A neuroendocrine tumor arising in a tailgut cyst: Case report and literature review.

INTRODUCTION AND IMPORTANCE: Cystic lesions in the retrorectal space include developmental abnormality, inflammatory process, and tumor-relevant cysts. Among them, the tailgut cyst is the most common lesion which is featured by the complex epithelium lining the wall. It is generally accepted that tailgut cysts are embryonic residues and are mostly benign, but there are also reports about malignant transformation and even metastasis. CASE PRESENTATION: A 44-year-old female complained a sacrococcygeal discomfort more than one year. The imaging diagnosis was an infectious cyst. After surgery, a solid region was defined in a cyst. Morphologically, the region was composed of bland epithelia forming glandular or ribbon-like structure, with round nuclei and fine chromatin. Immunohistochemically, the cells were positive for CK7, CD56 and synaptophysin. The Ki-67-positive cells were about 1 %. The final diagnosis is a low-grade neuroendocrine tumor arising in a tailgut cyst. The patient was living without recurrence by the follow-up of 20 months after surgery. CLINICAL DISCUSSION: By reviewing the previously reported NET arising from tailgut cysts, we summarized 29 cases of neuroendocrine neoplasms that reported detailed information, and the majority are women. We found that the higher-grade tumor presented a higher tendency of distant metastasis or recurrence after surgery. Complete resection and full evaluation by pathologists are necessary to get a correct diagnosis and avoid disease progression. CONCLUSION: We reported the rare case of NET G1 arising from a tailgut cyst and reviewed relevant reports, in order to broaden differential diagnoses when an isolated mass is identified in the retrorectal space.

A Clinical-Anatomical-Radiological Study of Extraperitoneal Spaces: A Case Series.

Complications can arise secondary to anorectal suppurative diseases, with infections spreading along the extraperitoneal space, such as the peri-vesical, prevesical, pre-sacral, and pararectal spaces, resulting in abscesses at remote sites, which can make diagnosis more challenging. Due to the absence of peritonitis symptoms, there is a delay in presentation among such patients. Comprehending the intricacies of these areas and the way infection can spread within them is crucial for promptly identifying and effectively draining the extraperitoneal abscess. We present a case series of six patients with a mean age of 45, all males. A total of three patients had undergone incision and drainage after being diagnosed with anorectal suppurative disease and remained symptomatic after the initial surgical intervention of incision and drainage. Two patients initially diagnosed with anterior abdominal abscesses patients, after being treated with incision and drainage, continued to have purulent discharge from the drainage site. Finally, the last patient continued to present with perianal pain after an open hemorrhoidectomy. CT scans of all six patients showed collections in the extraperitoneal spaces correlated with the observed complications. To deepen our understanding of pelvic extraperitoneal spaces, cadaver dissections were conducted and compared with CT images. Through cadaver dissections and CT imaging, the study provides insights into the anatomy and interconnections of pelvic extraperitoneal spaces, emphasizing the importance of early CT scans for diagnosis. Understanding these intricate anatomical structures is essential for accurate diagnosis and efficient and effective treatment. Timely diagnosis is vital to prevent prolonged illness and reduce the risk of complications and mortality. The importance of early CT scans in suspected patients is underscored, which is highly important to expedite appropriate actions.

Retroperitoneoscopy of the presacral space in horses: Surgical access and anatomy.

BACKGROUND: Surgical approaches to the equine rectum and perirectal area are described in the literature. However, surgeries in this region can be challenging. OBJECTIVE: To describe the surgical anatomy of the presacral space and to evaluate its access using a retroperitoneoscopic approach. STUDY DESIGN: Ex vivo experiment. METHODS: Preliminary dissections were performed in two cadavers to define the boundaries of the presacral space and to determine portal locations for the surgical approach. After that, nine cadavers were used for experimental presacral retroperitoneoscopic procedure in a standing position. Following retroperitoneoscopy, cadavers were dissected to confirm the anatomical structures observed during the endoscopic procedures, to control the location of each portal and to record iatrogenic trauma. RESULTS: The presacral space was bordered by the vertebral column from the ventral aspect of lumbosacral promontorium to the first coccygeal vertebra dorsally and by the presacral fascia and peritoneum ventrally. Lateral limits were composed of the sacrosciatic ligament and transversalis fascia. Cranial and caudal borders were composed of the peritoneum and coccygeal and levator ani muscles respectively. Retroperitoneoscopic portals were placed between the external anal sphincter and semimembranosus muscles and between the base of the tail and the external anal sphincter muscle through the anococcygeal fascia to enter the space by its caudal border. The retroperitoneal space was reached in all cases and the dorsal and lateral aspects of the rectum were visualised after creation of a working space. MAIN LIMITATIONS: Use of cadaver specimens do not permit to evaluate the tolerance in living animals and the surgical complications such as rectal damage, haemorrhage and infection. CONCLUSION: This study provides an anatomical description and surgical access of the presacral space with a minimal invasive approach. Retroperitoneoscopy allows access to the rectum and the dorsal aspect of the pelvis.

