ORIGINAL ARTICLE Year : 2023  |  Volume : 14  |  Issue : 1  |  Page : 50-54  

Safety and effectiveness of a posterior approach alone for surgical treatment of sacral-presacral tumors

Fatih Demir, Metin Kaplan, Bekir Akgün, Selman Kök, Sait Öztürk, Fatih Serhat Erol
Department of Neurosurgery, Faculty of Medicine, Firat University, Elazig, Türkiye

Date of Submission17-Dec-2022Date of Acceptance15-Jan-2023Date of Web Publication13-Mar-2023

Correspondence Address:
Metin Kaplan
Department of Neurosurgery, Faculty of Medicine, Firat University, Tip Fakultesi, PK 23200, Elazig
Türkiye

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jcvjs.jcvjs_155_22

   Abstract 

Aim: We aimed to examine the safety and effectiveness of a posterior approach alone in the surgical treatment of sacral-presacral tumors. In addition, we investigate factors that determine the selection of a posterior approach alone.
Materials and Methods: Patients with sacral-presacral tumors who underwent surgery in our institution between 2007 and 2019 were examined in this study. Data regarding patient age, gender, tumor size (>6 cm and <6 cm), tumor localization (below or above S1), tumor pathology (benign or malignant), surgical approach (anterior alone, posterior alone, or combined), and extent of resection were recorded. The Spearman's correlation analyses were conducted between surgical approach and tumor size, localization, and pathology. Factors influencing the extent of resection were also examined.
Results: Complete tumor resection was achieved in 18 of 20 patients. A posterior approach alone was used in 16. No strong or significant relation was detected between surgical approach and tumor size (r = 0.218; P = 0.355). There was no strong or significant relationship between surgical approach and tumor localization (r = 0.145; P = 0.541) or tumor pathology (r = 0.250; P = 0.288). Tumor size, localization, and pathology were not independent factors that determined surgical approach. The only significant independent determining factor for incomplete resection was tumor pathology (r = 0.688; P = 0.001).
Conclusion: A posterior approach is safe and effective in the surgical treatment of sacral-presacral tumors independent of tumor localization, size, or pathology and is a feasible first-line treatment option.

Keywords: Posterior approach, sacral-presacral tumors, surgical management

How to cite this article:
Demir F, Kaplan M, Akgün B, Kök S, Öztürk S, Erol FS. Safety and effectiveness of a posterior approach alone for surgical treatment of sacral-presacral tumors. J Craniovert Jun Spine 2023;14:50-4
How to cite this URL:
Demir F, Kaplan M, Akgün B, Kök S, Öztürk S, Erol FS. Safety and effectiveness of a posterior approach alone for surgical treatment of sacral-presacral tumors. J Craniovert Jun Spine [serial online] 2023 [cited 2023 Mar 13];14:50-4. Available from: https://www.jcvjs.com/text.asp?2023/14/1/50/371569    Introduction 

A wide spectrum of tumors that differ in clinical characteristics and embryologic origin arises from the anatomic structures of the sacral-presacral region, which is defined by the sacrum posteriorly, rectum anteriorly, sacral promontory and sacral peritoneum superiorly, and the iliac arteries laterally. This spectrum expands further when metastatic masses are considered.[1],[2] Surgical treatment of tumors in this region is challenging and requires a multidisciplinary approach.

Anterior, posterior, and combined surgical approaches have been applied in the surgery of these tumors. The main determining factors in the selection of approach are tumor size, location, and invasiveness. As the anterior approach is recommended for tumors localized superiorly, those do not invade the sacrum, and those closely associated with large vascular structures. A posterior approach is recommended for smaller cystic tumors that do not invade the rectum and are a safe distance from large veins. A combined approach is recommended for large invasive tumors that extend toward the sacral promontory and are closely related to the large vascular bodies.[3],[4],[5]

This study aimed to examine the safety and effectiveness of a posterior approach alone in the surgical treatment of sacral-presacral tumors. In addition, we investigate factors that determine the selection of a posterior approach alone.

