World J. Surg. 7, 620-628, 1983

Wo

Journal

of Sdrgery

9 1983 by the Soci6td |nternationale de Chirurgie

A Posterior Approach to the Presacral Mass Glenn W. Geelhoed, M.D., and Herbert L. K o t z , M . D . Departments of Surgery and Obstetrics-Gynecology, The George Washington University Medical Center, Washington, D.C., U.S.A.

Mass lesions in the presacral space are not readily accessible from the transabdominal approach. The posterior transcoccygeal technique is a nearly ideal approach to the presacral mass, and allows the combined use of abdominosacral resection for more extensive tumors. Four patients with presacral mass, which later proved to be benign cystic teratomas, each had transcoccygeal operation for resection. The technique gave adequate exposure, satisfactory margins, minimal patient morbidity, and no recurrence of the primary presacral teratomas. The diagnostic evaluation of the presacral mass and the operative technique of a modified Kraske approach are described with suggestions for resection technique. The utility, flexibility, and limitations of the posterior transcoccygeal approach are reviewed in application to the management of the presacral mass.

Most teratomas of the sacrococcygeal region are encountered in infants and children, with an incidence estimated at 1 in 30,000 live births. The term sacral teratoma was suggested by Virchow in 1869, and the eponym M i d d e l d o r p f tumor has also been used since 1885 to describe teratomas of the retrorectal space. Presacral teratomas in the adult are much less frequent than the sacrococcygeal teratoma of infancy, with one review citing 71 documented cases reported up to 1975 [1]. The posterior approach to low-lying pelvic tumors has been used for the resection of rectal carcinoma as advocated by Kraske [2] and as modified by Localio [3, 4] and others [5, 6]. We present a modification of this posterior approach to the presacral mass for pelvic tumors seen in 4 adult patients. These women were found to have presa-

Reprint requests: Glenn W. Geelhoed, M.D., 2150 Pennsylvania Avenue, NW, Washington, D.C. 20037, U.S.A.

cral cystic teratomas which were readily exposed, identified, and resected through this posterior operative approach.

Case Reports

Patient no. 1

J.R. is a 28-year-old woman who had had 4 years of pelvic pain and recurrent presacral cysts. She had a spontaneous coccygeal fracture in 1974 and underwent coccygectomy. At that time it was noted that a dermoid cyst was contiguous with the area of the pathologic fracture of the coccyx. The cyst recurred in 1975 when the patient was 3 months pregnant. The patient underwent laparotomy and the cyst was drained transabdominally. In 1976, the pain and pressure recurred with dyspareunia and stress incontinence, and she underwent repeat laparotomy in 1977. The patient had constant pain and recurrent low back discomfort along with stress incontinence and decreased sensation in her genitalia. She presented in 1978 for complete evaluation, occasioned by pelvic and back pain and dyspareunia. A very large mass which could be palpated abdominally, was encountered on physical examination and pelvic examination showed the vagina deviated sharply anteriorly and to the left. An intravenous pyelogram was obtained to check on a history of multiple urinary tract infections the patient had experienced, and a very large pelvic mass was demonstrated, showing the ureters diverted around this mass (Fig. 1). A computed tomography (CT) scan of the pelvis was carried out, showing postoperative bony deformities with a partial absence of the sacrum and coccyx, and a very large presacral cyst thought to represent a presacral meningocele (Fig. 2). Myelography was performed to demonstrate a communi-

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Fig. 2. The large cystic mass in patient no. 1 originates in the presacral space and fills the entire pelvis.

