Presacral Tumors
Presacral tumors are a heterogeneous group of tumors with a predominance of the tumors being congenital in origin and the remainder being neurogenic, osseous, or miscellaneous in origin. These tumors should be removed surgically as fully a third of them m
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Key Concepts • Unless contraindicated, presacral tumors should be surgically excised because of the risk of malignancy. • MRI should be performed to characterize the lesions and to plan surgery. • Lesions that are below sacral level S4 can be excised through a posterior/perineal approach. • Complete, non-piecemeal excision is critical to avoiding recurrence or infection.
Introduction Retrorectal masses are a group of lesions that encompass a wide spectrum of disease processes, ranging from congenital lesions (with varied malignant potential) to inflammatory disease processes and overt malignancy [1, 2]. In general, retrorectal tumors are extremely rare, with the incidence of the tumors varying in the reported literature [1–3]. The Mayo Clinic has reported that retrorectal tumors represent 1 in 40,000 hospital admissions [4]. Diagnosis of these lesions is usually incidental on physical exam or on imaging studies, as symptomatology is usually vague [4]. Imaging remains the key to preoperative characterization of these lesions in addition to preoperative planning. Although the majority of patients will have undergone computed tomography (CT scan), magnetic resonance imaging (MRI) is an essential element in the preoperative evaluation. Although the role of preoperative biopsy has been a source of debate, because of the fear of recurrence at or seeding of biopsy tracts, there is a good single institutional data to support its selective use [5].
Anatomic Considerations The presacral or retrorectal space is not a true space but rather a potential space (see Chap. 1). It is a unique area in that it represents a developmentally critical location where
several types of embryological distinct cell lines converge for the final steps prior to the completion of ontogeny. It is these changes that produce the variety of benign and malignant and solid and cystic growths that can occur in this space [1]. The retrorectal space is the area posterior to the rectum, but, more specifically, its superior extent is the pelvic peritoneal reflection, its lateral limits are the ureters and iliac vessels, posteriorly it is defined by the sacrum, and anteriorly it is defined as the posterior wall of the rectum. The inferior border is the levator complex and the coccygeal muscles (Figure 22-1) [3]. The retrorectal space presents a multitude of challenges to the surgeon, and this subset of procedures is not recommended for those uninitiated in pelvic surgery. The sacral nerve rootlets are located in this retrorectal space, and thus injury to and sacrifice of these structures can have substantial implications on rectoanal and sexual function. In cases requiring the unilateral sacrifice of all of the sacral nerve rootlets, the patient will likely retain normal anorectal and sexual function. Bilateral sacrifice of the third sacral nerve rootlet will usually result in fecal incontinence [6, 7].
Classification Histology/Pathology The classification of presacral masses encompasses a wide variety of etiologies and tissue types (Table 22-1). The clas
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