- Email: [email protected]
Superficial laser vulvectomy
Hiilesmaa, Bardy, and Teramo
4. Fedrick J. Epilepsy and pregnancy: a report from the Oxford Record linkage study. Br Med J 1973;2:442-8. 5. Nelson KB, EllenbergJH. Maternal seizure disorder, outcome of pregnancy, and neurologic abnormalities in the children. Neurology 1982;32:1247-54. 6. Speidel BD, Meadow SR. Maternal epilepsy and abnormalities of the fetus and newborn. Lancet 1972;2:839-43. 7. Weber M, Schweitzer M, Mur J-M, Andre M, Tridon P, Vert P. Epilepsie, medicaments antiepileptiques et grossesse. Arch Franc Pediatr 1977;34:374-84. 8. Watson JD, Spellacy WN. Neonatal effects of maternal treatment with the anticonvulsant drug diphenylhydantoin. Obstet Gynecol1971;37:881-5. 9. Martin F. Grossesse et epilepsie. Rev Med Suisse Romande 1978;98: 199-208. 10. Gastaut H. Dictionary of epilepsy. Part 1: Definitions. Geneva: World Health Organization: 1973. 11. Meyer ]G. The teratological effect of anticonvulsants and
July I, 1985 Am J Obstet Gynecol
12.
13. 14. 15. 16.
the effects on pregnancy and birth. Eur Neurol 1973;10:179-90. Hill R, Tennyson L. Premature delivery, gestational age, complications of delivery, vital data at birth on newborn infants of epileptic mothers. In Janz D, Dam M, Richens A, Bossi L, Helge H, Schmidt D, eds. Epilepsy, pregnancy and the child. New York: Raven Press, 1982:167-73. Teramo K, Hiilesmaa V, Bardy A, Saarikoski S. Fetal heart rate during a maternal grand mal epileptic seizure. J Perinat Med 1979;7:3-6. Anonymous: Teratogenic risks of antiepileptic drugs. Br MedJ 1981;283:515-6. Hiilesmaa VK, Teramo K, Granstrom M-L, Bardy A. Fetal head growth retardation associated with maternal antiepileptic drugs. Lancet 1981;2:165-7. Janz D. Antiepileptic drugs and pregnancy: altered utilization patterns and teratogenesis. Epilepsia 1982; 23(suppl l):S53.
Superficial laser vulvectomy III. A new surgical technique for appendage-conserving ablation of refractory condylomas and vulvar intraepithelial neoplasia Richard Reid, M.D.
Detroit, Michigan Despite the unique properties of the carbon dioxide laser, many surgeons do not know how to exploit the full potential of this sophisticated instrument. Effective laser operation on the vulva depends upon the accuracy of delineation of disease, the use of optimum power densities, and the ability to exercise precise control over depth of ablation. This article describes a surgical technique that capitalizes upon these principles, thereby maximizing the margin between favorable and poor outcomes. Superficial laser vulvectomy is a safe and efficient procedure in the hands of expert physicians, but should not be attempted by those who are less experienced. Indications for this operation and safeguards against surgical misadventure are also discussed. (AM J OBSTET GYNECOL 1985;152:504-9.)
Key words: Laser, vulvectomy, condyloma, vulvar intraepithelial neoplasia, surgical technique
Over the last decade, the prevalence of vulvar intraepithelial neoplasia in young women has increased dramatically, particularly the multifocal "Bowenoid" variety. 1 Although the treatment originally proposed for squamous carcinoma in situ of the vulva was wide local excision, fears that the disease was preinvasive led to the widespread use of vulvectomy (simple or skinning) in such patients. However, most documented instances of invasion have occurred in immunosup-
From the Department of Obstetrics and Gynecology, Sinai Hospital of Detroit. Received for publication june 4, 1984; revised October 31, 1984; accepted November 21, 1984. Reprint requests: Dr. Richard Reid, Associate Director of Research and Education, Sinai Hospital of Detroit, 6767 West Outer Drive, Detroit, MI 48235.
504
pressed or elderly women. 1 In healthy patients, the risk of malignant progression is insufficient to justify such a mutilating surgicai procedure. Treatment of vulvar intraepithelial neoplasia is controversial, with recommendations ranging from wide excision to skinning vulvectomy.2 Wide excision of small foci produces excellent results, but multifocal or extensive lesions are difficult to treat by this method. In the past, the only other alternative was skinning vulvectomy with grafting. 3 Although it was a definite improvement over conventional vulvectomy, cosmetic and functional results were still poor. 2 Fortunately, the carbon dioxide laser offers an escape from this dilemma (Fig. 1), by providing an effective but nonmutilating treatment for this distressing, possibly premalignant disease.•- 7 As a consequence of changing social values, Western
Superficial laser vulvectomy. Ill 505
Volume 152 Number 5
Fig. 1. A diagram depicting the first three surgical planes. Reading from surface to base, the points of reference for each plane are indicated as stepwise expansions. The first surgical plane corresponds to the basement membrane, the second to the papillary dermis, and the third to the midreticular dermis.