remarkably diminished pelvic and back pain, and a repeat CT scan has shown no evidence of recurrent pelvic tumor 4 years postoperatively. Careful review of the specimen showed no evidence of malignant degeneration in this multiply recurrent presacral dermoid cyst. Fig. 1. A large recurrent pelvic mass diverts the course of the ureters as seen in this urogram of patient no. 1. cation of this large cystic mass with the meninges, but no communication could be demonstrated (Fig. 3). The patient was taken to the operating room in May, 1978, and positioned for combined abdominal and sacral approach to the pelvic mass. The very large cyst was approached posteriorly with dissection up to the level of the pelvic brim. The surgeon entered the iliac fossa with a simultaneous lower abdominal incision to demonstrate the superior portion of the cyst, dissecting it free from its adherence to the peritoneum and delivering it down for excision by means of the posterior approach. In the final stages of excision, a trocar was used for decompression of the cystic contents, and 7 liters of fluid were evacuated. The cyst lining was excised intact, and the patient had multiple transfusions for blood replacement due to blood loss from the inflammatory adhesions around the cyst at previous operative sites. The patient had an uneventful recovery. An indwelling bladder catheter remained for several weeks, but bowel and bladder retraining brought the patient to the point of self-sufficiency without requirement for catheterization. In regular follow-up, the patient noted that she had partial recovery of vaginal sensation and recovery of bowel and bladder control. She has had

Patient no. 2

S.S. is a 36-year-old woman who complained of dyspareunia. At the time of gynecologic examination, a fixed, soft, minimally tender retrorectal presacral mass with dimensions estimated at 5 x 7 cm was noted. Neurologic consultation showed no neurologic abnormality. Intravenous urography revealed a horseshoe kidney with rotation and slight displacement of the left renal component of the horseshoe, but no other urologic abnormality. Films of the lumbar spine revealed a transitional vertebra at S 1 with lumbarization on the right, and no evidence of spina bifida. A pelvic sonogram revealed a cystic presacral mass extrinsic to the bowel. A pelvic CT scan (Fig. 4) before and following contrast infusion revealed a presacral mass displacing the rectum and uterus. The mass was avascular and homogenous in density. The mass extended inferiorly to the superior aspect of the ischiorectal fossa, and superiorly to the inferior aspect of the sacrum. The sacrum and coccyx were normal. Laboratory and other physical findings were normal. The patient underwent excision of the presacral mass by means of the posterior transcoccygeal approach. The mass was excised intact without complications. On pathologic examination, the cyst was opened to reveal sebaceous material and hair included within the cystic mass; the final pathologic diagnosis was benign cystic teratoma. The patient

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Fig. 4. ACT scan of patient no. 2 shows the presacral location of the teratoma.

Fig. 3. A preoperative myelogram disproves the likelihood of an anterior myelomeningocoele in the case of patient no. 1. experienced a normal postoperative course and was discharged on the fifth hospital day.

P a t i e n t no. 3

P.E. is a 34-year-old woman who had the discovery of an asymptomatic soft, cystic, nontender 5 x 4 cm mass at the time of her routine postpartum examination following vaginal delivery of her second child. The mass was fixed in the retrorectal presacral position. X-ray examination of the lumbosacral spine was normal. The patient remained asymptomatic, and experienced another uncomplicated vaginal delivery 2 years later. The patient moved to another city where the presacral mass was noted by other examiners, but it remained unchanged. Three years later, the patient returned to the present authors for routine examination, and the findings of the presacral mass were unchanged, but the patient complained of low back pain and occasional numbness of the right lower extremity. Neurologic consultation showed no evidence of neurologic abnormality. A CT scan of the pelvis before and following contrast infusions (Fig. 5) demonstrated a rightsided pararectal mass with coefficients of absorption less than the surrounding muscles and uterus.

It was not attached to adjacent pelvic muscles or organs. A preoperative diagnosis of benign cystic teratoma was made and resection by the posterior approach advised. The patient underwent excision of the presacral mass by means of the posterior approach (Fig. 6) and the cyst was excised intact without injury to the surrounding structures. The resected specimen (Fig. 7) showed a cystic mass with contents of hair and sebaceous materials. The microscopic diagnosis was benign cystic teratoma. The patient experienced an uneventful postoperative course. She was discharged on the fifth hospital day, without deficits in bowel or bladder function. When examined 2 weeks postoperatively, the wound was healed primarily (Fig. 8) and the patient was asymptomatic and denied any discomfort while sitting. P a t i e n t no. 4

