VM33 - Operative Approaches to Presacral Mass Resection

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Purpose/Background: The challenge in treating presacral tumors lies in the difficulty of surgically accessing the retrorectal space, compounded by the variety of tumor types that may occur, and their overall rarity, necessitating an individualized approach to each case. It is recommended that all nonmetastatic presacral masses be resected if possible, based on their high underlying rate of malignancy, and risk of infection for cystic lesions. Prior studies have described alternative surgical approaches including ventral abdominal exposure versus posterior excision with bony resection. Yet, variable techniques are described within each of these approaches. We aimed to catalogue a series of successful resections, to elucidate some of the tumor morphologies that may be encountered by the Colorectal surgeon in the presacral space and some of the corresponding surgical options one may consider.

Methods/Interventions: In a video series we demonstrate three different approaches for resection, out of a single hospital institution within a two-month period. The approaches are a posterior parasacral excision for a lateral tailgut cyst, a posterior midline approach with partial sacrectomy for a solitary fibrous tumor, and combined robotic abdominoperineal resection and en-bloc posterior wide excision for a coccygeal chordoma abutting the rectum.

Results/Outcomes: Each case yielded negative margins with uneventful recovery.

Conclusion/Discussion: Careful and holistic operative planning enables successful resection of difficult-to-reach lesions in the retrorectal space with case-specific approaches. Multidisciplinary involvement of Orthopedics and Plastic Surgery is valuable for preoperative and intraoperative decision-making. We agree with previously published series that lesions inferior to the S4 level may best be approached posteriorly while those spanning above and below S4 may need a combined approach. Lateral masses may favor an oblique parasacral approach, obviating the need for sacrectomy.