Table I. Summary of salient features of the four surgical planes that can be used for more accurate control of depth during carbon dioxide laser operations Surgical plane Parameter
First
Target tissue Zone of vaporization
Surface epithelium Proliferating layer
Zone of necrosis Type of healing
Basement membrane Rapid, cosmetic
Visual landmark
Opalescent cell debris
Second
Third
Fourth*
Dermal papillae Superficial papillary dermis Deep papillary Rapid, cosmetic
Pilosebaceous ducts Upper reticular dermis Midreticular Usually cosmetic, may hypertrophy
Pilosebaceous glands Midreticular dermis
Scorched basement membrane
Coarse collagen fibers
Deep reticular Atrophic or hypertrophic; needs grafting "Sand grains" (skin appendages)
*Described in Reference 7.
society has also experienced an epidemic of sexually transmitted papillomaviral infections. 8 Condylomas result from the direct transmission of human papillomaviral infections during physical contact. After an incubation period of 1 to 6 months, infected tissues undergo a phase of rapid epithelial and capillary proliferation. Even without treatment, many lesions will regress spontaneously over the succeeding 6 to 12 months, apparently as a result of a combined cellular and humoral immune response. 9 Subsequent to simple therapy with caustic agents or thermal cautery, most patients with vulvar condylomas will be free of clinical lesions within 1 year. 6 Since these infections are always more widespread than is appreciated by examination with the naked eye, it is difficult to explain the apparent success of such crude measures. However, the small residue of patients with unusually extensive lesions or
infections that are refractory to conventional treatments constitutes management problems, and is a source of frustration to patients and physicians alike. Several authors have reported favorably on the result of laser operations in such patients. 10 Despite the unique physical properties ofthe carbon dioxide laser, using this instrument as a "spot welder" does not offer a solution to the treatment of patients who have refractory surrounding subclinical infection. 6 Likewise, although it is a very simple surgical exercise to use a laser on a patch of vulvar intraepithelial neoplasia, poor control of depth can lead to full-thickness epithelial destruction and a cosmetic result that is no better than would follow any other type of third-degree burn. Hence, surgeons who use the carbon dioxide laser for the ablation of large areas of vulvar epithelium must learn to recognize the three surgical planes de-
506
Reid
July I, 1985 Am J Obstet Gvn"r~!
Fig. 2. A broad sessile condyloma in the right upper portion of the field has been undercut to a deep dermal plane by using the laser as an excisional rather than an ablative tool. After the thick layer of charred proteins that ordinarily covers a laser impact site has been wiped away, the coarse collagen fibers of the deep dermis are readily visible. Surrounding condylomas have been vaporized.
fined in a previous article (Table 1). Otherwise, laser operations will carry unacceptable risks of delayed healing and scar formation. 5 · 12 This article, the third in a series of five, describes the actual surgical technique of superficial laser vulvectomy.
Surgical technique Preparation of patient. If a patient has condylomas that are sufficiently extensive or refractory to require treatment by this method, the area of affected epithelium will almost always be too large for treatment under local infiltration. Likewise, since vulvar intraepithelial neoplasia in young women is usually multicentric, and is often surrounded by even larger areas of subclinical papillomaviral infection, most such cases will also require general or regional anesthesia. After the induction of anesthesia, the perineum is carefully shaved (both to facilitate colposcopy and to simplify postoperative care). The use of antiseptic solutions is neither desirable (because it impairs response of tissue to acetic acid) nor necessary (because of the high temperatures attained at the site of laser impact). Rather, the vulva and anus are soaked for 3 minutes with acetic acid or white vinegar (with the use of very wet cotton balls or gauze squares). The perineum is then carefully examined with a colposcope. The borders of any foci of vulvar intraepithelial neoplasia and the outer margins of the surrounding subclinical pap-
Fig. 3. The initial vaporization of benign condylomas, sufficient to extend the central crater to about the level of the surrounding epidermis. This maneuver will loosen the epidermal cells in the base of the condyloma, so that wiping with a moist gauze swab will detach most of the lesion. The laser can then be applied again to any residual islands of adherent epithelium.
illomaviral infections are then outlined, before the acetic acid reaction fades. Collection of biopsy specimens. Provided that the correct technique is used, the carbon dioxide laser is an ideal tool for collecting additional biopsy specimens. Since the emissions from the carbon dioxide laser are not hemostatic for vessels larger than I mm, the stalks of any condylomas to be excised must first be compressed by means of a fine Vicryl or catgut ligature. The condyloma can then be excised with scissors, and the arterioles in the base of the condylomas sealed by lasing to the pedicle. Since the edges of any laser crater tend to shrink toward the center of the impact site, the laser is of value as a thermal scalpel only if it is used with skillful traction and countertraction. Hence, sessile condylomas or acetowhite plaques are excised by first grasping the lesion with fine tissue forceps and having an assistant apply countertraction to the surrounding skin. The laser can
Volume 152 Number 5
then be used to collect a bloodless biopsy specimen, by undercutting the plaque through a deep dermal or subcutaneous plane (Fig. 2). At the completion of the operation, these biopsy sites should be closed with fine Vicryl sutures. Application of the laser to any foci of vulvar in· traepithelial neoplasia. First, the laser is used to expose the proliferating zone of the epidermis by "brushing" the skin surface with a layer of laser energy, as previously described.' The epidermal debris can now be removed from the operative field by gently wiping with a moistened gauze swab, thereby revealing smooth pink-white basement membrane overlying the anatomically intact papillary dermis. It is now an easy task to vaporize down to the third surgical plane (Fig. I). Lasing to the second plane is accomplished by moving the laser beam quickly enough to scorch, rather than crater, the exposed dermal surface.' Such oscillations are done at about the same speed as used for "brushing" the epidermis. In contrast, lasing to the third plane is done by slow deliberate movements, controlling depth of penetration by careful hand-eye coordination.' Ablation of remaining condylomas and adjacent subclinical papillomaviral infection. The surgeon should not attempt to remove the remaining condylomas by undercutting them with the laser. Except for long-standing lesions (which can become quite pedunculated), most condylomas have a flat base. Attempts to undercut condylomas that are not required for histologic examination produce unnecessary dermal defects, and can be attended by troublesome bleeding (especially in pregnancy). Rather, the strategy should be to umbilicate the center of each lesion, debride the loosened epidermis, and relase to any residue (Fig. 3). Each condyloma should be umbilicated by lasing to the center and allowing tissue shrinkage at the laser impact site to pull the edge of the lesion into the operative field. It is unnecessary to lase to the edge of each condyloma; hence, the problem of unwanted damage to adjacent skin is easily avoided. The initial application of the laser should extend the vaporization crater to about the level of the surrounding skin, but there should be no penetration of the basement membrane at this point. Although it will be visually apparent that the zone of vaporization has not yet destroyed all of the abnormal keratinocytes at the base of the condyloma, lasing to this level will separate most of these cells from the basement membrane. Hence, this technique will minimize the extent of any unwanted thermal damage within the superficial dermis. Once the condylomas have been umbilicated, the area is easily debrided by gentle wiping with a moist gauze swab. Any residual epithelial fronds or capillary spikes can then be accurately destroyed by spot lasing. Before debridement of the residues of these con-
