Cirurgia para câncer de vulva

Escolher o melhor tratamento cirúrgico para cada mulher significa equilibrar a importância de manter o funcionamento sexual com a necessidade de remover toda a doença. Antigamente, os cirurgiões removiam todo o tumor, além de uma grande quantidade do tecido normal adjacente e os linfonodos próximos, independente do estadiamento da doença. Essa cirurgia extensa resultou em uma boa chance de cura, mas causou muita deformação e diminuição da vida sexual da mulher, principalmente quando o clitóris era retirado. Além disso a retirada de todos os gânglios linfáticos da virilha muitas vezes levou ao linfedema nas pernas.


Atualmente, a importância da sexualidade para a qualidade de vida da mulher está bem estabelecida. Também foi estabelecido que, quando a doença é diagnosticada em estágio inicial, não é necessário remover tanto tecido saudável circundante para obter a cura. Além disso, a biópsia de linfonodo sentinela surgiu como uma alternativa à remoção das cadeias ganglionares, principalmente se a doença não se disseminou. Quando o estágio da doença se encontra mais avançado, pode ser necessário um procedimento mais extenso. A radioterapia combinada com a quimioterapia e a cirurgia também pode ser realizada para destruir as células cancerígenas de estágios mais avançados.

Os principais tipos de procedimentos cirúrgicos para o câncer de vulva são:

  • Cirurgia a Laser

Um feixe de laser localizado vaporiza a camada de pele da vulva que contém as células anormais. A cirurgia a laser é utilizada como um tratamento para a neoplasia intraepitelial vulvar. Não é usada para o tratamento de tumores invasivos.

  • Excisão

Neste procedimento, o tumor e uma margem de pele normal adjacente são retirados. Esta técnica muitas vezes é denominada excisão local ampla. Se for extensa, pode ser chamada de vulvectomia parcial simples.

  • Vulvectomia

Neste tipo de cirurgia, uma parte ou a totalidade da vulva é removida:

  1. Vulvectomia de descamação. Significa que apenas a camada superior da pele afetada pela doença é removida. Embora esta seja uma opção para o tratamento das neoplasias intraepiteliais extensas, é raramente realizada.
  2. Vulvectomia simples. Toda a vulva é removida.
  3. Vulvectomia radical. Pode ser completa ou parcial. Quando parte da vulva, incluindo tecidos profundos, é removida, a cirurgia é denominada vulvectomia parcial radical. Na vulvectomia radical completa, toda a vulva e os tecidos profundos, incluindo o clitóris, são removidos.

Às vezes, nestes procedimentos uma grande área da pele da vulva é retirada, sendo necessária a realização de enxertos de pele de outras regiões. No entanto, na maioria das vezes não são necessários enxertos e ainda é possível proporcionar uma aparência muito satisfatória. Se o enxerto de pele for necessário, muitas vezes pode ser realizado pelo próprio ginecologista ou por um cirurgião plástico após a vulvectomia.

A cirurgia de reconstrução está disponível para mulheres que fizeram cirurgias extensas. A cirurgia de reconstrução utiliza um retalho de pele e tecido adiposo de suporte. Muitos locais do corpo podem ser utilizados, a complicação é o fato de que o fluxo de sangue ao tecido transplantado deve ser mantido intato. O cirurgião deve ser habilidoso o suficiente, uma vez que o tecido deve ser movido sem prejudicar o suprimento de sangue.

  • Exenteração Pélvica

A exenteração pélvica é uma cirurgia ampla que, quando realizada para tratar o câncer de vulva inclui vulvectomia e frequentemente a remoção dos linfonodos pélvicos, assim como a retirada de uma ou mais das seguintes estruturas: porção inferior do cólon, reto, bexiga, útero, colo do útero e vagina, dependendo da extensão da doença.

  • Dissecção dos Linfonodos Inguinais

Como o câncer de vulva muitas vezes se dissemina para os linfonodos inguinais, estes podem precisar ser removidos. Este procedimento é denominado dissecção linfonodal inguinal. Normalmente, apenas os nódulos linfáticos do mesmo lado do tumor são retirados.