P.S. is a 23-year-old woman who complained of constipation and dyspareunia following the vaginal birth of her first child 3 months prior to examination. On physical examination a soft, movable midline mass was palpable by rectal examination in the midline in the retrorectal space. She stated that she had had numbness and tingling in either lower extremity during prolonged sitting, but at no point had she experienced the sensation simultaneously in both lower extremities. Intravenous urography and barium enema examination were normal. Pelvic sonography suggested a composite cystic mass below the peritoneal reflection posterior to the rectum. The patient underwent a posterior transsacral resection of a presacral mass which was proven to be a benign cystic teratoma. A rectal tube had been inserted prior to the operative positioning of the patient, and was useful in defining the limits of the

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Fig. 5. The presacral teratoma in patient no. 3 is seen as a smaller lesion that displaces the rectum here outlined with the radiopaque contrast. anterior plane of dissection, since the mass was adherent to the posterior muscular coating of the rectum. The patient had no complications following the operation, and was discharged 4 days postoperatively, and has subsequently experienced no paresthesias in either extremity.

Discussion

Presacral Tumors in the Adult Tumors of the presacral space include a variety of congenital lesions, bone tumors, neurogenic neoplasms, and other metastatic soft tissue tumors. Retrorectal tumors in adult patients are typically slow-growing and produce symptoms by pressure on pelvic viscera and nerves. Symptoms are characteristically present for many months or years, and tumors generally attain considerable size despite the fact that they are readily palpable by digital examination of the rectum. Like the higher retroperitoneal area, the presacral space is typically "silent" of symptoms that result from a slowgrowing mass. Preliminary differentiation of malignant from benign tumors may not be necessary if the mass has already reached symptomatic size. Incisional biopsy should be avoided to prevent local recurrence of the neoplasm which would be very likely if the mass were malignant, and has even occurred in benign cystic teratoma as evidenced by the recurrence of a benign tumor in patient no. 1. The extent of the tissue margins might be assessed intraoperatively, with guidance from frozen section diagnosis, but preoperative biopsy by perineal, transrectal, or

Fig. 6. The operative approach to the presacral mass is illustrated in this diagram.

abdominal approach should be avoided to prevent tumor dissemination and recurrence. Symptoms and signs such as root pain, neurologic deficits, urinary or bowel complaints, and apparent bony fixation do not discriminate between benign and malignant tumors. Urinary or fecal incontinence is more likely indicative of malignancy in the experience reported in larger series of presacral tumors [7-9]. The size of the sacrococcygeal teratoma appears to be unrelated to whether it is malignant [10], and the single most reliable indication of malignancy is bone destruction of the sacrum detected radiographically.

Clinicopathologic Features

The teratoma is a composite tissue mass derived from more than one germinal layer. Presacral dermoids are derived from ectoderm and occur most commonly in young women. Sacrococcygeal teratomas are well-encapsulated, solid or cystic lesions arising in the region of the coccyx. A grossly recognizable structure may be found within the walls of the cyst or projecting into the cystic cavity which frequently contains dermal glandular elements, and even peripheral nerve tissue. Foot-like structures have been reported in some teratomas. The tumors maintain a strong attachment to the coccyx, and sometimes also to the sacrum, but are rarely adherent to the pelvic viscera unless previous inflammation has resulted in secondary adhesions. The blood supply comes mainly from the mid-sacral

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Fig. 7. The resected specimen cleared of its secretion content shows the cyst lining and hair typical of benign presacral teratoma. vessels of the sacrococcygeal segments of the spine, but also may be from hypogastric vessels.

Growth Pattern The presacral teratoma may remain confined to the pelvis where it may completely surround the rectum. It may also grow out of the pelvis upward into the retroperitoneal space, or downward, distending the perineum, distorting the anus and displacing this orifice and the external genitalia down between the legs. A fingerlike projection of the tumor has been reported in some cases growing extradurally in the spinal canal. The tumor may also extend out of the pelvis through the lesser sacrosciatic notch and emerge in the region of the buttocks under the gluteus muscles. Here it presents a bulky mass in the gluteal area that may typify the external lesion seen in infancy and childhood. Without treatment, the tumor may develop as a rapidly growing malignancy with lethal consequences within months, or it may continue growing through childhood reaching a large size in the adult. Part of the bulk of the tumor may be due to the cystic contents with several liters of fluid present in such a tumor as exhibited in patient no. 1 in this series.