Superficial laser vulvectomy. Ill
507
dylomas, it is convenient to ablate any surrounding areas of subclinical infection to the first surgical plane (Fig. 1). Using the laser within the vagina. If the cervical transformation zone shows papillomaviral infection or intraepithelial neoplasia, it is ablated to a measured depth of 7 mm, with the use of a power density of 750 to 1500 w/cm 2 • To ensure destruction of the upper limit of the transformation zone, the treatment area is domed another 5 mm proximally, along the axis of the canal. 13 Extensive papillomaviral infection may necessitate treatment of the vault, the lower third, or the entire vagina. To avoid any risk of bladder or rectal injury, the depth of destruction must be kept within the submucosa. Control of depth is achieved by lasing until the surface epithelium chars, with the use of a power density of 750 to 1200 w/cm 2 • 6 The vaginal side walls are exposed between the open blades of a bivalve speculum. Successive rotations of the speculum will expose the anterior and posterior walls. In the lower part of the vagina, a better angle of impact is obtained by aiming through the sides (rather than the central aperture) of the speculum. After the entire circumference has been treated, the speculum is withdrawn and the epithelial debris is wiped away by vigorous swabbing with a moist gauze square. When the speculum is reinserted, any untreated areas are easily identifiable, and can be ablated under direct vision. Recognition of residual islands of intact epithelium is sometimes aided by staining the vaginal walls with Lugol's iodine. Such islands stain mahogany brown and stand out against the unstained stroma. Using the laser within the anal canal or urethra. Ablation within the anal canal or urethra requires special caution to limit the depth of destruction to the basement membrane. Circumferential destruction of the epithelium and submucosa will lead to anal or urethral stenosis. However, the technique of surface charring, debridement, and localized reapplication of the laser negates these risks. Low-power densities (350 to 450 w/cm 2 ) are recommended. The anal canal can be visualized with a large nasal speculum, a small Peterson vaginal speculum, Sim's anoscope, or two pairs of uterine polyp forceps. Because of a theoretical risk of explosion, any flatus should be sucked from the rectum before the laser is used within the anus. Exposure within the urethra is best done by using an endocervical speculum, or a small nasal speculum. If the surgeon is using a superpulsed laser, he should take advantage of this adaptation to minimize the zone of thermal coagulation within the urethra. 14 Postoperative care. To counteract the inflammation and edema provoked by mild thermal injury to the underlying tissues, the vulva is liberally dressed with
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Reid
July 1, 1985 Am J Obstet Gynecol
Table II. A guide to the best level of destruction for different disease entities Surgical plane
First Second Third Fourth
Fig. 4. Photograph taken 10 days after laser vulvectomy, showing how healing should be advanced and almost complete. Application of the laser to an excessive depth is characterized by a relative delay in early healing, and an end result that is distinguishable from normal skin.
0.1% triamcinolone cream, while the patient is still in the lithotomy position. 13 Following the empiric observation that urinary diversion will prevent a great deal of anticipated postoperative pain, patients who require large areas of vulvar ablation are offered a suprapubic catheter with leg bag for 2 weeks. Malodor is prevented by the daily instillation of I ounce of white vinegar into the collecting bag. Safeguards against bacterial infection include the prescription of prophylactic antibiotics and the daily cleansing of the collection system with household detergents. The catheter is removed at an office visit, when healing is well advanced. Except in pregnant patients, treatments are performed as outpatient operations. Before discharge, each patient must have her ability to micturate normally verified by the recovery room nurse. Patients who void frequent small amounts should be specifically checked for retention with overflow. In the latter case it will be necessary to insert an indwelling Foley catheter. Before discharge, patients must also receive a prescription for a schedule 3 narcotic, a complete set of postoperative instructions, and an appointment for office follow-up in 1 week. The most important part of the postoperative regimen is to soak for 30 minutes every 4 hours in a bath of reconstituted sea water (Instant Ocean) 4 or hypertonic Epsom salt solution (1 cup per gallon). The vulva
Appropriate for
Condyloma acuminatum Flat subclinical lesions Micropapillary subclinical lesions Hypertrophic dystrophies Intraepithelial neoplasia, pilosebaceous glands not involved Intraepithelial neoplasia, involving pilosebaceous glands
should then be dried with a hair dryer, and dressed with a thin application of neomycin-bacitracin ointment. A prescription of Nupercainal2% gel and a stool softener will make defecation less uncomfortable. Prophylactic antibiotics are not necessary, except to cover any indwelling Foley catheter. Patients must be seen weekly for 3 weeks, to correct any early coaptation of adjacent raw surfaces. Healing should be virtually complete within 14 to 2I days (Fig. 4). Thereafter, women with refractory condylomas should return every 2 to 4 weeks for the next 3 months, so that any focal recurrences can be controlled by caustic agents. Because women with vulvar neoplasia or papilloma viral infections are at high risk for developing squamous neoplasia at other sites within the genital tract, surveillance by annual Papanicolaou smears is mandatory."· 16
Comment Lasers are powerful but predictable surgical tools. Used with skill and discretion, they open new vistas in many medical specialties. However, despite their unique properties, careless or unskilled laser operations will yield undesirable results. Misadventure may arise (I) from accidental injuries to staff or patients, (2) by selection error, or (3) through the occurrence of conventional surgical complications. 11 Avoidance of accidental injury requires an awareness of the path of the laser beam (from source to dissipation), and the exclusion of flammable drapes, plastic speculums, or dry swabs from the operative field. The major selection error is failure to detect occult invasion. Safeguards are a sound knowledge of lower genital tract neoplasia, colposcopic expertise, and strict adherence to triage rules. The risk of treatment failure is minimized by setting surgical margins with the colposcope, by individualization of depth according to histologic findings, and by treating focal recurrences of papillomaviral infection with topical trichloroacetic acid. Skillfully executed, this technique of superficial laser vulvectomy carries a very low rate of complications. However, less precise methods can lead to delayed healing, atrophic or hypertrophic scar formation, and vulvar coaptation.
