Laparoscopy-assisted resection of tailgut cysts: report of a case

Robotic approach to remove four tailgut cyst cases in Brazil: a case series

Tailgut cysts are rare congenital lesions that are remnants of the embryonic hindgut. This abnormality presents with non-specific symptoms or no symptoms; therefore, misdiagnosis is common. Here, we present four cases of tailgut cysts that were successfully removed using a robotic surgical approach. A 42-year-old woman with tenesmus, pain in the right gluteal region, and discomfort in the rectal region during evacuation was referred to our medical center. Another patient was a 28-year-old woman who presented with the same symptoms to our general practitioner. Both patients underwent upper abdominal and pelvic magnetic resonance imaging that revealed a tailgut cyst. Further, a 36-year-old woman was referred with coccyx and hypogastric pain. Magnetic resonance imaging revealed two pararectal cystic formations. She underwent robot-assisted surgery, and after analysis by a pathologist, the conclusion was that the tailgut cyst was associated with scarring fibrosis. A 55-year-old woman with posterior epigastric pelvic pain associated with heartburn underwent robot-assisted surgery to resect a retroperitoneal tumor. These cases highlighted the importance of tailgut cysts in the differential diagnosis of rectal lesions. Surgical treatment is preferred because malignant transformations can occur. The difference between laparoscopic and robotic approaches is the better visualization and stability of the latter, inducing less tissue damage. Robotic resection is a safe procedure, especially in patients with a narrow pelvis, because it reduces tissue damage.

Epidemiology, diagnostic approach and therapeutic management of tailgut cysts: A systematic review

BACKGROUND

Tailgut cysts (TGCs) are benign congenital abnormalities that usually present with non-specific symptoms, constituting a diagnostic dilemma for physicians. The aim of this study was to systematically review the literature concerning clinical manifestations, diagnostic modalities and histologic findings of TGCs and highlight current knowledge on therapeutic management of this rare entity.

METHODS

PubMed and Embase databases were systematically searched by two independent investigators (last search 18 February 2021) for studies concerning TGCs published in the past two decades.

RESULTS

Totally, 144 articles, including 135 case reports and 9 case series, met our inclusion criteria. One hundred eighty-four patients were included (3:1/female:male) with an age of 42.3 ± 18.7 years (mean, SD), while 5 cases concerned new-born infants. Pain was the prevailing clinical manifestation (41.8%), whereas 16.8% were asymptomatic. MRI and CT were utilized for diagnosis in 58.7% and 54.7% of cases, respectively. The majority of cysts were multilocular, while ciliated columnar epithelium and smooth muscles of the cyst wall were the prevailed histological findings. Malignant degeneration of TGCs was reported in 32.1% of cases, while carcinoid tumours were the most frequent malignancies. Surgical resection was performed in 155 cases, while laparoscopic and robotic approach was preferred in 18 and 2 cases, respectively. A posterior approach was implemented in 80.9%, anterior technique in 9% and combined technique in 6.7% of cases. Postoperative complications and recurrence of the cystic lesion were reported in 17.4% and 7.6% of cases, respectively.

CONCLUSIONS

TGCs constitute a dilemma for the physicians. Surgical resection comprises the ultimate treatment to avoid complications or malignant transformation of the cyst. Concrete follow-up strategies and optimal therapeutic options should be outlined through consensus guidelines and at the time being, such decisions can be made only on the basis of extrapolation and on a case-by-case approach.

Laparoscopic Resection of a Huge Retrorectal Tumor

Retrorectal space tumors are rare, and so are frequently unrecognized, misdiagnosed, and mistreated. A 57-year-old man visited the outpatient clinic with the chief complaints of thin stool and lower pelvic heaviness. A smooth, round huge palpable mass on the right posterolateral rectal wall was detected and pelvic computed tomography showed a 7.8-cm cystic lesion in the right retrorectal space. Laparoscopic procedures were initiated with perirectal dissection for rectal mobilization. After fixation of the peritoneum and tying the rectum for intracorporeal traction, the rectum was mobilized to identify the cyst. The cyst was removed using an endo-bag, with completion of cyst dissection. The final pathologic diagnosis was a tailgut cyst, or retrorectal cystic hamartoma without evidence of malignancy. The patient was discharged without any complications. The patient had no dyschezia or problems with bowel function. Laparoscopic resection is a safe and feasible method for surgical treatment, even for bulky retrorectal tumors, with an early recovery period.

