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15.5%, p > 0.05, 7.1% versus 10.3%, p > 0.05, respectively). Dardarian et al.76 showed that the
difference of short-term oedema in favour of saphenous vein ligation did not reach statistical
significance (67% versus 72%, p > 0.05). Finally, groin wound breakdown or cellulitis occurred in
18% of patients with saphenous vein preservation, and 24% where the vein was sacrificed in the
study published by Paley et al.77.
In contrast, some investigators73,74,77,78 described an increase of morbidity in patients with saphenous
vein sparing compared to patients where it was sacrificed. Paley et al.77 described an increase of the
incidence of lymphoedema and lymphocyst formation (36% versus 21%, 27% versus 14%,
respectively). Zhang et al.73,74 observed a slight increase of postoperative fever, lymphocyst
formation, and pulmonary embolism (96.8% versus 93.9%, 10% versus 4%, 2% versus 0%,
respectively) but it should be noted that the differences did not reach statistical significance (p >
0.05, p = 0.19, p = 0.45, respectively). In the study published by Lin et al.78, lymphoedema occurred
in 17% of patients who had preservation of the long saphenous vein during the groin dissection
versus 13% in whom the long saphenous vein was sacrificed (p = 0.50). It should be noted that the
risk of groin recurrence did not change with preservation of the saphenous vein (6% versus 6%).
Finally, Soliman et al.79 did not find significant correlations between saphenous vein ligation and the
development of any local complications (data not shown).
Triple incision technique versus en bloc dissection (the butterfly incision) : no randomised trials have LoE 2+
been performed to evaluate whether the use of the triple incision technique is as safe as the en bloc
approach, but all the identified studies42,80-83 that compared these two surgical approaches showed
that vulvectomy and inguinofemoral lymphadenectomy via three separate incisions provide similar
outcome in terms of survival compared to an en bloc butterfly resection. In multivariate analysis, van
der Velden et al.81 reported that surgical technique has no impact on disease-specific survival (after
adjustment for tumour diameter, extracapsular lymph node involvement, TNM stage, and number of
nodal metastases, HR = 0.99, 95% CI = 0.43-2.30, p = 0.996) and overall survival (data not shown).
After correction for tumour dimension, depth of invasion, presence or absence of lymph/vascular
invasion, and grade, de Hullu et al.42 observed that wide local excision with inguinofemoral
lymphadenectomy through separate incisions was not related independently to an increased risk of
death within 4 years related to vulvar carcinoma (OR = 1.98, 95% CI = 0.80-4.80, p > 0.05) even if
they described more frequent fatal recurrences in the groin or the skin bridge (6.3% versus 1.3%, p =
0.029).
Among the seven identified studies42,80-85, a skin bridge recurrence was observed in only 1.8% of LoE 2+
patients (6/336). It should be noted that Hacker et al.84 published 2 skin bridge recurrences, both in
patients with lymph node metastases. However, the majority of identified studies42,81,83 described a
lower local recurrence rate among patients treated by an en bloc resection. With regard to the risk of
vulvar recurrence, van der Velden et al.81 reported that patients treated by an en bloc resection
showed a significantly lower risk of local recurrence than those treated by the triple incision
technique after adjustment for tumour diameter, extracapsular lymph node involvement, TNM stage,
and number of nodal metastases (HR = 0.10, 95% CI = 0.02-0.44, p = 0.002). But the type of
surgical treatment was not an independent predictor for regional recurrence (HR = 0.39, 95% CI =
0.13-1.17, p > 0.05) or distant recurrence (HR = 0.97, 95% CI = 0.32-2.91, p > 0.05). In multivariate
analyses, after correction for tumour dimension, depth of invasion, presence or absence of
lymph/vascular invasion, and grade, de Hullu et al.42 mentioned that wide local excision with
inguinofemoral lymphadenectomy through separate incisions was associated with a higher risk of
developing recurrences 2 and 4 years after primary treatment (OR = 2.29, 95% CI = 1.00-5.28, p <
0.05, and OR = 2.272, 95% CI = 1.11-4.67, p < 0.05, respectively).
Fambrini et al.86 assessed the feasibility and safety of a modified triple incision total radical
vulvectomy and inguinofemoral lymphadenectomy in 57 patients with locally advanced vulvar
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