Superficial laser vulvectomy. Ill
Volume 152 Number 5
Although safe and effective, superficial laser vulvectomy subjects patients to the risks of anesthesia and involves an absence from work or domestic duties of 10 to 14 days. 6 • 7 Hence, surgeons should satisfy themselves that the extent and severity of the problem are sufficient to warrant this operation. Since occasional malignant progression of carcinoma in situ has been reported in young, immunocompetent women, 14 the eradication of vulvar intraepithelial neoplasia can be justified on the grounds of cancer prophylaxis, provided that nonmutilating methods are used!· 3 Hence, superficial laser vulvectomy is usually my treatment of choice for extensiv~ or multifocal carcinomas in situ. However, the risk of malignant progression of hyperplastic dystrophies (with or without mild atypia) is too remote to justify operations on these same grounds. Rather, this diverse group of dermatologic disorders should be treated with topical steroids! with laser operations being reserved for those that continue to cause intractable itching or discomfort. Likewise, I believe that only refractory or extensive condylomas should be treated by laser ablation. 6 However, when this decision has been made, the systematic approach outlined in this series of articles would appear to be more logical than the simple use of the laser as a "spot welder." An important factor in poor outcome with the laser is the prevalence of a naive attitude that a favorable result is guaranteed by the technical sophistication of this tool. Unhappily, this is not true. Quality of outcome depends upon surgical precision (with the use of strategies that infer actual depth of thermal necrosis from the visual characteristics of more superficial landmarks), and accurate pathologic assessment (providing a rational basis for selecting different depths of destruction for different disease entities) (Table II). Once mastered, this method will consistently yield optimum results and allow confident preoperative counseling about the speed and cosmetic quality of eventual healing. The technique of superficial laser vulvectomy is an exacting one that requires both careful attention to detail and considerable facility with the carbon dioxide laser. Inexperienced laser surgeons should not, under any circumstances, attempt this operation. As a generalization, laser operations perf~rmed by less experienced physicians tend to be too shallow on the cervix, but too deep on the vulva. Such habits can be difficult
509
to break. Hence, even experienced laser surgeons should ideally receive preceptorship in this procedure. If this is not possible, they should at least arrange to see a film that explicitly details the operative technique. I wish to thank Lawrence Elston, Michael Menlo, and Robert Lane for the photography and Sue Pasqua! for the medical artwork. REFERENCES 1. Buscema J, Woodruff JD, Parmley TH, Genadry R. Carcinoma in situ of the vulva. Obstet Gynecol 1980;55:22530. 2. Friedrich EG. Intraepithelial neoplasia of the vulva. In: Coppleson M, ed. Gynecologic oncology. Fundamental principles and clinical practice. London: Churchill Livingstone, 1981:303-19. 3. Rutledge F, Sinclair M. Treatment of intraepithelial carcinoma of the vulva by skin excision and graft. AM J OBSTET GYNECOL 1968;102:806-15. 4. Baggish MS, Dorsey JM. C02 laser for the treatment of vulvar carcinoma in situ. Obstet Gynecol1980;57:371-5. 5. Ferenczy A. Using the laser to treat vulvar condyloma acuminata and intraepidermal neoplasia. Can Med Assoc J 1983;128:135-37. 6. Reid R. Superficial laser vulvectomy. I. The efficacy of extended epidermal ablation for refractory and very extensive condylomas. AM J OBSTET GYNECOL. In press. 7. Reid R, Elfont EA, Zirkin RM, Fuller TA. Superficial laser vulvectomy. II. The anatomic and biophysical principles permitting accurate control over the depth of dermal destruction with the carbon dioxide laser. AMJ 0BSTET GYNECOL. In press. 8. Leads from the MMWR. Condylomas acuminata: United States, 1966-81. JAMA 1983;250:336. 9. Reid R, Laverty CR, Coppleson M, et a!. Noncondylomatous cervical wart virus infection. Obstet Gynecol 1980;55:4 76-83. 10. Baggish MS. Carbon dioxide laser treatment for condylomata acuminata venereal infections. Obstet Gynecol 1980;55:711-15. 11. Reid R. Laser safety. I. Avoidance of surgical misadventure with the C0 2 laser. Colposcopy Laser Surg 1984; 1:117-40. 12. Reid R, Muller S. Tattoo removal by C0 2 laser dermabrasion. Plast Reconstr Surg 1980;65:717-28. 13. Stanhope CR, Phibbs GD, Stuart GCE, Reid R. Carbon dioxide laser surgery. Obstet Gynecol 1983;61:624-7. 14. Rattner WH, Rosemberg SK, Fuller TA. Differences between continuous wave and superpulse carbon dioxide laser in bladder surgery. Urology 1979; 13:264-6. 15. Reid R. Papillomaviruses and cervical neoplasia. Modern implications and future prospects. Colposcopy Laser Surg 1984;1:3-34. 16. Reid R, Fu YS, Herschman BR, et a!. Genital warts and cervical cancer. IV. The relationship between aneuploid and polyploid lesions. AMJ 0BSTET GYNECOL 1984; 150:189.
