Approaching Presacral Tumors

Christy Cauley

Michael A. Valente

Perioperative Considerations

Preoperative Evaluation

History and examination

Tumor location—“retrorectal space” (Fig. 30-1)

FIGURE 30-1 ▪ The presacral space. The third sacral vertebral body is the landmark to separate high versus low tumors of the presacral space. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)

Anterior: rectum
Cranial: peritoneal reflection
Lateral: iliac vessels and ureters
Posterior: sacrum
Inferior: levator ani and coccygeal muscles
S3 (third sacral vertebral body) is the unofficial landmark for distinguishing “high” versus “low” presacral tumors.

Assess potential nerve involvement: sensory, motor, sexual function, and continence
- Bilateral S3 involvement results in fecal incontinence.
  - Unilateral involvement usually does not result in functional decline.
Digital rectal examination: determine the extent of the tumor and assess invasion into the rectum (if the surgeon can palpate the uppermost extent of the tumor, this is most likely amendable for posterior approach in many cases)

Diagnostic studies

Magnetic resonance imaging best defines the relationship and potential invasion of the tumor into adjacent structures (urogenital, rectum, bone, vasculature, and nerves) (Fig. 30-2A-C).

FIGURE 30-2 ▪ A. Axial magnetic resonance imaging (MRI) representing large presacral mass compressing the rectum anteriorly toward the prostate. (Image courtesy of Emre. Gorgun, MD.) B. Sagittal MRI imaging of presacral mass demonstrating that the mass extends up to the level of S2. (Image courtesy of Emre Gorgun, MD.) C. MRI revealing large cystic presacral mass entirely below S3 without invasion of adjacent structure in a patient who is pregnant. (Image courtesy of Sherief Shawki, MD.)

Computed tomography scan is commonly performed initially; may rule out metastatic disease (Fig. 30-3).
Endoscopic examination evaluates for any other lesions/invasion into colorectum.
- Typical finding of extrinsic compression of the rectum without mucosal changes from the space occupying mass in the retrorectal space (Fig. 30-4).
  
  FIGURE 30-3 ▪ Computed tomography scan revealing multilobulated presacral, cystic mass with lateral displacement of the rectum. (Image courtesy of Pedro Aguilar, MD.)
  
  FIGURE 30-4 ▪ Colonoscopic evaluation of the mass. On retroflexion, there is evidence of external compression of the rectum. (Image courtesy of Emre Gorgun, MD.)

When is biopsy indicated?
- This is controversial and not always needed.
- Biopsy is needed prior to neoadjuvant or definitive chemoradiotherapy in cases of potential sarcoma or lymphoma or inoperable malignancies.
- If biopsy is performed, it should never be transvaginal or transrectal in nature due to possible tumor seeding and need for organ resection.
- Biopsy site needs to be excised at time of surgery.
- Tumors of the spinal cord/thecal sac should not be biopsied for risk of meningitis.

Pathologic Considerations

All operations should be performed with the tumor capsule intact to avoid tumor spillage, recurrence, and infection.
- Malignant tumors should be removed with a clear circumferential margin of tissue to ensure complete resection and avoid recurrence.
  - Adjacent structures (rectum, sacrum, ureters, blood vessels, and nerves) require en bloc resection if involved.
- Benign tumors should also be excised completely with the capsule intact if feasible to avoid recurrence; however, adjacent structures should be preserved, if possible, to preserve quality of life.
- Natural planes might not be preserved in malignancy or inflammatory/infectious processes.

Multidisciplinary Team Approach

Preoperative coordination is compulsory in cases where a complex resection of adjacent structures is undertaken.
Team members may include:
- Colorectal surgery (ostomy marking should be performed preoperatively)
- Orthopedic/neurosurgery
- Vascular surgery
- Urology
- Plastic surgery

Operative Considerations

Patient positioning
- Tumors located above S3 or large, bulky tumors: abdominal approach or combined abdominal and posterior approach
  - Begin with the abdominal approach in a lithotomy position.
    - Ensure the legs are positioned neutrally to avoid nerve impingement.
    - The arms should be tucked at the patient’s sides if possible.
  - Once the abdominal portion is complete, the patient should be flipped into the prone position for completion of the en bloc resection. (Occasionally, the posterior approach can be performed in the high lithotomy position, but this may pose to be difficult secondary to poor exposure.)
- S3 and below: posterior approach
  - Prone jackknife position
Urinary stents
- If tumor is large and bulky or if the patient has had prior radiation or pelvic dissection, cystoscopy with ureteral stent placement should be considered.
Full mechanical bowel preparation is performed in all cases.
Antibiotic coverage, including third-generation cephalosporin and metronidazole, is used.
Venous thromboembolism prophylaxis with subcutaneous anticoagulation is administered in all cases.

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