Tailgut Cysts with Malignant Transformation: Features, Diagnosis, and Treatment

A tailgut cyst is a type of benign congenital disease that mainly develops in the retro-rectal space. However, malignant transition can occur in some cases of tailgut cysts. Early and precise diagnosis, and proper treatment, are vital for patients with tailgut cysts with malignant transformation. In this review, we aim to summarize the similarities and differences in the diagnosis and treatment methods among the 3 most frequently reported types of tailgut cysts with malignant transformation. In our study, PubMed and Web of Science databases were used to search for the studies and the key words were “tailgut cysts” and “malignancy”. We found 176 articles and selected 75 articles in our survey, with 9 reviews, 35 case reports, and 31 case reports and reviews.

Laparoscopic Resection of Presacral Tumor: A New Approach in the Era of the Minimally Invasive Surgery

Presacral tumors are rare; however, once diagnosed, surgical resection is recommended even in asymptomatic patients as there is potential risk for growth or malignant transformation. Many different types of surgical approaches to resect presacral tumors have been reported including posterior, anterior, and combined abdominosacral approaches. With introduction of the minimally invasive approach, laparoscopic or robotic approaches to resect presacral tumors are reported increasingly. We report a case of successful anterior laparoscopic resection for a presacral mass that was incidentally diagnosed during management of pancreatitis.

Malignant transformation of tailgut cysts is significantly higher than previously reported: systematic review of cases in the literature

AIM

The best treatment for tailgut cysts has not been firmly established. We report a systematic review of the cases in the available literature in order to provide an evidence base for treatment.

METHOD

A systematic search of articles wholly or partly in English was made of PubMed, Embase and Google Scholar; additional studies were discovered by searching reference lists and contacting authors directly. Search terms 'tailgut cyst', 'tail gut cyst', 'retrorectal hamartoma' and 'retrorectal tumour' were used for case reports or case series; no publication date restrictions were imposed. Only studies with histological confirmation of diagnosis and reporting the age and gender of patients were included. Papers were excluded by consensus between the first two authors.

RESULTS

A total of 196 individual cases were analysed in detail including 51 cases of neoplasia. The overall rate of neoplastic transformation was 26.6%. Although the male:female cyst incidence ratio was 1:4, men over 18 had a significantly greater relative risk of neoplasm at 1.94 (P = 0.0055). Radiological evidence of nodular thickening of the cyst wall significantly increased the relative risk of the presence of cancer (P = 0.0023).

CONCLUSIONS

Current orthodoxy that these are not dangerous embryological remnants is unfounded and may be false. The available data suggest the risk of malignant transformation is high and will apply to any residual tissue after excision. The same rationale behind total mesorectal excision in rectal cancer applies to tailgut cysts. Consequently they should be resected with similar oncological margins.

Alcohol injection for nonsurgical management of tailgut cyst in a middle-aged woman: A case report

Managing recurrent tailgut cyst in a patient who is refraining from the definitive surgical en bloc resection can be challenging. Therefore, in this case report we outlined a less invasive approach which is computed tomography-guided aspiration with alcohol injection which resulted in prolongation of symptoms free period in our patient.

Tailgut cyst: report of three cases and review of the literature

INTRODUCTION

Tailgut cysts or retrorectal cystic hamartomas are congenital developmental lesions which are often misdiagnosed due to their rare incidence, anatomical position and variable clinical presentation.

CASE REPORT

We report three clinical cases: one of a 67-year old woman with high fever and anal bulging; the second case was a 50-year old woman with diffuse abdominal pain and the third case was a 52-year old woman with high fever and no abdominal or rectal pain. The rectal examination and MRI indicated the presence of a tailgut cyst. In all the cases a complete resection through a posterior perineal route was performed. Histopathological examination confirmed the diagnosis of a tailgut cyst, with a malignant component identified in the third case.

DISCUSSION

The discussion presents a brief review of the relevant information described in the literature to highlight the cornerstones for appropriate diagnosis and treatment of a tailgut cyst. Tailgut cysts are to be considered in the differential diagnosis of retrorectal or presacral masses as malignant transformation can occur.