4. Fedrick J. Epilepsy and pregnancy: a report from the Oxford Record linkage study. Br Med J 1973;2:442-8. 5. Nelson KB, EllenbergJH. Maternal seizure disorder, outcome of pregnancy, and neurologic abnormalities in the children. Neurology 1982;32:1247-54. 6. Speidel BD, Meadow SR. Maternal epilepsy and abnormalities of the fetus and newborn. Lancet 1972;2:839-43. 7. Weber M, Schweitzer M, Mur J-M, Andre M, Tridon P, Vert P. Epilepsie, medicaments antiepileptiques et grossesse. Arch Franc Pediatr 1977;34:374-84. 8. Watson JD, Spellacy WN. Neonatal effects of maternal treatment with the anticonvulsant drug diphenylhydantoin. Obstet Gynecol1971;37:881-5. 9. Martin F. Grossesse et epilepsie. Rev Med Suisse Romande 1978;98: 199-208. 10. Gastaut H. Dictionary of epilepsy. Part 1: Definitions. Geneva: World Health Organization: 1973. 11. Meyer ]G. The teratological effect of anticonvulsants and
July I, 1985 Am J Obstet Gynecol
12.
13. 14. 15. 16.
the effects on pregnancy and birth. Eur Neurol 1973;10:179-90. Hill R, Tennyson L. Premature delivery, gestational age, complications of delivery, vital data at birth on newborn infants of epileptic mothers. In Janz D, Dam M, Richens A, Bossi L, Helge H, Schmidt D, eds. Epilepsy, pregnancy and the child. New York: Raven Press, 1982:167-73. Teramo K, Hiilesmaa V, Bardy A, Saarikoski S. Fetal heart rate during a maternal grand mal epileptic seizure. J Perinat Med 1979;7:3-6. Anonymous: Teratogenic risks of antiepileptic drugs. Br MedJ 1981;283:515-6. Hiilesmaa VK, Teramo K, Granstrom M-L, Bardy A. Fetal head growth retardation associated with maternal antiepileptic drugs. Lancet 1981;2:165-7. Janz D. Antiepileptic drugs and pregnancy: altered utilization patterns and teratogenesis. Epilepsia 1982; 23(suppl l):S53.
Superficial laser vulvectomy III. A new surgical technique for appendage-conserving ablation of refractory condylomas and vulvar intraepithelial neoplasia Richard Reid, M.D.
Detroit, Michigan Despite the unique properties of the carbon dioxide laser, many surgeons do not know how to exploit the full potential of this sophisticated instrument. Effective laser operation on the vulva depends upon the accuracy of delineation of disease, the use of optimum power densities, and the ability to exercise precise control over depth of ablation. This article describes a surgical technique that capitalizes upon these principles, thereby maximizing the margin between favorable and poor outcomes. Superficial laser vulvectomy is a safe and efficient procedure in the hands of expert physicians, but should not be attempted by those who are less experienced. Indications for this operation and safeguards against surgical misadventure are also discussed. (AM J OBSTET GYNECOL 1985;152:504-9.)
Key words: Laser, vulvectomy, condyloma, vulvar intraepithelial neoplasia, surgical technique
Over the last decade, the prevalence of vulvar intraepithelial neoplasia in young women has increased dramatically, particularly the multifocal "Bowenoid" variety. 1 Although the treatment originally proposed for squamous carcinoma in situ of the vulva was wide local excision, fears that the disease was preinvasive led to the widespread use of vulvectomy (simple or skinning) in such patients. However, most documented instances of invasion have occurred in immunosup-
From the Department of Obstetrics and Gynecology, Sinai Hospital of Detroit. Received for publication june 4, 1984; revised October 31, 1984; accepted November 21, 1984. Reprint requests: Dr. Richard Reid, Associate Director of Research and Education, Sinai Hospital of Detroit, 6767 West Outer Drive, Detroit, MI 48235.
504
pressed or elderly women. 1 In healthy patients, the risk of malignant progression is insufficient to justify such a mutilating surgicai procedure. Treatment of vulvar intraepithelial neoplasia is controversial, with recommendations ranging from wide excision to skinning vulvectomy.2 Wide excision of small foci produces excellent results, but multifocal or extensive lesions are difficult to treat by this method. In the past, the only other alternative was skinning vulvectomy with grafting. 3 Although it was a definite improvement over conventional vulvectomy, cosmetic and functional results were still poor. 2 Fortunately, the carbon dioxide laser offers an escape from this dilemma (Fig. 1), by providing an effective but nonmutilating treatment for this distressing, possibly premalignant disease.•- 7 As a consequence of changing social values, Western
Superficial laser vulvectomy. Ill 505
Volume 152 Number 5
Fig. 1. A diagram depicting the first three surgical planes. Reading from surface to base, the points of reference for each plane are indicated as stepwise expansions. The first surgical plane corresponds to the basement membrane, the second to the papillary dermis, and the third to the midreticular dermis.