Determination of the width of the presacral space on magnetic resonance imaging among adults in south-western Nigeria.

BACKGROUND: The presacral space is a clinically relevant potential space and contents may give rise to a variety of benign and malignant conditions, hence the need for detailed knowledge of its dimensions. PURPOSE: To determine the width of the presacral space and existing variations among adults in south-western Nigeria using a magnetic resonance imaging (MRI) technique. MATERIAL AND METHODS: A total of 369 consenting adults were included in the study. Measurements of the presacral space were then made electronically by consensus of two radiologists. Values derived were recorded and subjected to analyses of variance. RESULTS: The mean normal widths of the presacral space in men and women were 11.7 mm and 11.1 mm at the S1 level, 11.7 mm and 10.35 mm at the S2 level, and 12.3 mm and 9.7 mm at the S3 level, respectively. Measurements of the presacral space width were significantly larger in the male population. Variations in the dimensions due to age greater than 40 years, male sex, and increasing body mass index (BMI) were also noted. CONCLUSION: This study provides baseline dimensions under more physiological conditions and gives more accurate information about the true width of the space in Nigerian adults. Variations due to age, sex, and BMI may also be considered while interpreting abnormal values.

Chinese expert consensus on standardized treatment for presacral cysts.

Presacral cysts are cystic or cyst-solid lesions between the sacrum and rectum, almost involving adjacent pelvic floorstructures including sacrococcygeal fascia, rectum, and anal sphincter. Presacral cysts are usually benign, currently believed to arise from aberrant embryogenesis. Presacral cysts are clinically rare and the true incidence is unknown. Surgical resection remains the major treatment for presacral cysts. Unless the cysts are completely resected, recurrence is unavoidable. Recurrent cysts or hard-to-heal sinuses in the sacrococcyx cause patients extreme pain. However, the current knowledge of presacral cysts is insufficient. They are occasionally confused with other diseases such as ovarian cysts and perianal abscesses. Moreover, lack of the correct surgical concept and skills leads to palliative treatment for complex presacral cysts and serious complications such as impairing the function of the anal sphincter or important blood vessels and nerves. The consensus summarizes the opinions and experiences of multidisciplinary experts in presacral cysts and aims to provide clinicians with a more defined concept of the treatment, standardize the surgical approach, and improve the efficacy of presacral cysts.

Pediatric presacral tumors with intraspinal extension: a rare entity with diagnostic challenges.

The presacral space is a potential space located between the rectum and the lumbosacral spine. It contains various primitive germ cell types that serve as the origin for a range of tumors. Imaging is crucial in characterizing, assessing the extent of and evaluating the treatment response to these tumors. We report a series of six cases of pediatric presacral tumors with intraspinal extension, including an immature sacrococcygeal teratoma (Altman type II), a malignant sacrococcygeal teratoma (Altman type IV), a neuroblastoma, a rhabdomyosarcoma, a clear cell sarcoma and an Ewing's sarcoma of the ilium. These tumors can be broadly categorized as tumors of germ cell, neuroblastic, mesenchymal and osteogenic origin. Despite overlapping imaging features, a review of the existing literature and careful retrospective observation revealed several distinctive features that aid in the optimal characterization of tumors. These include the tumor's epicenter, the pattern and degree of bone involvement, the status of sacral foramina and neural elements, and internal tumor characteristics such as the presence of fat, calcification, hemorrhage and necrosis.

The characteristics of the urogenital fascia in the retrorectal space based on male cadaveric dissection and its clinical application.

BACKGROUND: The architecture of retrorectal fasciae is complex, as determined by different anatomical concepts. The aim of this study was to examine the anatomical characteristics of the inferomedial extension of the urogenital fascia (UGF) involving the pelvis to explore its relationship with the adjacent fasciae. Furthermore, we have expounded on the clinical application of UGF. METHOD: For our study, we examined 20 adult male pelvic specimens fixed in formalin, including 2 entire pelvic specimens and 18 semipelvic specimens. Our department has performed 466 laparoscopic rectal cancer procedures since January 2020. We reviewed the surgical videos involving UGF preservation and analyzed the anatomy of the UGF. RESULTS: The bilateral hypogastric nerves ran between the visceral and parietal layers of the UGF. The visceral fascia migrated ventrally at the fourth sacral vertebra, which formed the rectosacral fascia together with the fascia propria of the rectum; the parietal layer continually extended to the pelvic diaphragm, terminating at the levator ani muscle. At the third to fourth sacral vertebra level, the two layers constituted the lateral ligaments. CONCLUSION: The double layers of the UGF are vital structures for comprehending the posterior fascia relationship of the rectum. The upper segment between the fascia propria of the rectum and the visceral layer has no evident nerves or blood vessels and is regarded as the " holy plane" for the operation.