Combined laparoscopic and perineal approach for the management of recurrent tailgut cyst

Tailgut cyst is an uncommon developmental anomaly arising from the embryonic hindgut in the retrorectal space. The patient frequently is asymptomatic or has vague perineal complaints that pose a diagnostic dilemma. Moreover, the patient is often misdiagnosed and therefore mismanaged. MRI is the investigation of choice for diagnosis. After the diagnosis is established, complete surgical excision is required to alleviate patient discomfort and to prevent complications such as infection, malignant transformation, and recurrence. Proper clinical examination and imaging not only establish the accurate diagnosis but also help in determining the best surgical approach for the patient (anterior abdominal, posterior sacral perineal, or combined approach). We hereby report a case of recurrent tailgut cyst managed with a combined anterior laparoscopic and perineal approach.

Surgical and molecular characterization of primary and metastatic disease in a neuroendocrine tumor arising in a tailgut cyst

Neuroendocrine tumors (NETs) arising from tailgut cysts are a rare but increasingly reported entity with gene expression profiles that may be indicative of the gastrointestinal cell of origin. We present a case report describing the unique pathological and genomic characteristics of a tailgut cyst NET that metastasized to liver. The histologic and immunohistochemical findings were consistent with a well-differentiated NET. Genomic testing indicates a germline frameshift in BRCA1 and a few somatic mutations of unknown significance. Transcriptomic analysis suggests an enteroendocrine L cell in the tailgut as a putative cell of origin. Genomic profiling of a rare NET and metastasis provides insight into its origin, development, and potential therapeutic options.

Neuroendocrine carcinoma arising in a tailgut cyst

INTRODUCTION

A tailgut cyst, also called retrorectal cystic hamartoma, is a rare congenital lesion that forms most commonly in the retrorectal space. It is presumed to arise from remnants of early embryogenesis.

PRESENTATION OF CASE

The following report describes a unique case of a retrorectal cystic hamartoma in a 53 year-old French Canadian man with a history of low back pain. The tumour underwent malignant transformation into a well-differentiated neuroendocrine carcinoma three years after the beginning of symptoms.

DISCUSSION

This condition can be found at any age, but occurs especially among middle-aged women. Not only is it frequently misdiagnosed, but also several complications associated to the cyst have been reported such as infection and malignant transformation. This is why complete surgical excision of the tailgut cyst is currently recommended.

A systematic review of minimally invasive surgery for retrorectal tumors

Retrorectal tumors are rare tumors that require resection for symptoms, malignancy and potential malignant transformation. Traditional approaches have included laparotomy, perineal excision or a combination. Multiple minimally invasive techniques are available which have the potential to minimize morbidity and enhance recovery. We performed a systematic review of the literature to determine the feasibility and surgical outcomes of retrorectal tumors approached using minimally invasive surgical techniques. Publications in which adult patients (≥ 18 years) had a minimally invasive approach (laparoscopic or robotic) for resection of a primary retrorectal tumor were included. Data were collected on approach, preoperative investigation, size and sacral level of the tumor, operating time, length of stay, perioperative complications, margins and recurrence. Thirty-five articles which included a total of 82 patients met the inclusion criteria. The majority of patients were female (n = 65; 79.2%), with a mean age of 41.7 years (range 18-89 years). Seventy-three patients (89.0%) underwent laparoscopic or combined laparoscopic-perineal resection, and 9 (10.8%) had a robotic approach. The conversion rate was 5.5%. The overall 30-day morbidity rate was 15.7%, including 1 intraoperative rectal injury (1.2%). Ninety-five percent (n = 78) of the retrorectal tumors were benign. Median length of stay was 4 days for both laparoscopic and robotic groups, with ranges of 1-8 and 2-10 days, respectively. No tumor recurrence was noted during follow-up [median 28 months (range 5-71 months)]. A minimally invasive approach for the resection of retrorectal tumors is feasible in selected patients. Careful patient selection is necessary to avoid incomplete resection and higher morbidity than traditional approaches.

Retrorectal Tumors: A Comprehensive Literature Review

IMPORTANCE

Retrorectal tumors are rare lesions that comprise a multitude of histologic types. Reports are limited to small single-institution case series, and recommendations on the ideal surgical approaches are lacking.