Clinical Features in the Adult In the adult age group, the tumors may be associated with necrosis, infection, and clinical signs and symptoms of anorectal disease, particularly perirectal abscess and fistula. Occasional reports have described patients treated for chronic anorectal fistulas for many years before discovery of an underlying sacrococcygeal teratoma. A presacral cystic teratoma in the adult may sometimes rupture into the rectum and grow as a pedunculated tumor within the rectum. Of the 71 documented cases of presacral teratomas in adults reported through 1975, a total of 63% of the patients were under 40, and 81% under 50.

Fifty-three cases (75%) occurred in females. A history of tumor mass or cyst noted in infancy was known in 35% of cases and symptoms beginning between the ages of 2 and 19 years of age could be elicited in 21% of cases. Symptoms that developed only in adulthood occurred in 28% of cases, and 8 other cases were asymptomatic, discovered incidentally on routine pelvic or rectal examination. The duration of symptoms prior to medical intervention was greater than 10 years in most patients (31 of 56 determinant cases). In only 9 cases were symptoms present for less than 1 year before discovery of the teratoma. The presenting complaint in most instances (21 of 60 determinant cases) was that of a mass, frequently located at the base of the spine or protruding in the area of the buttock. In 3 cases, the mass was a large pendulous tumor that had been present since birth. The mass was associated with draining fistulas in 4 cases. Abscesses, draining sinuses, and fistulous tracts led to the discovery of the presacral teratoma in 12 cases and pain was the primary complaint in 10. Presacral teratomas complicated delivery by pelvic dystocia in 3 cases. A mass was evident on rectal examination in all cases reported. Roentgenographic studies were obtained in 39 of the cases reported, and calcification or bone formation was noted in 11 of these cases. Sacrococcygeal anomalies were discovered in 4 patients. Barium enema examinations were useful in outlining retrorectal soft tissue densities, and urography was helpful in demonstrating ureteral diversion when present. Myelography was useful in the evaluation of cystic presacral masses when neurologic complaints were part of the preoperative history (Fig. 3).

Embryology The embryogenesis of presacral teratoma is uncertain, and several theories have been advanced. Middeldorpf in 1885 proposed that these tumors represent remnants of postanal gut. The postanal gut is a part of the embryonic hindgut which is present in the true tail of the 3.5-8.0-mm embryo, and usually fills with epithelial debris and disappears as the tail is resorbed. If regression of the postanal gut were incomplete, a retrorectal cyst might form, giving rise to presacral teratomas. Askanazy proposed a theory in 1876 that a group of isolated embryonic cells in the presacral region may be liberated from the influence of "hormonal organizers" and might develop into teratomatous masses. Current opinion favors the theory that these tumors are derived from pluripotential primordial cells derived from a "primitive knot" [11]. The primitive knot, or " H e n s o n ' s node," is a swelling at

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formities consisting of anterior crescentic defects ("scimitar sacrum"), cortical expansion suggestive of an intrasacral cyst, or enlarged sacral foramina. Sacral anomalies on roentgenographic evaluation of patients with presacral masses should, therefore, warrant consideration of myelography with delayed films if necessary to demonstrate a possible meningocele. At least one patient has been reported in whom a presacral teratoma was found in association with an anterior meningocele in adulthood [13]. Fig. 8. A satisfactory postoperative functional result was reported by each of the patients in this series. the anterior end of the primitive streak, from which most of the embryo is derived. As somatic growth occurs cephalad, this node assumes a caudad position near the coccyx. Pluripotential cells from this primitive knot may then develop into presacral teratomas. The genital ridge is also derived from the primitive streak, and as the female gonads terminate their differentiation later than the male gonads, there is more opportunity for aberrations to occur in the female. The greater prevalence of presacral teratomas in the female is a fact that might tend to support this theory.

Evaluation of Presacral Mass Careful physical examination will occasionally reveal an asymptomatic retrorectal presacral mass. Occasionally, examination will reveal the mass to be the cause of pain, dyspareunia, and gastrointestinal or neurologic complaints. The physician should first perform a complete neurologic examination to detect any involvement of the lumbosacral nerve plexus. Beyond physical examination, the most significant localization study in this series has been a CT scan of the pelvis, with or without contrast injection. If the pelvic mass is very large, an intravenous urogram may be helpful (Fig. 1).

