(084) The Evolution of the Vulvar Vestibulectomy

Abstract Introduction Vulvar vestibulectomy is a surgical procedure involving the excision of the vestibule-the tissue of endodermal origin located between the external vulva and vagina. Surgical vestibulectomy was developed for the treatment for chronic vulvar pain syndromes. First described by Woodruff and Parmley in 1983 (1), the vestibulectomy has evolved from a last-resort surgical treatment for dyspareunia into a targeted, evidence-based surgical option for neuroproliferative vestibulodynia (NPV). Advances in histopathology and neuroimmunology have clarified that NPV is characterized by increased peripheral nerve fiber density and mast cell proliferation within the vestibular mucosa (2-5). These insights, along with the 2015 ISSVD/ISSWSH/IPPS consensus terminology standardizing the classification of vulvar pain, have transformed the diagnostic framework for NPV and thus the surgical indications for vestibulectomy (6). Objective This review aims to describe the evolution in diagnostic indications and surgical vestibulectomy technique. Methods A comprehensive literature review was conducted through PubMed between April and May 2025 using search terms including “vulvar vestibulectomy,” “vestibulodynia,” “vulvar vestibulitis,” and “neuroproliferative vestibulodynia.” Relevant clinical studies, histopathologic investigations, and surgical innovations were qualitatively analyzed to trace the procedural indications, techniques, outcomes, and emerging adjunctive technologies. Results The vestibulectomy has been refined to reflect parallel advances in diagnostic precision and surgical technique. Early procedures were broad perineoplasties (1,7,8), later refined to more targeted excisions guided by pain localization and histopathological markers such as PGP9.5 and CD117 (3,4,9-11). The recognition of NPV as a distinct subtype of vestibulodynia has refined surgical indications, limiting vestibulectomy to patients unresponsive to conservative management such as topical medication or physical therapy (12-16). Modern techniques, including the Complete Sub-Epithelial Vestibulectomy (CSEV) and regional vestibulectomy with buccal mucosal grafting, emphasize tissue preservation. Patient-reported outcomes from more recent surgeries demonstrate high rates of satisfaction and durable symptom relief with favorable cosmetic outcomes (16,18, 22-27). (27). Conclusions Vulvar vestibulectomy has progressed from an empiric, last-line operation to a more precise intervention. These advances have been based on improved anatomic and pathologic understanding of neuroproliferative vestibulodynia. Improvements in patient-centered evaluation have also narrowed surgical indications, which has further enhanced outcomes. Emerging surgical innovations may include incorporation of regenerative and laser-based therapies to enhance healing and more personalized multidisciplinary management strategies for chronic vulvar pain (16, 19, 28, 29). Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Evvy, Pelva Health, Dare Bioscience, Gynecologic Cancers Research Foundation, Leo, Strat Pharma, Nuvig, Celldex, National Vulvodynia Association.