Vaginectomy

Vaginectomy is performed to remove the vagina, generally for primary cancer (the first/original tumour or cancerous mass) or recurrent (cancer that has recurred or come back) vaginal cancers. Vaginal cancers that originate in the vagina (primary) are uncommon - only 16% to 27% of the cancers have their origin in the vagina. 

Vagina is a muscular, elastic tube, about 7 to 10 cm in length, that extends from the cervix (the neck of the uterus or womb) to the external genitalia or the vulva of a woman. It plays an important role in female reproduction and sexual pleasure. The vaginal opening lies posterior (behind) to the urethral opening. It is enclosed medially by the labia minora (inner lips of the vagina) and laterally by the labia majora (the outer lips of the vagina).

Vaginectomy is commonly carried out as a part of other procedures such as a radical hysterectomy (removal of the uterus), radical vulvectomy (removal of the vulva) or pelvic exenteration (removal of one or more of the pelvic organs).

Vaginectomy can be:

• Simple - removal of the vaginal lining (mucosa) and the underlying muscles
• Partial - removal of a part of the vagina 
• Radical - includes removal of the connective tissue adjacent to the vagina
• Total - removal of the entire vagina.

The type of vaginectomy to be performed depends on the extent of cancer, how defined the boundaries of lesions are, and if the lesions grow simultaneously (multifocal lesions).

A vaginectomy may also be done as a part of gender transition surgery from female to male when a trans-masculine person desires to close the vaginal canal and opening.

A vaginal reconstruction may be planned based on how much of the vagina is removed. Some of the advantages of vaginal reconstruction are that it helps reestablish sexual function and body image and promotes wound healing.

Vaginectomy can be indicated in the following cases:

• Preinvasive (cancerous or malignant cells that have not yet spread) or early invasive (cancerous or malignant cells that have started to spread) cancers of the vagina (rare).
• Cancer of the vagina or cancer of the cervix, vulva, rectum, or bladder that has spread to the vagina.
• Coexisting preinvasive lesion of vaginal mucosa.
• To prevent close margins (cancer cells being close to the edge of healthy tissue) in cases of the above cancers.
• Pelvic exenteration (removal of all organs from the pelvic cavity) for cancer of the vagina or nearby organs.
• To treat cancers in the upper vagina.
• Recurrent cancers.

It is also done as a part of gender change surgery.

 The following are the symptoms of vaginal cancer:

• Bleeding or discharge unrelated to menstruation
• Pain in the pelvis
• Pain during sexual intercourse
• Constipation
• Pain when urinating
• A lump in the vagina

Your doctor may suggest a vaginectomy if you have stage I and II vaginal cancers. Stages of cancer indicate the extent of spread of the cancer. 

Vaginal surgeries are rarely recommended for stage III or IVA cancer. They are also not advised for stage IVB cancer because the cancer has spread to distant places.

You can ask your healthcare provider any questions you may have about the surgery during the preceding visits. The following preparatory steps may be taken before the surgery:

• Tests for the staging of the cancer will be done.
• You will be advised to undergo a CT or MRI to get a clear view of the pelvis and to assess the extent of the surgery. Cancer antigen (CA-125), carcinoembryonic antigen (CEA), and squamous cell carcinoma antigen tests will be recommended to assist in follow-up/monitoring after the operation.
• Women can lose a large portion of the vagina depending on the extent of the spread of the cancer. Therefore, psychosexual counselling may be done before surgery.

Make sure to inform your healthcare provider about any prescription or non-prescription medicines or supplements you are currently taking. He/she may ask you to stop taking some medicines if they could affect your surgery or recovery. 

After you are admitted to the hospital, the following steps will be taken before the surgery.

• Preoperative bowel preparation will be done since the rectum is close to the vagina and voiding of the bowels during surgery can lead to contamination of the surgery site. You will be asked to consume a low-residue diet (low-fibre food) and take mild laxatives for a few days before the procedure. Then, on the morning of the surgery, a phosphate enema will be administered, which will help in clearing out the rectum and aid in a better dissection.
• To prevent blood clot formation during and after the surgery (as they may cause embolisms), you will be administered anticoagulants such as low-dose heparin (5000 U twice a day) as a precautionary measure.
• You will receive antibiotics intramuscularly or intravenously immediately before the procedure, which will be continued for every 6 hours for more two doses.
• Before the surgery, certain tests such as colposcopy (to study the cervix, vagina, and vulva) will be carried out to identify the site and extent of surgery required. Based on this, either partial or complete vaginectomy is done. 

