of the sartorius include flexing the hip and knee joints, and aiding in the external rotation and abduction of the hip, and these functions are affected to a certain extent. Furthermore, during this process, the lateral femoral cutaneous nerve might be cut off, which might cause persistent pain and sensory disturbances in the femoral anterolateral area. All of these factors increase tissue edema following the operation, which leads to poor wound healing and promotes edema and ischemia in the tissues of the inguinal operation area and results in flap incision necrosis reduced QOL for the patients following such operations [1718].

In the present study, rather than cutting the sartorius itself, we only tore the tendon off of the surface of the sartorius and assessed the efficacy of replacing the sartorius transposition method in terms of reducing groin wound complications in vulvar carcinoma patients who underwent inguinal-femoral lymphadenectomy. Compared with the traditional operation method [1920], this modification not only obviated the need to cut off skeleton muscle but also protected the femoral vascular and femoral nerve. The postoperative healing time and the average hospital stay in the tendon transposition group were significantly reduced. Furthermore, this new procedure was well tolerated and greatly reduced the overall complication rate. Despite the similarities of the patient populations and the surgical factors, significant differences were found at wound break and chronic lymphedema, which decreased from 30.0% to 3.6% and 33.3% to 7.1% respectively. The incidences of lymphocele and groin cellulitis decreased from 13.3% to 7.1% and 20.0% to 10.7% respectively due to the use of this new method although on significance were noticed.

Concerning the postoperative life quality in our study, the postoperative QOL of the in tendon transposition group was significantly improved compared to that of the control group as indicated by the postoperative follow-up EORTC QLQ-C30 questionnaire, which included the overall QOL, physical functioning, emotional functioning, and pain. This is consistent to Gunther et al. [21] report that women who had wide local excision with radical vulvectomy instead of underwent radical vulvectomy have a superior QOL with regard to global health status and physical, role, emotional and cognitive functioning. Sexual activity, in addition, was a major concern for most QOL studies in relation to vulvar cancer, and factors associated with sexual dysfunction after vulvar surgery include age, depression and anxiety, and type of surgery. Gunther et al. [21] found that there is a correlation between the extent of the operation and the presence of problems in desire, orgasm, and resolution phase. In our finding, as indicated by ratio in the tendon transposition group, more patients resumed intercourse than sartorius transposition group.

The benefits observed in the tendon transposition group demonstrate that this technique is an effective means of reducing complications in patients who undergo vulvectomy and inguinofemoral lymphadenectomy. However, the present study cannot determine it is the muscle and/or nerve preservation that made the difference and due to its non-randomized nature and the size of the groups of patients is small because of low prevalence of vulvar cancer; future prospective, randomized studies with larger samples are needed. Another limitation is that several gynecologic oncologists working in our unit during the studied period performed groin lymphadenectomies, which likely resulted in variations in surgical practice.