A Case Report of Rare Sacral Solitary Fibrous Tumor.

Huge primary epidural solitary fibrous tumors in the sacrum are a rare clinical entity. The purpose of this article is to present our experience in treating such large and complex neoplasms in a 31-year-old woman. The patient complained of constant nocturnal bilateral hip and lower back pain and unilateral radicular symptoms (numbness, paresthesias) in the left S1/S2 dermatomal distribution. Diagnostic imaging, biopsy, preoperative endovascular embolization, two-staged tumor resection, and lumbosacroiliac fusion were performed. The treatment resolved the patient's neurological symptoms and resulted in overall good postoperative functionality. The patient has been in remission for more than five years despite her refusal of adjuvant radiotherapy.

Standard practice of presacral exposure during transvaginal natural orifice transluminal endoscopic surgery for sacrocolpopexy.

We describe the standard practice of presacral exposure during transvaginal natural orifice transluminal endoscopic surgery (vNOTES) for sacrocolpopexy in women with uterine prolapse. In this video, we demonstrate the key techniques: identifying the right hypogastric nerve (rHN) before opening the pelvic peritoneum; removing the fat and loose connective tissue along the rHN to expose the presacral fascia; incising the presacral fascia to reach the presacral space to expose the middle sacral vasculature and the anterior longitudinal ligament (ALL) of the first sacral vertebra (S1) below the promontory; attaching the mesh to the ALL to avoid vessel injury; and completing the peritonealisation.

[Chinese expert consensus on standardized treatment of presacral cysts].

Presacral cysts are cystic or cyst-solid lesions between the sacrum and rectum. They are closely connected with adjacent pelvic floor structures such as sacrococcygeal fascia, rectum and anal sphincter. They are usually benign and are believed to be caused by aberrant embryogenesis. Clinically they are rare and its true incidence rate is unknown. Surgical resection remains the major treatment of presacral cysts. Unless the cysts are completely resected, the recurrence are unavoidable. The recurrent cysts even generate hard-to-heal sinus in the sacrococcyx, and cause the patients extreme pain. However, the current knowledge of presacral cysts is vague, even confused with other diseases such as ovarian cysts and perianal abscesses. Moreover, lack of the correct surgical concept or skills leads to palliative treatment of complex presacral cysts and serious complications such as fecal incontinence and massive haemorrhage which were attributed to impairing the function of anal sphincter or important blood vessels and nerves. The consensus summarizes the opinions and experiences of multidisciplinary experts in presacral cysts, and aims to provide clinicians with more detailed concept of the treatment, standardize the surgical approach and improve the resected efficacy of presacral cysts.

Chinese expert consensus on standardized treatment of presacral cysts / 中华肿瘤杂志

Presacral cysts are cystic or cyst-solid lesions between the sacrum and rectum. They are closely connected with adjacent pelvic floor structures such as sacrococcygeal fascia, rectum and anal sphincter. They are usually benign and are believed to be caused by aberrant embryogenesis. Clinically they are rare and its true incidence rate is unknown. Surgical resection remains the major treatment of presacral cysts. Unless the cysts are completely resected, the recurrence are unavoidable. The recurrent cysts even generate hard-to-heal sinus in the sacrococcyx, and cause the patients extreme pain. However, the current knowledge of presacral cysts is vague, even confused with other diseases such as ovarian cysts and perianal abscesses. Moreover, lack of the correct surgical concept or skills leads to palliative treatment of complex presacral cysts and serious complications such as fecal incontinence and massive haemorrhage which were attributed to impairing the function of anal sphincter or important blood vessels and nerves. The consensus summarizes the opinions and experiences of multidisciplinary experts in presacral cysts, and aims to provide clinicians with more detailed concept of the treatment, standardize the surgical approach and improve the resected efficacy of presacral cysts.

Laparoscopic approach to tailgut cyst (retrorectal cystic hamartoma).

