Upper Vaginectomy for the Treatment of Vaginal Intraepithelial Neoplasia

Abstract

To evaluate the outcomes of patients with vaginal intraepithelial neoplasia (VAIN) who were treated by upper vaginectomy, the medical records at the University of Florida between August 1985 and April 2004 were reviewed. One hundred five patients with VAIN 1 or 2 who had undergone upper vaginectomy were identified. Colposcopy was routinely performed before surgery to verify that disease was confined to the upper one third of the vagina. All procedures were done in the operating room under general anesthesia. Most patients were discharged the day after surgery. Follow up consisted of cervical smears performed every 3 to 4 months for at least a year, every 6 months for the next year, then annually. The mean age of patients was 58 years (range, 28–85 years). All patients except one had undergone previous hysterectomy, most commonly for treatment of premalignant or malignant disease (64%). Ten women had previous radiation therapy. Thirty-four percent had undergone previous treatment for VAIN with laser vaporization, topical 5-fluoracil, and/or upper vaginectomy. The average length of surgery was 55 minutes (range, 12–135 minutes). Median blood loss was 50 mL, but ranged from 25 mL to 1150 mL in a woman with thrombocytopenia and a histologic diagnosis of microinvasive squamous cell carcinoma. Four other patients had blood loss greater than 500 mL. Premature ventricle contractions developed in one woman, and 5 sustained an intraoperative cystotomy. In the postoperative period, 2 patients had a spinal headache, one had a fever thought to be the result of cellulitis at the incision site, and one required vaginal packing 3 weeks after surgery to control bleeding of approximately 1000 mL. No disease was seen in the VAIN specimen in 23 (22%) of patients. None of these patients developed a recurrence of disease during follow up (range, 18–208 weeks). Invasive squamous cell carcinoma was found in 13 patients, 6 of whom undergone previous treatment for VAIN. Eight of the 13 had invasive disease and were treated with radiation therapy. Seven women had undergone previous hysterectomy, 3 for cervical cancer, 3 for carcinoma in situ of the cervix, and one reason was unknown. One patient died from disease 23 months after treatment and one was lost to follow up. Six were disease-free after 22 to 82 months of follow up. The remaining 5 positive patients were diagnosed with microinvasive carcinoma less than 2 mm in depth. Four of these women had been treated for carcinoma of the cervix. One patient developed a superficially invasive squamous cell carcinoma of the vagina 31 months after treatment. Three patients were alive without disease after 31 to 54 months of follow up, and one was lost to follow up. VAIN, grades 1 to 3, was diagnosed in the remaining 69 patients, 52 of whom had follow-up data. Forty-six (88%) were alive without disease after a mean follow up of 25 months (range, 4–90 months). Among the 6 patients who had a recurrence of disease, the mean time to recurrence was 24 months (range, 8–53 months). Five of these women had grade 3 VAIN in the pathologic diagnosis at the time of the original treatment. Patients were treated with radiation therapy, repeat upper vaginectomy, topical 5-fluoruracil, or laser vaporization.