Table I. Summary of salient features of the four surgical planes that can be used for more accurate control of depth during carbon dioxide laser operations Surgical plane Parameter
First
Target tissue Zone of vaporization
Surface epithelium Proliferating layer
Zone of necrosis Type of healing
Basement membrane Rapid, cosmetic
Visual landmark
Opalescent cell debris
Second
Third
Fourth*
Dermal papillae Superficial papillary dermis Deep papillary Rapid, cosmetic
Pilosebaceous ducts Upper reticular dermis Midreticular Usually cosmetic, may hypertrophy
Pilosebaceous glands Midreticular dermis
Scorched basement membrane
Coarse collagen fibers
Deep reticular Atrophic or hypertrophic; needs grafting "Sand grains" (skin appendages)
*Described in Reference 7.
society has also experienced an epidemic of sexually transmitted papillomaviral infections. 8 Condylomas result from the direct transmission of human papillomaviral infections during physical contact. After an incubation period of 1 to 6 months, infected tissues undergo a phase of rapid epithelial and capillary proliferation. Even without treatment, many lesions will regress spontaneously over the succeeding 6 to 12 months, apparently as a result of a combined cellular and humoral immune response. 9 Subsequent to simple therapy with caustic agents or thermal cautery, most patients with vulvar condylomas will be free of clinical lesions within 1 year. 6 Since these infections are always more widespread than is appreciated by examination with the naked eye, it is difficult to explain the apparent success of such crude measures. However, the small residue of patients with unusually extensive lesions or
infections that are refractory to conventional treatments constitutes management problems, and is a source of frustration to patients and physicians alike. Several authors have reported favorably on the result of laser operations in such patients. 10 Despite the unique physical properties ofthe carbon dioxide laser, using this instrument as a "spot welder" does not offer a solution to the treatment of patients who have refractory surrounding subclinical infection. 6 Likewise, although it is a very simple surgical exercise to use a laser on a patch of vulvar intraepithelial neoplasia, poor control of depth can lead to full-thickness epithelial destruction and a cosmetic result that is no better than would follow any other type of third-degree burn. Hence, surgeons who use the carbon dioxide laser for the ablation of large areas of vulvar epithelium must learn to recognize the three surgical planes de-
506
Reid
July I, 1985 Am J Obstet Gvn"r~!
Fig. 2. A broad sessile condyloma in the right upper portion of the field has been undercut to a deep dermal plane by using the laser as an excisional rather than an ablative tool. After the thick layer of charred proteins that ordinarily covers a laser impact site has been wiped away, the coarse collagen fibers of the deep dermis are readily visible. Surrounding condylomas have been vaporized.
fined in a previous article (Table 1). Otherwise, laser operations will carry unacceptable risks of delayed healing and scar formation. 5 · 12 This article, the third in a series of five, describes the actual surgical technique of superficial laser vulvectomy.
Surgical technique Preparation of patient. If a patient has condylomas that are sufficiently extensive or refractory to require treatment by this method, the area of affected epithelium will almost always be too large for treatment under local infiltration. Likewise, since vulvar intraepithelial neoplasia in young women is usually multicentric, and is often surrounded by even larger areas of subclinical papillomaviral infection, most such cases will also require general or regional anesthesia. After the induction of anesthesia, the perineum is carefully shaved (both to facilitate colposcopy and to simplify postoperative care). The use of antiseptic solutions is neither desirable (because it impairs response of tissue to acetic acid) nor necessary (because of the high temperatures attained at the site of laser impact). Rather, the vulva and anus are soaked for 3 minutes with acetic acid or white vinegar (with the use of very wet cotton balls or gauze squares). The perineum is then carefully examined with a colposcope. The borders of any foci of vulvar intraepithelial neoplasia and the outer margins of the surrounding subclinical pap-
Fig. 3. The initial vaporization of benign condylomas, sufficient to extend the central crater to about the level of the surrounding epidermis. This maneuver will loosen the epidermal cells in the base of the condyloma, so that wiping with a moist gauze swab will detach most of the lesion. The laser can then be applied again to any residual islands of adherent epithelium.
illomaviral infections are then outlined, before the acetic acid reaction fades. Collection of biopsy specimens. Provided that the correct technique is used, the carbon dioxide laser is an ideal tool for collecting additional biopsy specimens. Since the emissions from the carbon dioxide laser are not hemostatic for vessels larger than I mm, the stalks of any condylomas to be excised must first be compressed by means of a fine Vicryl or catgut ligature. The condyloma can then be excised with scissors, and the arterioles in the base of the condylomas sealed by lasing to the pedicle. Since the edges of any laser crater tend to shrink toward the center of the impact site, the laser is of value as a thermal scalpel only if it is used with skillful traction and countertraction. Hence, sessile condylomas or acetowhite plaques are excised by first grasping the lesion with fine tissue forceps and having an assistant apply countertraction to the surrounding skin. The laser can
Volume 152 Number 5
then be used to collect a bloodless biopsy specimen, by undercutting the plaque through a deep dermal or subcutaneous plane (Fig. 2). At the completion of the operation, these biopsy sites should be closed with fine Vicryl sutures. Application of the laser to any foci of vulvar in· traepithelial neoplasia. First, the laser is used to expose the proliferating zone of the epidermis by "brushing" the skin surface with a layer of laser energy, as previously described.' The epidermal debris can now be removed from the operative field by gently wiping with a moistened gauze swab, thereby revealing smooth pink-white basement membrane overlying the anatomically intact papillary dermis. It is now an easy task to vaporize down to the third surgical plane (Fig. I). Lasing to the second plane is accomplished by moving the laser beam quickly enough to scorch, rather than crater, the exposed dermal surface.' Such oscillations are done at about the same speed as used for "brushing" the epidermis. In contrast, lasing to the third plane is done by slow deliberate movements, controlling depth of penetration by careful hand-eye coordination.' Ablation of remaining condylomas and adjacent subclinical papillomaviral infection. The surgeon should not attempt to remove the remaining condylomas by undercutting them with the laser. Except for long-standing lesions (which can become quite pedunculated), most condylomas have a flat base. Attempts to undercut condylomas that are not required for histologic examination produce unnecessary dermal defects, and can be attended by troublesome bleeding (especially in pregnancy). Rather, the strategy should be to umbilicate the center of each lesion, debride the loosened epidermis, and relase to any residue (Fig. 3). Each condyloma should be umbilicated by lasing to the center and allowing tissue shrinkage at the laser impact site to pull the edge of the lesion into the operative field. It is unnecessary to lase to the edge of each condyloma; hence, the problem of unwanted damage to adjacent skin is easily avoided. The initial application of the laser should extend the vaporization crater to about the level of the surrounding skin, but there should be no penetration of the basement membrane at this point. Although it will be visually apparent that the zone of vaporization has not yet destroyed all of the abnormal keratinocytes at the base of the condyloma, lasing to this level will separate most of these cells from the basement membrane. Hence, this technique will minimize the extent of any unwanted thermal damage within the superficial dermis. Once the condylomas have been umbilicated, the area is easily debrided by gentle wiping with a moist gauze swab. Any residual epithelial fronds or capillary spikes can then be accurately destroyed by spot lasing. Before debridement of the residues of these con-
