Contemporary surgical management of vulvar cancer is associated with improved survival but increased reoperation rate: A Finnish nationwide study

Abstract

Introduction: Surgical treatment of vulvar squamous cell carcinoma (VSCC) has evolved in the 21st century following the implementation of radical local excision, sentinel lymph node biopsy, and reconstructive techniques. Population-level studies focusing on survival trends of surgically treated VSCC patients are scarce. Methods: All primary VSCC surgeries performed in Finland between 2000 and 2021 were identified from the Care Register for Health Care. Historical cohorts representing radical and personalized surgical eras [2000–2005 (n = 301) and 2014–2019 (n = 359)] were compared. Primary outcome was overall survival (OS); secondary outcomes were disease-specific survival (DSS), progression-free survival (PFS), postoperative complications, reoperations, and adjuvant treatment delays. Survival analyses were performed using Kaplan-Meier estimates, and multivariable Cox proportional hazards models adjusted for Charlson Comorbidity Index (CCI) and adjuvant treatment. Results: Personalized surgery cohort demonstrated significantly improved 2-year OS (67.1% vs 77.4%; p = 0.003) and DSS (74.2% vs 82.6%; p = 0.009) compared to the radical surgery cohort. After adjusting for adjuvant treatment and CCI score, personalized surgery cohort was independently associated with reduced all-cause mortality (aHR 0.4 (0.3–0.6); p < 0.001), disease-specific mortality (aHR 0.4 (0.3–0.6); p < 0.001), and risk of recurrence/death (aHR 0.7 (0.5–0.9); p = 0.008). Increased rates of postoperative complications (7.6% vs 20.3%; p < 0.001) and reoperations (5.6% vs 10.0%; p = 0.039) were observed in the personalized surgery cohort; treatment delays were not increased. Conclusions: Personalized surgical management, likely together with more accurate targeting of adjuvant treatment, has led to improved survival in VSCC patients undergoing primary surgery. Increased reoperation rate may reflect increased surgical complexity, more proactive complication management, and/or improved documentation practices.