OBJECTIVE

The purpose of the study was to provide a comprehensive review of the epidemiology, pathologic subtypes, surgical approaches, and clinical outcomes of retrorectal tumors.

EVIDENCE REVIEW

We conducted a review of the literature using PubMed and searched the reference lists of published studies.

RESULTS

A total of 341 studies comprising 1708 patients were included. Overall, 68 % of patients were female. The mean age was 44.6 ± 13.7 years. Of all patients, 1194 (70 %) had benign lesions, and 514 patients (30 %) had malignant tumors. Congenital tumors (60.5 %) were the most frequent histologic type. Other pathologic types were neurogenic tumors (14.8 %), osseous tumors (3.1 %), inflammatory tumors (2.6 %), and miscellaneous tumors (19.1 %). Biopsy was performed in 27 % of the patients. Of these patients, incorrect diagnoses occurred in 44 %. An anterior surgical approach (AA) was performed in 299 patients (35 %); a posterior approach (PA) was performed in 443 (52 %), and a combined approach (CA) was performed in 119 patients (14 %). The mean length of stay (LOS) of PA was 7 ± 5 days compared to 8 ± 7 days for AA and 11 ± 7 days for CA (p < 0.05). The overall morbidity rate was 13.2 %: 19.3 % associated with anterior approach, 7.2 % associated with posterior approach, and 24.7 % after a combined approach (p < 0.05). Overall postoperative recurrence rate was 21.6 %; 6.7 % after an anterior approach, 26.6 % after a posterior approach, and 28.6 % after a combined approach (p < 0.05). A minimally invasive approach (MIS) was employed in 83 patients. MIS provided shorter hospital stays than open surgery (4 ± 2 vs. 9 ± 7 days; p < 0.05). Differences in complication rate were 19.8 % in MIS and 12.2 % in open surgery and not statistically significant.

CONCLUSIONS AND RELEVANCE

Retrorectal tumors are most commonly benign in etiology, of a congenital nature, and have a female predominance. Complete surgical resection is the cornerstone of retrorectal tumor management. A minimal access surgery approach, when feasible, appears to be a safe option for the management of retrorectal tumors, with shorter operative time and length of stay.

Surgical Management of Tailgut Cysts: A Report of Two Cases

A tailgut cyst is an uncommon congenital developmental cyst that arises from the postnatal remnants of the primitive gut. These cysts are generally located in the retrorectal space. The rarity of this lesion and its anatomical position frequently lead to difficulties in its diagnosis and surgical management. Complete surgical resection remains the cornerstone of treatment, and numerous surgical approaches to achieve this objective have been described in the literature. We present 2 cases of tailgut cysts that were resected using a trans-sacral approach. We discuss the surgical management of these cases, including the operative approach that was adopted. Two cases of tailgut cysts that presented as incidentally detected retrorectal tumors are described here. A pelvic magnetic resonance imaging scan revealed a retrorectal multicystic tumor consistent with a tailgut cyst. The patients underwent surgery via a trans-sacral approach with coccygectomy. The histopathologic diagnosis for each patient was a tailgut cyst with no evidence of malignancy. Surgical approaches for tailgut cysts depend on the exact locations of the cysts and suspicions regarding the malignancies of the cysts. En bloc organ resection, including coccygectomy, is required if malignancy is suspected. We endorse the trans-sacral approach as a feasible, easy to perform, minimally invasive, and safe option for treating relatively low-lying tailgut cysts.

Tailgut cyst accompanied with bony defect

Retro-rectal cystic hamartoma (tailgut cyst), is an uncommon congenital developmental lesion, generally located in the retro-rectal space. Its diagnosis and approach is challenging because the retropelvic space is not familiar. We report a 51-year-old woman who presented with paresthesia and pain in perianal area. The magnetic resonance image showed high signal intensity on the T1-weighted image and iso to high signal intensity on the T2-weighted image of the retropelvic space and CT showed sacral bony defect. We chose the posterior approach for removal of the tailgut cyst. Histopathology exam of the retropelvic cyst revealed a multiloculated cyst containing abundant mucoid material lined by both squamous and glandular mucinous epithelium. The patient has recovered nicely with no recurrence. Tailgut cyst needs complete surgical excision for good prognosis. So, a preoperative high-resolution image and co-operation between neurosurgen and general surgeon would help to make safe and feasible diagnosis and surgical access.