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dylomas, it is convenient to ablate any surrounding areas of subclinical infection to the first surgical plane (Fig. 1). Using the laser within the vagina. If the cervical transformation zone shows papillomaviral infection or intraepithelial neoplasia, it is ablated to a measured depth of 7 mm, with the use of a power density of 750 to 1500 w/cm 2 • To ensure destruction of the upper limit of the transformation zone, the treatment area is domed another 5 mm proximally, along the axis of the canal. 13 Extensive papillomaviral infection may necessitate treatment of the vault, the lower third, or the entire vagina. To avoid any risk of bladder or rectal injury, the depth of destruction must be kept within the submucosa. Control of depth is achieved by lasing until the surface epithelium chars, with the use of a power density of 750 to 1200 w/cm 2 • 6 The vaginal side walls are exposed between the open blades of a bivalve speculum. Successive rotations of the speculum will expose the anterior and posterior walls. In the lower part of the vagina, a better angle of impact is obtained by aiming through the sides (rather than the central aperture) of the speculum. After the entire circumference has been treated, the speculum is withdrawn and the epithelial debris is wiped away by vigorous swabbing with a moist gauze square. When the speculum is reinserted, any untreated areas are easily identifiable, and can be ablated under direct vision. Recognition of residual islands of intact epithelium is sometimes aided by staining the vaginal walls with Lugol's iodine. Such islands stain mahogany brown and stand out against the unstained stroma. Using the laser within the anal canal or urethra. Ablation within the anal canal or urethra requires special caution to limit the depth of destruction to the basement membrane. Circumferential destruction of the epithelium and submucosa will lead to anal or urethral stenosis. However, the technique of surface charring, debridement, and localized reapplication of the laser negates these risks. Low-power densities (350 to 450 w/cm 2 ) are recommended. The anal canal can be visualized with a large nasal speculum, a small Peterson vaginal speculum, Sim's anoscope, or two pairs of uterine polyp forceps. Because of a theoretical risk of explosion, any flatus should be sucked from the rectum before the laser is used within the anus. Exposure within the urethra is best done by using an endocervical speculum, or a small nasal speculum. If the surgeon is using a superpulsed laser, he should take advantage of this adaptation to minimize the zone of thermal coagulation within the urethra. 14 Postoperative care. To counteract the inflammation and edema provoked by mild thermal injury to the underlying tissues, the vulva is liberally dressed with
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Table II. A guide to the best level of destruction for different disease entities Surgical plane
First Second Third Fourth
Fig. 4. Photograph taken 10 days after laser vulvectomy, showing how healing should be advanced and almost complete. Application of the laser to an excessive depth is characterized by a relative delay in early healing, and an end result that is distinguishable from normal skin.
0.1% triamcinolone cream, while the patient is still in the lithotomy position. 13 Following the empiric observation that urinary diversion will prevent a great deal of anticipated postoperative pain, patients who require large areas of vulvar ablation are offered a suprapubic catheter with leg bag for 2 weeks. Malodor is prevented by the daily instillation of I ounce of white vinegar into the collecting bag. Safeguards against bacterial infection include the prescription of prophylactic antibiotics and the daily cleansing of the collection system with household detergents. The catheter is removed at an office visit, when healing is well advanced. Except in pregnant patients, treatments are performed as outpatient operations. Before discharge, each patient must have her ability to micturate normally verified by the recovery room nurse. Patients who void frequent small amounts should be specifically checked for retention with overflow. In the latter case it will be necessary to insert an indwelling Foley catheter. Before discharge, patients must also receive a prescription for a schedule 3 narcotic, a complete set of postoperative instructions, and an appointment for office follow-up in 1 week. The most important part of the postoperative regimen is to soak for 30 minutes every 4 hours in a bath of reconstituted sea water (Instant Ocean) 4 or hypertonic Epsom salt solution (1 cup per gallon). The vulva
Appropriate for
Condyloma acuminatum Flat subclinical lesions Micropapillary subclinical lesions Hypertrophic dystrophies Intraepithelial neoplasia, pilosebaceous glands not involved Intraepithelial neoplasia, involving pilosebaceous glands
should then be dried with a hair dryer, and dressed with a thin application of neomycin-bacitracin ointment. A prescription of Nupercainal2% gel and a stool softener will make defecation less uncomfortable. Prophylactic antibiotics are not necessary, except to cover any indwelling Foley catheter. Patients must be seen weekly for 3 weeks, to correct any early coaptation of adjacent raw surfaces. Healing should be virtually complete within 14 to 2I days (Fig. 4). Thereafter, women with refractory condylomas should return every 2 to 4 weeks for the next 3 months, so that any focal recurrences can be controlled by caustic agents. Because women with vulvar neoplasia or papilloma viral infections are at high risk for developing squamous neoplasia at other sites within the genital tract, surveillance by annual Papanicolaou smears is mandatory."· 16
Comment Lasers are powerful but predictable surgical tools. Used with skill and discretion, they open new vistas in many medical specialties. However, despite their unique properties, careless or unskilled laser operations will yield undesirable results. Misadventure may arise (I) from accidental injuries to staff or patients, (2) by selection error, or (3) through the occurrence of conventional surgical complications. 11 Avoidance of accidental injury requires an awareness of the path of the laser beam (from source to dissipation), and the exclusion of flammable drapes, plastic speculums, or dry swabs from the operative field. The major selection error is failure to detect occult invasion. Safeguards are a sound knowledge of lower genital tract neoplasia, colposcopic expertise, and strict adherence to triage rules. The risk of treatment failure is minimized by setting surgical margins with the colposcope, by individualization of depth according to histologic findings, and by treating focal recurrences of papillomaviral infection with topical trichloroacetic acid. Skillfully executed, this technique of superficial laser vulvectomy carries a very low rate of complications. However, less precise methods can lead to delayed healing, atrophic or hypertrophic scar formation, and vulvar coaptation.