Retrorectal cystic hamartomas, or tailgut cysts, are complex congenital cystic lesions which arise from embryologic tissues. Fewer than 200 cases have been reported worldwide, with women outnumbering men by 3:1. They are asymptomatic in 50% of the cases; the remainder present with back pain or mass effect as the most common symptoms. Malignant transformation rarely occurs. Guided biopsy is controversial, while surgery is the therapy of choice. We report the case of a 31-year-old woman complaining about perineal and vague lower abdominal pain, who was submitted to magnetic resonance imaging, which revealed a multilocular cystic, well-circumscribed retrorectal mass. Subsequently, laparoscopic excision was successfully accomplished. Operative time was 175 min. Intra- and post-operative course was uneventful. Hospital stay was 75 h. While any malignancy suspicion should lead to open surgery, given the risk of rupture, we support the benefits of laparoscopy may also be applied.

Clinical analysis of 33 cases on laparoscopic resection of presacral cysts / 中国综合临床

Objective To summarize and analyze our experiences uponperforming laparoscopic resection ofpresacral cysts,at the aim of generalizing the minimally invasive surgery in the treatment of this disease.Methods The clinical data of 33 patients with presacral cysts treated by laparoscopy in Peking Union Medical College Hospital of Chinese Academy of Medical Sciences from November 2012 to June 2017 were retrospectively analyzed.The operation time, the incidence of intraoperative and postoperative complications and the length of hospital stay were counted.Results Tumor excision was completed according to the plan without conversion to open surgery.The average operation time was ( 124.4 ± 63.0) minutes.There were 1 case of rectal injury and 1 case of presacral venous plexus hemorrhage.The complications were 6%.Postoperative rectal leakage occurred in 2 cases ( 6%).The average hospitalization time after operation was ( 6.7 ± 4.3) days.Of 33 cases, 2 cases were lost.One case had recurrence of presacral cyst one year after operation.Conclusion Laparoscopic resection of presacral cysts is technically feasible,and helps to improve intraoperative exposure,increase operating space and improve the resection rate of tumors.

Laparoscopic Resection of Retroperitoneal Presacral Schwannoma: A Case Report

Retroperitoneal presacral schwannomas are uncommon and are usually diagnosed accidentally. We present here the case of a 23-year-old woman diagnosed with an expansive pelvic lesion during a routine gynecological examination. The precise location of the tumor, as well as its relation to adjacent structures, was determined through magnetic resonance imaging (MRI). The patient underwent laparoscopic lesion resection and the diagnosis was confirmed by immunohistochemistry. An MRI performed 2 months after surgery confirmed complete lesion resection.

First sacral nerve and anterior longitudinal ligament anatomy: clinical applications during sacrocolpopexy.

BACKGROUND: The recommended location of graft attachment during sacrocolpopexy is at or below the sacral promontory on the anterior surface of the first sacral vertebra. Graft fixation below the sacral promontory may potentially involve the first sacral nerve. OBJECTIVE: The objectives of this study were to examine the anatomy of the right first sacral nerve relative to the midpoint of the sacral promontory and to evaluate the thickness and ultrastructural composition of the anterior longitudinal ligament at the sacral promontory level. STUDY DESIGN: Anatomic relationships were examined in 18 female cadavers (8 unembalmed and 10 embalmed). The midpoint of the sacral promontory was used as reference for all measurements. The most medial and superior point on the ventral surface of the first sacral foramen was used as a marker for the closest point at which the first sacral nerve could emerge. Distances from midpoint of sacral promontory and the midsacrum to the most medial and superior point of the first sacral foramen were recorded. The right first sacral nerve was dissected and its relationship to the presacral space was noted. The anterior longitudinal ligament thickness was examined at the sacral promontory level in the midsagittal plane. The ultrastructural composition of the ligament was evaluated using transmission electron microscopy. Height of fifth lumbar to first sacral disc was also recorded. Descriptive statistics were used for data analyses. RESULTS: Median age of specimens was 78 years and median body mass index was 20.1 kg/m2. Median vertical distance from midpoint of sacral promontory to the level of the most medial and superior point of the first sacral foramen was 26 (range 22-37) mm. Median horizontal distance from the midsacrum to the first sacral foramen was 19 (range 13-23) mm. In all specimens, the first sacral nerve was located just behind the layer of parietal fascia covering the piriformis muscle, and thus, outside the presacral space. Median anterior longitudinal ligament thickness at the sacral promontory level was 1.9 (range 1.2-2.5) mm. Median fifth lumbar to first sacral disc height was 16 (8.3-17) mm. CONCLUSION: Awareness of the first sacral nerve position, approximately 2.5 cm below the midpoint of the sacral promontory and 2 cm to the right of midline, should help anticipate and avoid somatic nerve injury during sacrocolpopexy. Knowledge of the approximate 2-mm thickness of the anterior longitudinal ligament should help reduce risk of discitis and osteomyelitis, especially when graft is affixed above the level of the sacral promontory.