Perineal approach for surgical treatment in a patient with retro-rectal tumor: a case report and review of the literature

BACKGROUND

Retrorectal tumors in adults are very rare and little known condition. These tumors, often misdiagnosed or mistreated, should be completely excised because of the potential for malignancy or infection. A suitable operative approach is the key to the successful surgical management.

CASE PRESENTATION

We report the case of a 45-year-old Arab male who presented with chronic pelvic pain accompanied by straining to defecate and dysuria. The clinical examination showed a painless mass in the left perineal area. Pelvic magnetic resonance imaging and computed tomography scan demonstrated a huge and well-limited pelvic mass causing displacement and compression of the rectum and bladder. Although the large size of the mass (>7 cm in the greater diameter), it was successfully and completely excised through only perineal approach without undertaking coccygectomy or sacrectomy. The histopathological study revealed a low-grade leiomyosarcoma. The patient is currently in 4-years follow-up with no signs of recurrence or metastasis.

CONCLUSION

Even large retro-rectal tumors may be successfully excised by the perineal approach especially in carefully selected patients, but require extensive knowledge of pelvic anatomy and expertise in pelvic surgery.

A laparoscopic approach to benign retrorectal tumors

BACKGROUND

Retrorectal tumors (RTs) are rare in adults. Their surgical excision is often difficult because of their anatomic location. The aim of this study was to evaluate the results of straight laparoscopic resection of RTs in our institution.

METHODS

Eight patients (six women and two men) with benign RTs were treated by laparoscopic resection in our tertiary care center between September 2012 and June 2013. Exclusion criteria included malignant tumors, lesions with fistula formation, and anterior sacral meningoceles. Clinical data, imaging features, operative details, pathological results, and treatment outcomes were reviewed and analyzed.

RESULTS

Eight cases of benign RT with an average diameter of 8.9 ± 1.7 cm were treated by a straight laparoscopic procedure. The mean operative time was 122 ± 36 min, and the average intraoperative blood loss was 46 ± 33 ml. The median postoperative stay was 5 days (range 3-8 days), and all patients were discharged without serious complications. During a median follow-up of 11 months, no tumor recurrence was observed.

CONCLUSIONS

In our experience, a laparoscopic approach is safe for removing benign tumors in the retrorectal space. This approach may provide access to this difficult-to-reach space and has the advantages of allowing excellent visualization, meticulous dissection, less morbidities, and fast recuperation.

Surgical management of a retro-rectal cystic hamartoma (tailgut cyst) using a trans-rectal approach: a case report and review of the literature

Introduction

Retro-rectal cystic hamartoma (tailgut cyst) is a rare congenital developmental lesion arising from post-natal primitive gut remnants in the retro-rectal space. The rarity of the lesion and its anatomical position usually leads to difficulty in diagnosis and surgical management. Complete surgical resection remains the cornerstone of treatment. A dozen or so surgical approaches have been described in the literature to date to make the operation as simple as possible, but the trans-rectal access route is extremely rarely reported and not well described. Here, we present a case that demonstrates the trans-rectal approach to a retro-rectal tumor is a feasible option in terms of surgical radicality, minimal invasiveness and safety for carefully selected patients with this rare type of retro-rectal cystic lesion.

Case presentation

A 29-year-old Caucasian woman was referred to our institution due to perineal pain extending to the right inguinal region. Her symptoms had been present for the last two months. She was first examined at her regional hospital for a suspected ruptured ovarian cyst; however, after consultation with a gynecologist and a computed tomography scan of her pelvis, a tumor in the retro-rectal space was discovered. Our patient was admitted to our hospital and when a pelvic magnetic resonance imaging study confirmed the diagnosis of the retro-rectal cystic formation, a complete extirpation of retro-rectal tumor fixed to the coccyx using trans-rectal approach was performed. The final pathological diagnosis was retro-rectal cystic hamartoma (tailgut cyst) with no evidence of malignancy. Her post-operative course was uneventful, and at four months after surgery our patient is symptom free with no evidence of recurrent or residual disease.

Conclusions

Trans-rectal excision is feasible in terms of surgical radicality and is a simple to perform, minimally invasive and safe option, providing complete recovery for carefully selected patients with retro-rectal cystic hamartoma treated operatively.