Differential Diagnosis

Management of the Presacral Mass

The differential diagnosis of presacral masses includes any presacral mass of congenital, inflammatory, neurogenic, or osseous origin--such as ependymoma, lipoma, meningocele, giant cell tumor of the sacrum, various types of sarcoma, chordoma, mucoid carcinoma, angioma, coccygeal glioma, and perirectal abscesses. Because of the hazards of surgery a specific effort must be made to identify an anterior sacral meningocele. A neurologic deficit favors a diagnosis of meningocele, since a benign teratoma is rarely responsible for this. Weakness of the lower extremities has been reported in malignant sacrococcygeal teratoma as part of a characteristic symptom triad, consisting of constipation, urinary frequency, and weakness in the legs. Seventy-five cases of anterior sacral meningocele have been reported in literature available before 1968 [12]. Most occurred in females (85%) and the mortality rate in 20 patients who did not undergo surgery was 30%, usually from rupture of the meningocele or fistulization to the rectum. The operative mortality rate in the other 55 cases was 35%, although only 2 deaths have been reported in the 21 operations performed since 1945. Of the 17 operative deaths before 1945, 15 were associated with meningitis. Most anterior sacral meningoceles are accompanied by characteristic sacrococcygeal de-

Particularly for the asymptomatic patient, surgical treatment of the presacral lesion requires justification. Indication for operation for symptomatic relief in patients with large, draining, or painful masses is obvious. A reasonable question is the possibility of malignant degeneration of the benign mass or the presence of malignancy in the asymptomatic lesion. A presacral tumor, even if initially benign, has a significant tendency toward malignancy with increasing age of the patient and inadequate removal [14]. Gross [15] reported 32 instances of teratoma discovered at birth, all benign. Later in life, 5 of 8 of those discovered were malignant. In other series, more than 90% of tumors removed from the presacral area in patients up to 2-4 months of age were benign, while after this age, malignancy approached 60-90%. In a survey conducted by the American Academy of Pediatric Surgery, when the diagnosis of presacral teratoma was not established until after age 2 months, 66% of the males and 50% of the females had malignant teratomas. In the presacral masses that present primarily in adult life, there is a much lesser incidence of malignancy, and a far less chance that malignant degeneration may take place in benign teratoma. Although transcoccygeal aspirations of cystic teratomas have been performed, these tumors are

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usually multicystic, and the recurrence rate is high. The mass might seem to disappear following aspiration, but malignant change can still occur, as has been reported in at least one published case [16]. Aspiration should not be carried out unless the possibility of a meningocele is clearly excluded to prevent the possibility of meningitis. The surgical approach should be determined by the size and location of the tumor. In 3 of the 4 patients presented herewith, a posterior, transsacral approach similar to the technique advocated by Kraske for exposure of the low-lying rectum affords excellent exposure as well of the presacral and retrorectal space. The Kraske approach has an interesting range of useful modifications that may be applied to various problems in the perirectal space (Table 1). To this list of applications of the Kraske approach, we suggest the following technique and its modifications for approach to the presacral mass as applied in the patients described in this report: The patient is placed in the Bowie position if the preoperative assessment of the presacral mass shows it to be of such a size that it does not enter the pelvis to the level of the peritoneal reflection. If the mass is larger than this by preoperative assessment, the patient is placed in the lateral position and simultaneous prepping and draping of the abdomen and posterior pelvis are carried out for abdominosacral technique, if applicable. The c o c c y x is palpated in the lower midline position, and a horizontal incision is carried out at the level of the sacrococcygealjunction. The subcutaneous tissues overlying the midline posteriorly and the posterior fascia are exposed, and then the midline fascial raphe is incised to expose the c o c c y x and dissect it free from the fascia that holds it in place posteriorly. This maneuver frees the c o c c y x from its inferior attachment. A forceps is used to grasp the c o c c y x inferiorly, and the c o c c y x is mobilized superiorly and c o c c y g e c t o m y performed (Fig. 6). The operator sections the lateral attachments of the c o c c y x by staying close to the c o c c y x to avoid retraction or compression of the lateral major nerve trunks. After the c o c c y x is dislocated and excised, a rongeur is used to trim the fragments of bone at the sacrum. Bone wax is applied to the cut edges of the osteotomy. Digital development of the space beneath the sacrum is then carried out. The space is dissected bluntly with care to remain within the confines of the immediately presacral space. After the initial development of the space with digital dissection, sufficient room is created to admit a hand for further exploration and delineation of the margins of the presacral tumor. This extensive superior-posterior exposure usually affords adequate exposure of the presacral mass which may