Classification and Operative Approaches of Adult Female Presacral Space Tumor / 中国微创外科杂志

[Summary] Adult female presacral space tumor involves in different disciplines .It could be typing according to the tumor location, size, mobility and the relationship with surrounding tissues .Understanding the classification of the tumor is helpful to select a suitable operative approach that lead to a better result .After the strict preoperative evaluation , transvaginal approach should not be neglected in adult female patients with presacral space tumor .

Progressive Transformation of Germinal Centers in Presacral Space: MRI Findings and Literature Review

Progressive transformation of germinal centers (PTGC) is an atypical feature seen in lymph nodes with unknown pathogenesis. PTGC most commonly presents in adolescent and young adult males as solitary painless lymphadenopathy with various durations. Cervical nodes are the most commonly involved ones while involvements of axillary and inguinal nodes are less frequent. PTGC develops extremely rarely in other locations. We report a rare case of solitary mass present in the presacral space. The mass as subsequently proven to be PTGC. To the best of our knowledge, PTGC in the presacral space has not been previously reported in the literature.

CT-guided Drainage of Deep Pelvic Abscesses via a Percutaneous Presacral Space Approach: A Clinical Report and Review of the Literature.

RATIONALE AND OBJECTIVES: Some deep pelvic abscesses are not accessible through anterior or lateral approaches because of the presence of organs and structures. The objective of this study was to assess the feasibility, safety, tolerability, and efficacy of a percutaneous presacral space approach by reviewing our clinical experience and the literature. MATERIALS AND METHODS: The outcomes of 12 patients, who have undergone computed tomography (CT)-guided percutaneous presacral space drainage, were retrospectively reviewed, including demographic, clinical, and morphological data in the medical records. RESULTS: From August 2010 to June 2015, 98 patients underwent CT-guided percutaneous drainage of pelvis abscesses in our institution. A percutaneous presacral space approach was adopted in 12 cases. The fluid collections were related to postoperative complications in nine patients (75%) and inflammatory or infectious intraabdominal disease in the remaining three patients (acute diverticulitis: n = 1; appendicitis: n = 1; Crohn disease: n = 1) (25%). The mean duration of drainage was 9.5 days (range 3-33). Escherichia coli was the most frequently present microorganism (in 50.0% of the all samples). No procedure-related complications were observed, either during or after the procedure. Drainage was successful in 10 patients (83.3%). Drainage failed in one patient because of massive anastomotic dehiscence. The other one died from pulmonary embolus 10 days after drainage. CONCLUSIONS: When an anterior or lateral transabdominal approach is inaccessible, CT-guided transperineal presacral space approach drainage is a safe, well-tolerated, and effective procedure, except for patients with massive anastomotic dehiscence.

MR imaging of the retrorectal-presacral tumors: an algorithmic approach.

The retrorectal-presacral space is located posterior to the mesorectum and anterior to the sacrum, and can harbor a heterogeneous group of uncommon masses. Retrorectal-presacral tumors may be classified as congenital, neurogenic, osseous, and miscellaneous. Magnetic resonance imaging (MRI) plays a crucial role in directing appropriate management through accurate diagnosis, detection of complications and anatomic extent. MRI aids in the selection of optimal surgical approach such as anterior, posterior, or combined-based on the lesion extent and relationship to adjacent structures. This article reviews the anatomy of the retrorectal-presacral space and the related tumors, optimal MRI protocol, MRI-based approach to differential diagnosis, and finally pertinent reporting pointers and implications of MR imaging findings for surgical management.

Retrorectal cystic hamartoma: a problematic 'tail'.

The retrorectal space is an uncommon seat for neoplastic masses. Retrorectal hamartoma or tailgut cyst (TGC) is an uncommon developmental cystic lesion occurring in this space which mostly occurs in middle-aged females. We recently cared for a 16-year-old girl who presented with vague lower abdominal pain and occasional constipation. Per rectal examination revealed an extraluminal mass bulging from posterior rectal wall. Preoperative radiological investigations revealed by suggested it to be a mature cystic teratoma. The patient underwent exploratory laprotomy with en masse excision of the cyst. Histopathological examination of the specimen showed it to be a TGC. This case highlights the possibility of a TGC as a differential for retrorectal cystic lesions and the need to completely excise them given the possibility of future malignant transformation.