   Materials and Methods 

We retrospectively reviewed all patients with sacral-presacral tumors who underwent surgical treatment in our institution between 2007 and 2019. Data regarding patient age, gender, tumor size (>6 cm and <6 cm), tumor localization (below or above S1), tumor pathology (benign or malignant), surgical approach (anterior alone, posterior alone, or combined), and extent of resection (complete or incomplete) were recorded [Table 1]. Preoperative embolization and intra-arterial balloons were not used in any case for hemorrhage control. Surgical stabilization and fusion were implemented in cases that were considered to be unstable.

Table 1: Gender, age, tumor size, tumor localization, tumor pathology, presence of residue, and surgical approach of cases

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Statistical analyses were conducted using SPSS software version 20 (IBM Corp., Armonk, NY, USA). The relationships between surgical approach and tumor size, localization, and pathology were examined using the Spearman's correlation. Similarly, the relationships between extent of resection and tumor size, localization, and pathology were also examined. P < 0.05 was considered statistically significant.

   Results 

The patients' age ranged between 0.1 and 62 years. Ten patients were male, and 10 were female. The surgery began with a posterior approach in all cases and combined with an anterior approach when considered necessary. No patient underwent an anterior approach alone. In addition, total sacrectomy was not performed on any patient. Only one patient underwent iliolumbar stabilization.

Complete tumor resection was achieved in 18 of 20 cases. A posterior approach alone was adequate [Figure 1] and [Figure 2] in 16 of the 18 completely resected tumors. A combined approach was required in the other two. In one of these, the tumor extended toward the upper level of S1 was >6 cm in size, and was benign. The other combined approach tumor was a recurrent rectal tumor, invaded the pelvic structures and was completely resected by adding an anterior approach to en bloc posterior S2 resection. In both incompletely resected tumors, the size was >6 cm, and the pathology was malignant; an anterior approach was not added, and the surgery was terminated due to severe tumor invasiveness.

Figure 1: Case 4 - (a) Preoperative sagittal T2-weighted magnetic resonance image, (b) preoperative sagittal computerized tomography

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Figure 2: Case 4 - (a) Postoperative sagittal T2-weighted magnetic resonance image, (b) postoperative sagittal computerized tomography, (c) tumor tissue for en bloc resected

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Tumor size

The mass was <6 cm in six patients and >6 cm in 14 patients. All masses <6 cm were benign and completely resected with a posterior approach alone. In 10 of the 14 tumors >6 cm in size (87.5%), the mass was completely resected with a posterior approach alone. The tumor was benign in nine of these 10; the remaining tumor was malignant. Complete resection was achieved with a combined approach in two of the tumors >6 cm in size. In the two incompletely resected tumors >6 cm in size, a posterior approach alone was used. Tumor size was not an independent factor that determined posterior approach effectiveness. There was a weak and insignificant relationship between surgical approach and tumor size.

Tumor pathology

The tumor was malignant in four patients and benign in 16. All benign tumors were completely resected. Only one of the 16 benign tumors required the addition of an anterior approach to achieve complete resection; a posterior approach alone was sufficient for complete resection in the other 15 (93.7%).

In the four malignant tumors, complete resection was achieved in two cases: one with a posterior approach alone and the other with a combined approach. In the two incompletely resected tumors, a posterior approach alone was used. Tumor pathology was not an independent factor that determined posterior approach effectiveness. There was a weak and insignificant relationship between surgical approach and tumor pathology (r = 0.250; P = 0.288).

Tumor localization

The tumor was located below S1 in 14 patients. In 12 of these 14, the tumor was completely resected using the posterior approach alone. One additional tumor was completely resected after using a combined approach (case 14). In the remaining patient, a posterior approach alone was used, and surgery was terminated due to severe tumor invasiveness (case 2). The pathology of the combined approach tumor and the incompletely resected tumor was malignant.