A retirada dos gânglios linfáticos é realizada através de uma incisão a parte da cirurgia principal, a cerca de 1 a 2 cm abaixo e paralela à prega da virilha. Esta incisão é profunda, permitindo a exposição da maioria dos linfonodos, que são então removidos. Após a cirurgia, um dreno é colocado dentro da incisão, que permanece no local até que não haja mais líquido a ser drenado.

  • Biópsia do Linfonodo Sentinela

A biópsia do linfonodo sentinela pode evitar a dissecção dos linfonodos inguinais. Este procedimento determina e retira os gânglios linfáticos que drenam a área do tumor. Estes gânglios linfáticos são conhecidos como linfonodos sentinela, porque seriam os primeiros a serem atingidos pela doença. Se eles foram invadidos, os linfonodos remanescentes desta região serão removidos. Se os linfonodos sentinelas não contiverem células cancerígenas, não será necessário nenhum procedimento adicional.

Para localizar o linfonodo sentinela, uma pequena quantidade de material radioativo ou de um corante azul é injetada no local do tumor, no dia anterior à cirurgia. A virilha é então examinada para identificar o lado que reteve o material radioativo. Durante a cirurgia para retirada do tumor, um corante azul é injetado no local do tumor, para permitir a identificação e retirada do linfonodo sentinela. Às vezes, dois ou mais linfonodos ficam azuis e são removidos.

Complicações e Efeitos Colaterais da Cirurgia

Após a cirurgia, as mulheres muitas vezes sentem desconforto, se usam calças apertadas ou jeans, porque a abertura uretral e a entrada da vagina ficaram muito diferentes após o procedimento.

A remoção de grandes áreas de pele da vulva pode levar a problemas de cicatrização, infecções ou rejeição do enxerto. Quanto mais tecido for removido, maior é o risco destas complicações.

O fluxo de urina pode ficar do lado, porque o tecido num ou em ambos os lados da abertura da uretra foi removido.

Outras complicações da cirurgia da vulva e dos linfonodos incluem a formação de cistos próximos às cicatrizes cirúrgicas, coágulos sanguíneos, infecção urinária e diminuição do desejo ou prazer sexual.

Linfedema

A remoção dos linfonodos ou linfadenectomia durante a vulvectomia radical pode resultar em uma drenagem deficiente da linfa das pernas, levando ao linfedema. O uso de meias elásticas de compressão ou dispositivos especiais pode ajudar a reduzir o inchaço. As mulheres com linfedema precisam tomar certas precauções para evitar infecção na perna (ou pernas) afetada, como:

  • Proteger a perna e o pé afetados de objetos pontiagudos.
  • Evitar cortes e arranhões na perna e pé afetado.
  • Evitar queimaduras na perna afetada.
  • Evitar cortar ou tirar a cutícula das unhas dos pés.
  • Comunicar qualquer vermelhidão, inchaço ou outros sinais de infecção para o médico.

Impacto Sexual da Vulvectomia

Muitas vezes, as mulheres temem que seus parceiros vão se desinteressar por elas em função das cicatrizes e perda dos órgãos genitais externos. Algumas mulheres podem realizar a cirurgia de reconstrução dos lábios maiores e órgãos genitais.

Pode ser difícil para as mulheres que fizeram vulvectomia atingir o orgasmo. Os órgãos genitais externos, especialmente o clitóris, são importantes no prazer sexual de uma mulher. As mulheres também podem notar dormência na área genital após a vulvectomia radical, a sensibilidade pode retornar com o tempo.

Ao tocar a área em torno da vagina, e, especialmente, a uretra, uma carícia leve e a utilização de um lubrificante podem ajudar a prevenir a irritação dolorosa. Se o tecido cicatricial estreitou a entrada da vagina, o uso de dilatadores vaginais pode ajudar a ampliar a abertura. Quando a cicatrização é importante, o cirurgião pode, às vezes, utilizar enxertos de pele para alargar a entrada.

O linfedema resultante da remoção dos linfonodos da região da virilha pode causar dor e fadiga, o que também pode ser um problema durante a relação sexual. Nesse sentido é importante que o casal seja honesto e aberto o suficiente para lidar com o problema.

Fonte: American Cancer Society (16/02/2016)

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