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Although safe and effective, superficial laser vulvectomy subjects patients to the risks of anesthesia and involves an absence from work or domestic duties of 10 to 14 days. 6 • 7 Hence, surgeons should satisfy themselves that the extent and severity of the problem are sufficient to warrant this operation. Since occasional malignant progression of carcinoma in situ has been reported in young, immunocompetent women, 14 the eradication of vulvar intraepithelial neoplasia can be justified on the grounds of cancer prophylaxis, provided that nonmutilating methods are used!· 3 Hence, superficial laser vulvectomy is usually my treatment of choice for extensiv~ or multifocal carcinomas in situ. However, the risk of malignant progression of hyperplastic dystrophies (with or without mild atypia) is too remote to justify operations on these same grounds. Rather, this diverse group of dermatologic disorders should be treated with topical steroids! with laser operations being reserved for those that continue to cause intractable itching or discomfort. Likewise, I believe that only refractory or extensive condylomas should be treated by laser ablation. 6 However, when this decision has been made, the systematic approach outlined in this series of articles would appear to be more logical than the simple use of the laser as a "spot welder." An important factor in poor outcome with the laser is the prevalence of a naive attitude that a favorable result is guaranteed by the technical sophistication of this tool. Unhappily, this is not true. Quality of outcome depends upon surgical precision (with the use of strategies that infer actual depth of thermal necrosis from the visual characteristics of more superficial landmarks), and accurate pathologic assessment (providing a rational basis for selecting different depths of destruction for different disease entities) (Table II). Once mastered, this method will consistently yield optimum results and allow confident preoperative counseling about the speed and cosmetic quality of eventual healing. The technique of superficial laser vulvectomy is an exacting one that requires both careful attention to detail and considerable facility with the carbon dioxide laser. Inexperienced laser surgeons should not, under any circumstances, attempt this operation. As a generalization, laser operations perf~rmed by less experienced physicians tend to be too shallow on the cervix, but too deep on the vulva. Such habits can be difficult
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to break. Hence, even experienced laser surgeons should ideally receive preceptorship in this procedure. If this is not possible, they should at least arrange to see a film that explicitly details the operative technique. I wish to thank Lawrence Elston, Michael Menlo, and Robert Lane for the photography and Sue Pasqua! for the medical artwork. REFERENCES 1. Buscema J, Woodruff JD, Parmley TH, Genadry R. Carcinoma in situ of the vulva. Obstet Gynecol 1980;55:22530. 2. Friedrich EG. Intraepithelial neoplasia of the vulva. In: Coppleson M, ed. Gynecologic oncology. Fundamental principles and clinical practice. London: Churchill Livingstone, 1981:303-19. 3. Rutledge F, Sinclair M. Treatment of intraepithelial carcinoma of the vulva by skin excision and graft. AM J OBSTET GYNECOL 1968;102:806-15. 4. Baggish MS, Dorsey JM. C02 laser for the treatment of vulvar carcinoma in situ. Obstet Gynecol1980;57:371-5. 5. Ferenczy A. Using the laser to treat vulvar condyloma acuminata and intraepidermal neoplasia. Can Med Assoc J 1983;128:135-37. 6. Reid R. Superficial laser vulvectomy. I. The efficacy of extended epidermal ablation for refractory and very extensive condylomas. AM J OBSTET GYNECOL. In press. 7. Reid R, Elfont EA, Zirkin RM, Fuller TA. Superficial laser vulvectomy. II. The anatomic and biophysical principles permitting accurate control over the depth of dermal destruction with the carbon dioxide laser. AMJ 0BSTET GYNECOL. In press. 8. Leads from the MMWR. Condylomas acuminata: United States, 1966-81. JAMA 1983;250:336. 9. Reid R, Laverty CR, Coppleson M, et a!. Noncondylomatous cervical wart virus infection. Obstet Gynecol 1980;55:4 76-83. 10. Baggish MS. Carbon dioxide laser treatment for condylomata acuminata venereal infections. Obstet Gynecol 1980;55:711-15. 11. Reid R. Laser safety. I. Avoidance of surgical misadventure with the C0 2 laser. Colposcopy Laser Surg 1984; 1:117-40. 12. Reid R, Muller S. Tattoo removal by C0 2 laser dermabrasion. Plast Reconstr Surg 1980;65:717-28. 13. Stanhope CR, Phibbs GD, Stuart GCE, Reid R. Carbon dioxide laser surgery. Obstet Gynecol 1983;61:624-7. 14. Rattner WH, Rosemberg SK, Fuller TA. Differences between continuous wave and superpulse carbon dioxide laser in bladder surgery. Urology 1979; 13:264-6. 15. Reid R. Papillomaviruses and cervical neoplasia. Modern implications and future prospects. Colposcopy Laser Surg 1984;1:3-34. 16. Reid R, Fu YS, Herschman BR, et a!. Genital warts and cervical cancer. IV. The relationship between aneuploid and polyploid lesions. AMJ 0BSTET GYNECOL 1984; 150:189.