Robot-assisted Anterior Pelvic Exenteration in Vulvovaginal Malignant Melanoma

Objective: Melanomas of the vulva and vagina are rare, and surgery is the gold standard of treatment [1, 2]. Since recent studies have reported pelvic exenteration by using robotic surgical system [3, 4], we showed the surgical procedures of robot-assisted anterior pelvic exenteration (rAPE) with ileal conduit urinary diversion for vulvovaginal malignant melanoma.

Methods: A 55-year-old woman who received vaginal wall resection due to vaginal malignant melanoma 8months before was referred. Multiple biopsies of pigmented lesions on the vulva, vagina, and urethral orifice confirmed the recurrence, whereas preoperative image studies revealed no abnormal findings. Thus, we performed rAPE with ileal conduit urinary diversion.

Results: First, we performed robot-assisted bilateral inguinal and pelvic lymphadenectomy. Thereafter, we conducted en bloc resection of the bladder, uterus, vagina, and vulva through abdominal and perineal approaches (Fig. 1): Under the 4-arm robotic surgical system, prevesical space was developed and laterally dissected along the undersurface of pubic bone, to the level of levator ani muscles. Bilateral infudibulopelvic ligaments, uterine arteries and parametrium, uterosacral ligaments, and pubovesical ligaments were ligated and resected. During the wide local excision of the vulva, the rectovaginal space was dissected along the posterior vaginal wall. En bloc specimen was successfully delivered. Finally, the ileal conduit urinary diversion was performed. Total operative time was 4.5h excluding set-up and docking times of the robotic surgical system. The pathologic report ascertained clear resection margin and no lymph node involvement.

Conclusion: rAPE with ileal conduit urinary diversion for treatment of vulvovaginal malignant melanoma is feasible (Fig. 1).