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Table 1. Applications of the Kraske approach a.

1. For anterior resections too low for a safe abdominal approach (Localio, 1971) [3] 2. Repair of rectal strictures (Marks, 1973) [17] 3. Repair of prostatorectal fistulae (Limbert, 1968) [18] 4. Rectal dysfunction (Nichol, 1980) [19] 5. Removal of primary bladder and congenital tumors in the sacrococcygeal area (Kishev, 1973) [20] 6. Treatment of imperforate anus (Hargrove, 1979) [6] 7. Resection of presacral teratomas (Present report, 1982) aApplications of the Kraske approach have been modified for treatment of several clinical problems; to this list we add the suggestion that the transsacral approach offers excellent exposure for resection of presacral masses with minimum morbidity. be grasped with a Babcock forceps and dissected. If the mass is so extensive as to extend above the exposure obtained by this transsacral approach, a lower abdominal incision can be carried out to expose the iliac fossa without entering the peritoneum. The exposure of the superior limits of the mass in this retroperitoneal iliac fossa was used to push down the very large mass encountered in patient no. 1, which was then delivered through the posterior transsacral incision. If the mass is adherent to, or closely associated with, the posterior muscular wall of the rectum, the limits of the rectum can be defined with assistance of an intraluminal finger or tube. Since the rectum has no serosal layer beneath the peritoneal reflection, insinuation into the muscular coat is one hazard of the anterior dissection of the presacral mass. The surgeon or an assistant can reach beneath the draping and perform digital rectal examination, and this bimanual control of the dissection of the presacral mass prevents entry into the rectum itself. With the rectum thus protected, and with care to avoid dissection near the lateral nerve trunks, the presacral mass is mobilized into the wound under traction and its final attachments, and hemorrhoidal blood supply controlled. Hemostasis is checked and a soft Silastic | drain is inserted for suction closure of the potential space. The sacrococcygeal ligaments are reapproximated and the midline raphe is reconstructed in the closure of the wound. We have employed a preoperative bowel preparation, but have not routinely administered systemic prophylactic antibiotics in these patients.

Conclusion

In summary, the posterior transcoccygeal approach is a useful surgical technique in the management of

G.W. Geelhoed and H.L. Kotz: Approach to Presacral Mass

presacral tumors as exhibited in this group of 4 w o m e n with benign cystic teratoma. This simple excision technique was associated with minimum morbidity and has b e e n followed to date without recurrence of the benign cystic teratomas.

R~sum~

Les 16sions tumorales pr6sacr6es sont difficiles aborder par voie abdominale, L a voie transcoccygienne repr6sente la meilleure voie d'acc6s. Combin6e & la voie abdominale, elle p e r m e t l'exdr6se des tumeurs les plus volumineuses, 4 malades qui prdsentaient des m a s s e s pr6sacrdes r6pondant/L des t6ratomes kystiques ont 6t6 op6r6s par cette voie qui donne un j o u r excellent grgtce & une incision satisfaisante, l'ex6r6se des tumeurs n ' a y a n t donn6 lieu ni fi complication, ni & rdcidive. L ' 6 v a l u a t i o n pr6op6ratoire de l ' i m p o r t a n c e de la tumeur pr6sacr6e et la technique op6ratoire de cette modification de la voie de K r a s k e sont exposdes par les auteurs, ainsi que les d6tails de l'exdr6se tumorale. L'utilit6, la souplesse et les limites de la voie d ' a b o r d transcoccygienne pour pratiquer l'exdr6se des tumeurs prdsacr6es sont passdes en revue par les auteurs.

