Retrorectal Tumors in Adults: A 10-Year Retrospective Study

The management of retrorectal tumors - a single-center analysis of 21 cases and overview of the literature

AIM

Retrorectal tumors are rare and heterogeneous. They are often asymptomatic or present with nonspecific symptoms, making management challenging. This study examines the diagnosis and treatment of retrorectal tumors.

METHODS

Between 2002 and 2022, 21 patients with retrorectal tumors were treated in our department. We analyzed patient characteristics, diagnosis and treatment modalities retrospectively. Additionally, a literature review (2002-2023, "retrorectal tumors" and "presacral tumors", 20 or more cases included) was performed.

RESULTS

Of the 21 patients (median age 54 years, 62% female), 17 patients (81%) suffered from benign lesions and 4 (19%) from malignant lesions. Symptoms were mostly nonspecific, with pain being the most common (11/21 (52%)). Diagnosis was incidental in eight cases. Magnetic resonance imaging was performed in 20 (95%) and biopsy was obtained in 10 (48%). Twenty patients underwent surgery, mostly via a posterior approach (14/20 (70%)). At a mean follow-up of 42 months (median 10 months, range 1-166 months), the local recurrence rate was 19%. There was no mortality. Our Pubmed search identified 39 publications.

CONCLUSION

Our data confirms the significant heterogeneity of retrorectal tumors, which poses a challenge to management, especially considering the often nonspecific symptoms. Regarding diagnosis and treatment, our data highlights the importance of MRI and surgical resection. In particular a malignancy rate of almost 20% warrants a surgical resection in case of the findings of a retrorectal tumour. A local recurrence rate of 19% supports the need for follow up.

Presacral tumors: A systematic review of literature

Presacral/Retrorectal tumors (RRT) are rare lesions that comprise a multitude of histological types. Data on surgical management are limited to case reports and small case series. The aim of the study was to provide a comprehensive review of the epidemiology, pathological subtypes, surgical approaches, and clinical outcomes. A PubMed search using terms "retrorectal tumor" and "presacral tumor" was used to identify articles reporting RRT of non-urological, non-gynecologic, and non-metastatic origin. Articles included were between 2015 and 2023. A total of 68 studies were included, comprising 570 patients. About 68.2% of patients were female, and the mean overall age of both sexes was 48.6 years. Based on histopathology, 466 patients (81.8%) had benign lesions, and 104 (18.2%) were malignant. In terms of surgical approach, 191 (33.5%) were treated anteriorly, 240 (42.1%) through a posterior approach, and 66 (11.6%) combined. The mean length of stay was 7.6 days. Patients treated using the posterior approach had a shorter length of stay (5.7 days) compared to the anterior and combined approaches. RRT are rare tumors of congenital nature with prevalence among the female sex. R0 resection is crucial in its management, and minimal access surgery appears to be a safer option in appropriate case selection.

Transanal endoscopic microsurgery technique: an acceptable approach for retrorectal tumors

INTRODUCTION

Retrorectal lesions (RRLs) are rare lesions that originate from the tissue present in the retrorectal space. The gold standard of care is complete resection regardless of pathology. The traditional approaches (anterior, posterior, and combined) are relatively well described. Transanal Endoscopic Microsurgery (TEM) is a minimally invasive technique offered as an alternative approach for RRLs.

AIM

To evaluate the outcomes of patients diagnosed with RRL and treated by the TEM approach, especially postoperative complications, and the recurrence rate.

METHODS

Patients with RRLs treated with the TEM technique in one medical center between 2000 and 2020 were identified. Their postoperative outcomes were compared with historical controls.

RESULTS

Thirty-nine patients diagnosed with RRL were operated on using the TEM platform. Thirty-seven RRLs were benign, and two were malignant. Their median size (IQR) was 20 mm (15, 32.5). The median distance (IQR) from the anal verge was 50 mm (50, 72.5). The median operative time (IQR) was 48.5 min (41.75, 60). All, except one lesion, were completely resected. The median length of stay (IQR) was one day (1, 1 day). Postoperative complications were diagnosed in three patients, two of which resolved following a second operation.

CONCLUSIONS

The implementation of TEM for the resection of RRLs demonstrated excellent overall results with acceptable complication and recurrence rate and represented a viable alternative surgical approach.

Is There Another Posterior Approach for Presacral Tumors Besides the Kraske Procedure? — A Study on the Feasibility and Safety of Surgical Resection of Primary Presacral Tumors via Transsacrococcygeal Transverse Incision

Background

The aim of the present study was to explore the feasibility and safety of the surgical resection of presacral tumors via a transsacrococcygeal transverse incision.

Methods

The clinical data and prognoses of patients with presacral tumors who underwent surgery at the Chinese People’s Liberation Army (PLA) General Hospital between January 2009 and December 2018 were retrospectively reviewed and analyzed.

Results

A total of 110 patients with presacral tumors were included in this study, including 82 female patients and 28 male patients, with a female-to-male ratio of 2.9:1. A posterior approach (transsacrococcygeal transverse incision) was utilized in 105 patients, an anterior approach (transabdominal excision) was utilized in 1 patient, and a combined (posterior plus anterior) approach was utilized in 4 patients. The mean tumor size was 8.72 ± 4.28 cm. More than half of the patients (n=59/110) with presacral tumors were asymptomatic. Twenty-six pathological types were observed in our study, including 97 benign lesions and 13 malignant lesions. The intraoperative complication rate was 42.7% (n=47/110), whereas the postoperative morbidity rate was 3.6% (n=4/110). The length of hospital stay for patients treated with the posterior approach was shorter than that of patients treated with the anterior and combined approaches. After a mean follow-up of 90.13 ± 31.22 months, 11 patients had local presacral tumor recurrence, and 1 patient had distant metastasis, with a combined recurrence rate of 10.9% (n=12/110).