The tumor extended above S1 in six patients. In four patients, the tumor was completely resected with a posterior approach alone; all of these were benign. One additional tumor was completely resected after using a combined approach (case 11). In the remaining patient, a posterior approach alone was used, and the tumor could not be completely resected; this tumor was malignant (case 20). Tumor localization was not an independent factor that determined posterior approach effectiveness. There was a weak and insignificant relationship between surgical approach and tumor localization (r = 0.145); (P = 0.541).

Incomplete resection after posterior approach alone

There was a weak and insignificant relationship between incomplete resection after the posterior approach alone and both tumor size (r = 0.055); (P = 0.819) and localization (r = 0.218); (P = 0.355). However, a strong and significant relationship was found with tumor pathology (r = 0.688); (P = 0.001). of the four cases that had residual tumor after a posterior approach alone, three had malignant pathology.

Complications

Surgical complications occurred in four of the 20 patients. A wound infection occurred in one, herniation toward the posterior occurred in the patient who underwent en bloc S2 resection, and loss of sphincter control occurred in one despite unilateral S2 nerve root preservation. In addition, one patient died of pulmonary embolism in the postoperative period.

   Discussion 

Surgical treatment of tumors of the sacral-presacral area is challenging due to the regional anatomy and the wide variety of tumors that may occur. The risk of hemorrhage, presence of the sacrum posteriorly, and presence of intestinal, neural, and large vascular structures complicate surgical manipulation. For this reason, a minimally invasive intervention, that is both safe and effective, is important. Although an anterior approach alone provides an important advantage in terms of access to the pelvic structures, particularly the large blood vessels, it also poses difficulty in resecting tumors involving the sacrum and/or extending to the pelvic floor.[6] From an anatomical perspective, the posterior approach alone allows resection of those particular tumors but has difficulty in removing those that extend over S1 or are in close proximity to the neighboring pelvic structures, including the large blood vessels. In such cases, a combined approach is recommended.[7],[8],[9],[10],[11],[12] However, the pelvic structures can be seen directly if an appropriate amount of sacrum is resected, taking into account the sacrococcygeal sinus angle [Figure 3]; some tumors can be safely resected even if they extend beyond S1, particularly for less invasive tumors.[1],[13]

We believe it is important to accurately predict which tumors can be resected with a posterior approach alone during surgical planning. In this study, 16 of 20 sacral-presacral tumors were completely resected with a posterior approach alone in 16 of the 20 cases. In the literature, the surgical approach is primarily determined based on tumor size >6 cm, extension beyond the S1 level, and tumor pathology. This study found that tumor size, localization, and pathology had no strong or significant correlation with the adequacy of surgical approach. Our 80% complete resection rate supports the results of the correlation analysis and suggests the use of a posterior approach alone as a minimally invasive first-line approach to the surgical treatment of sacral tumors. In addition, our results show that surgical planning of sacral-presacral tumor resection should be individualized on a case-by-case basis based on consideration of many clinical parameters.

In our series, incomplete resection was not associated with tumor size or localization, regardless of surgical approach. However, we found a strong and significant relationship between incomplete resection and tumor pathology. The tumor differential diagnosis before surgery is an important consideration for surgical planning – malignant tumors may be more difficult to completely resect.

Complications occurred in four of our cases, including one mortality. Wound infection and herniation toward the posterior may be considered directly related to the posterior approach. The low complication rate shows that a posterior approach carries acceptable risks and is safe.

One limitation of this study is the number of included patients. However, relative to other single-center studies on the subject, we believe that our number of cases is not small. We anticipate that our study will contribute to future meta-analyses that will be conducted.[12]

   Conclusion 

A posterior approach alone is safe and effective in the surgical treatment of sacral-presacral tumors regardless of tumor size, localization, or pathology. A posterior approach alone is a feasible first-line treatment option.

Statement of ethics

It was approved by Firat University's Ethics Committee (reference number 2021/04-18). The study was conducted in accordance with the principles of the Declaration of Helsinki.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 

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  [Figure 1], [Figure 2], [Figure 3]
 
 
  [Table 1]