Resumen

L a s masas ubicadas en el espacio presacro no son fftcilmente accesibles p o t la vfa transabdominal. L a t~cnica transcoccfgea posterior representa un acceso casi ideal p a r a la m a s a presacra, y permite el uso c o m b i n a d o de la reseccidn a b d o m i n o s a c r a en tumores de m a y o r extensidn. En una serie de 4 pacientes con masas presacras, que luego p r o b a r o n set teratomas qufstico benignos, la reseccidn fu6 realizada mediante la operaci6n transcoccfgea. E s t a t6cnica permiti6 una exposicidn a d e c u a d a con m~irgenes satisfactorios, y demostr6 morbilidad mfnima y ninguna recurrencia de los teratomas presacros primarios. Se describen la evaluacidn diagndstica de la m a s a y la operaci6n p o t medio de la t6cnica de K r a s k e modificada, con sugerencias para la reseccidn. L a utilidad, flexibilidad y limitaciones del acceso trans-

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coccfgeo posterior son revisados en cuanto a su aplicaci6n al manejo de las masas presacras. References

1. Graham, D.F.: Adult presacral teratoma. Postgrad. Med. J. 55:52, 1979 2. Kraske, P.: Zur Exstirpation hochsitzender mastdarmkrebse. Verh. Dtsch. Ges. Chir. 14:464, 1885 3. Localio, S.A., Eng, K., Ranson, J.H.C.: Abdominosacral approach for retrorectal tumors. Ann. Surg. 191:555, 1980 4. Localio, S.A.: Abdominal-transsacral resection and anastamosis for midrectal carcinoma. Surg. Gynecol. Obstet. 132: 123, 1971 5. Douglass, H.O., Krakousis, C., Holyoke, E.D.: Rectocolic reconstruction via a modified Kraske approach. J. Surg. Oncol. 7:289, 1975 6. Hargrove, W.C., Gertner, H.M., Fitts, W.Y.: The Kraske operation for carcinoma of the rectum. Surg. Gynecol. Obstet. 148:931, 1979 7. Law, A.A.: Pelvic tumors with sacral attachments. Surg. Gynecol. Obstet. 35:593, 1922 8. Izant, R.J., Filston, H.C.: Sacrococcygeal teratomas. Analysis of 43 cases. Am. J. Surg. 130:617, 1975 9. Pantoja, E., Rodriguez-Ibanez, I.: Sacrococcygeal dermoids and teratomas. Am. J. Surg. 132:377, 1976 10. Schey, W.L., Shkolnik, A., White, H.: Clinical and radiographic considerations of sacroiliac teratomas. Radiology 125:189, 1977 11. Willis, R.A.: Pathology of Tumors. London, Butterworths, 1967, p. 994 12. Killen, D.A., Jackson, L.M.: Sacrococcygeal teratoma in the adult. Arch. Surg. 155:230, 1964 13. Head, H.D., Gerstein, J.D., Muir, R.W.: Presacral teratoma in the adult. Am. Surg. 41:240, 1975 14. Hickey, P.C., Martin, R.G.: Sacrococcygeal teratomas. Ann. N.Y. Acad. Sci. 114:951, 1964 15. Gross, R.E., Clatworthy, H.W., Meeker, L.A.: Sacrococcygeal teratomas in infants and children. Surg. Gynecol. Obstet 92:341, 1951 16. Moore, R.M.: In discussion on "Sacrococcygeal teratomas," Wilcox, G.A., MacKenzie, W.C. Arch. Surg. 83:16, 1961 17. Marks, G.: Rectal reconstruction by a combined abdomino-transsacral approach. Dis. Colon Rectum 16:378, 1973 18. Limbert, Z.D.: Transcoccygeal repair of prostatorectal fistula. J. Urol. 100:666, 1968 19. Nichol, D.H.: Presented at the meeting of the Society of Pelvic Surgeons, Duke University, Durham, North Carolina, 1980 20. Kishev, S., Eaton, J.M., Jr.: Transsacral cystectomy. J. Urol. 109:835, 1973