A vaginectomy can be simple or radical depending on what areas are affected.

Simple vaginectomy:

A simple vaginectomy is done through the vagina. The procedure for simple partial vaginectomy is as follows:

• You will be asked to lie down with your legs parted wide and raised (lithotomy position).
• A Foley catheter (tube inserted to drain out urine) will be placed in your bladder.
• Local anaesthesia (only the part that will be operated is numbed) will be introduced in your vaginal tissues.
• Once the lesions are identified, the doctor will introduce saline in the loose connective tissue (submucosal space) around the area to raise the lesion from the surrounding tissues for excision.
• Next, the surgeon will make an incision (cut) below the lesion and dissect some of the region around the lesion.
• He/she will then suture your vagina.
• The doctor may use a bacteriostatic vaginal pack if the opening of your vagina near the cervix is to be left open. This pack and the urinary catheter are removed before discharge from the hospital.

If a major part of the upper vagina is to be resected, then your doctor may give you a general or spinal anaesthesia. In this case, a vaginal reconstruction using skin grafts (skin taken from a part of the body is transplanted to a new site) will also be needed to restore your sexual function and your uterus may also be removed.

Because of the close proximity of the vagina to the bladder at one end and to the rectum at the other great care is required when removing the vaginal mucosa from its supporting tissues to prevent damage to these organs.

Sometimes, this procedure may need to be done via the abdomen as an open abdominal, laparoscopic or robotic-assisted surgery. In such cases, adequate bladder care needs to be taken with long-term monitoring of the remaining vaginal tissue, if any. This is done to prevent bladder dysfunction - a possible complication of this surgery.

Radical vaginectomy:

A radical vaginectomy includes removal of a larger amount of tissue, sometimes involving removal of the rectum or bladder and may be done laparoscopically. 

• After you are given anaesthesia, your doctor will open your abdomen. 
• He/she will tie the connective tissues surrounding your uterus (parametrium) and lift up your bladder and ureters and move them away from your vagina.
• Next. the surgeon will cut and remove the affected part of your vagina.
• If the complete vagina is to be removed, your parametrium and supporting tissue of the vagina will also be removed.
• The vagina will be freed from all sides and removed along with the supporting tissues.
• The bleeding will be stopped and vaginal reconstruction will be done if required.

For extensive vaginectomies, such as total or radical vaginectomy with or without hysterectomy, greater care and monitoring is required. The function of your urinary bladder will be closely observed after the surgey.

You may feel weak or tired for some time after the surgery. You will be given medications to help with the pain. The following precautions should be taken when you are discharged to home:

• You may continue with your daily activities, but for a few weeks, you should avoid strenuous activities.
• Do not exercise vigorously until 6 weeks after the surgery.
• If you have constipation in the first few days after surgery, you should inform your healthcare provider to see if you need a stool softener.
• You may have some vaginal discharge for a few weeks after the surgery, which will reduce gradually.
• You can remove the dressing before a shower and place a clean dressing after your shower. Do not take a tub bath.
• You can continue with your regular diet when you are home.
• Do not lift things that weigh more than 10 pounds.
• If you are on pain medications that cause drowsiness, do not drive.

When to see the doctor?

You are advised to immediately see a doctor if you have:

• Bleeding from the wound
• Difficulty urinating
• Bladder problems
• Fever greater than 101.5^°F
• Pain that is not controlled with medicines
• Persistent vomiting

The following risks and complications are associated with this surgery:

• Bleeding from the wound
• Damage to the surrounding tissues
• Narrowing of the vaginal canal and loss of flexibility (vaginal stenosis) that affects sexual function
• Fever after surgery
• Bladder dysfunction

The hospital should inform you of the first postoperative visit around 4-6 weeks after surgery. Depending on the nature and extent of spread of the cancer for which vaginectomy is required, a follow-up is determined - it could either be short term or long term. For example, a five-year follow-up is needed for squamous cell carcinoma.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.