Laparoscopic resection of retrorectal tumors: a feasibility study in 12 consecutive patients

BACKGROUND

Surgical approaches for retrorectal tumors (RRT) are either abdominal, dorsal trans-sacrococcygeal, or perineal. Very few cases have been reported so far concerning a laparoscopic approach. The aim of this study was to assess the results of laparoscopy for the treatment of RRT.

METHODS

All patients who underwent laparoscopy for RRT between 2003 and 2012 were reviewed. Data included patient and tumor characteristics, surgical morbidity, and mortality.

RESULTS

A total of 12 consecutive women with a median age of 55 years underwent laparoscopy for RRT. Median operative time was 145 min (range 70-215). Two conversions in laparotomy occurred, and one patient needed a temporary diverting ileostomy for rectal injury. Postoperatively, two patients presented urinary tract infections. Median length of stay was 8 days (range 4-16). Pathological examinations showed complete resections (R0) for ten benign tumors and one malignant tumor (Ewing sarcoma). One lesion was incompletely resected, a colloid sarcoma (R1 status), and was re-operated on by laparotomy after neoadjuvant chemoradiation. No local recurrence was observed after a median follow-up of 34 months (range 12-79) for benign lesions, and 28 and 71 months for the two patients who underwent resection of Ewing and colloid sarcoma, respectively.

CONCLUSIONS

Laparoscopic resection for RRT seems feasible and safe. It allows complete excision of tumors located in the retrorectal space with low morbidity. Thus, this approach can be a valid alternative to standard Kraske or open abdominal approaches for the treatment of RRT.

Laparoscopic approach for retrorectal tumors

BACKGROUND

Retrorectal tumors are uncommon and may represent a surgical challenge. Laparoscopic excision has been reported in very few papers. We present our experience of nine cases operated by a transabdominal laparoscopic approach, between 2005 and 2011.

METHODS

There were two males and seven females with a mean age of 35 years (range 19-48). The tumors were discovered incidentally in four cases or because of nonspecific clinical signs. All patients have had an MRI preoperatively.

RESULTS

Only one patient required open conversion due to a huge tumor >7 cm of diameter. Postoperative mortality was nil. One patient developed a hematoma in the pelvic area. The median hospital stay was 4.7 days (range 4-8). Final diagnostic were as follows: four schwannomas, one ganglioneuroma, two tailgut cysts, one anterior meningocele, and one paragangliomas. During the follow-up showed no recurrences, but four of nine patients developed neurologic complications as parenthesis and sciatic pain and one patient developed retrograde ejaculation.

CONCLUSIONS

Our case series shows that the laparoscopic approach is a feasible and safe option. It reduces surgical trauma and offers an excellent tool for perfect visualization of the deep structures in the presacral space to minimize the vascular and neurological injuries.

Robot-assisted excision of a huge pararectal dermoid cyst via a totally transabdominal route

Herein is reported the case of a 17-year-old adolescent with a huge cystic mass located between the vagina and the rectum, with extension into the gluteal region. The lesion caused compression and dislocation of the bladder, uterus, adnexae, and rectum. The patient underwent robot-assisted surgical excision of the mass via a totally transabdominal route. Postoperative recovery was uneventful, with excellent functional and cosmetic results. To our knowledge, this is the first case of a huge pelvic pararectal cyst reaching up to the gluteus and excised via a totally transabdominal approach with the aid of robotic assistance. Robot-assisted surgery seems to be appropriate for therapeutic management of huge pararectal tumors, the major advantages being minimum damage to contiguous structures, rapid postoperative recovery, and excellent cosmetic results.

Retrorectal cystic hamartoma (tailgut cyst): report of a case and review of literature

Retrorectal cystic hamartoma is a rare type of congenital cystic lesion usually diagnosed in middle-aged women. Although mostly asymptomatic, patients may present with symptoms resulting from local mass effect or with a complication. The most important complications of these cysts are infection with secondary fistulization and malignant degeneration. Because of such non-specific nature of symptoms and rare incidence, it is not unusual to have a delay in clinical diagnosis. MRI has evolved to be the investigation of choice for the evaluation of presacral tumors as it can provide excellent anatomic detail and soft tissue contrast. Role of preoperative biopsy is controversial especially with improvements in the imaging techniques. When diagnosed these lesions should be excised because of the risk of malignant transformation.