Conclusions

The surgical resection of primary presacral tumors via a transsacrococcygeal transverse incision is feasible and safe, with acceptable oncological therapeutic outcomes and a low postoperative morbidity rate, making it worth popularizing in clinical practice.

Risk factors for perioperative complications in laparoscopic surgeries of retrorectal cystic lesions

BACKGROUND

The incidence of retrorectal lesions is low, and no consensus has been reached regarding the most optimal surgical approach. Laparoscopic approach has the advantage of minimally invasive. The risk factors influencing perioperative complications of laparoscopic surgery are rarely discussed.

AIM

To investigate the risk factors for perioperative complications in laparoscopic surgeries of retrorectal cystic lesions.

METHODS

We retrospectively reviewed the medical records of patients who underwent laparoscopic excision of retrorectal cystic lesions between August 2012 and May 2020 at our hospital. All surgeries were performed in the general surgery department. Patients were divided into groups based on the lesion location and diameter. We analysed the risk factors like type 2 diabetes mellitus, hypertension, the history of abdominal surgery, previous treatment, clinical manifestation, operation duration, blood loss, perioperative complications, and readmission rate within 90 d retrospectively.

RESULTS

Severe perioperative complications occurred in seven patients. Prophylactic transverse colostomy was performed in four patients with suspected rectal injury. Two patients underwent puncture drainage due to postoperative pelvic infection. One patient underwent debridement in the operating room due to incision infection. The massive-lesion group had a significantly longer surgery duration, higher blood loss, higher incidence of perioperative complications, and higher readmission rate within 90 d (P < 0.05). Univariate analysis, multivariate analysis, and logistic regression showed that lesion diameter was an independent risk factor for the development of perioperative complications in patients who underwent laparoscopic excision of retrorectal cystic lesions.

CONCLUSION

The diameter of the lesion is an independent risk factor for perioperative complications in patients who undergo laparoscopic excision of retrorectal cystic lesions. The location of the lesion was not a determining factor of the surgical approach. Laparoscopic surgery is minimally invasive, high-resolution, and flexible, and its use in retrorectal cystic lesions is safe and feasible, also for lesions below the S3 level.

Successful excision of a retrorectal cyst through trans-sacral approach: A case report

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Retrorectal cysts are rare congenital cystic lesions commonly seen in middle-aged women.

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A 38-year-old woman with retrorectal cyst underwent trans-sacral resection.

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She showed no postoperative complications.

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Trans-sacral resection provides adequate exposure of the posterior retrorectal cyst.

Introduction

Retrorectal cysts are rare congenital cystic lesions usually diagnosed in middle-aged women. They are generally asymptomatic; however, local pressure may result in complications. Pain or discomfort in the pelvic, sacral, lower back or perianal area are the most common symptoms. The diagnosis is difficult, and multidisciplinary management is required. An epidermoid cyst is the most common type. Surgical resection is the main treatment, and 3 operative approaches are commonly used: abdominal, trans-sacral, and combined abdominosacral. The selection of the approach depends on the nature and location of the lesion. Here, we present a case that demonstrates the trans-sacral approach to a retrorectal cyst is a feasible option in terms of safety and minimal invasiveness for selected patients with this rare type of retrorectal cystic lesion.

Presentation of case

A 38-year-old woman with no comorbidities incidentally showed a retrorectal cyst on magnetic resonance imaging performed during pregnancy. The patient underwent surgical resection under general anesthesia, trans-sacral incision was performed, the posterior rectum exposed, and the cyst removed. No complications were seen in the postoperative period.

Discussion

Posterior trans-sacral resection (Kraske) is preferred for patients with posterior retrorectal cyst because it provides adequate exposure.

Conclusion

Posterior trans-sacral resection allows proximal extension for elimination of the infection and in cases of adherence of the cyst to surrounding structures or in malignancy, which require en bloc resection.

Robotic Excision of Retrorectal Mass

BACKGROUND

Retrorectal cysts make up a small but challenging group of pelvic masses, especially if they extend high into the pelvis. We present a case of successful robotic removal of a large retrorectal cyst.

METHODS

Video presentation of a robotic excision of a retrorectal mass.

RESULTS

We present a case of robotic removal of a large retrorectal mass extending up to the S3 vertebra.

DISCUSSION

Robotic approach is a very useful tool for successful removal of large pelvic masses that cannot be removed by traditional posterior or trans perineal approach.

Colorectal Stenting for Obstruction due to Retrorectal Tumor in a Patient Unsuitable for Surgery

Fund of knowledge on palliative treatment of unresectable retrorectal tumors is scare. Here, we reported a non-surgical treatment of a huge retrorectal malignant tumor in an aged and debilitated patient complicated with colorectal obstruction. An 86-year-old male with severe comorbidities was admitted with acute colorectal obstruction owing to an untreated retrorectal malign epithelial tumor. There was a lobulated retrorectal mass, 20 cm × 15 cm at largest size, extending to the superior iliac bifurcation level, caused an obstruction of the rectal lumen. He was not suitable for surgical excision because of the severe comorbidities. Rectal obstruction was palliated by two self-expandable metallic stents. He tolerated the procedures well and post-procedural course was uneventful. After four months, stents were patent and the patient was continent. Stenting for colorectal obstruction owing to a retrorectal tumor can be feasible in patients who are not suitable for surgery (aged, debilitated, advanced tumor). It avoided the surgical trauma to a high-risk patient and ensured the continuity of continence. As far as we know, this was the first report on colorectal stenting for a retrorectal tumor.