Presacral tumors: A practical classification and treatment of a unique and heterogenous group of diseases

Sacrococcygeal sinus angle: as a new anatomic landmark for the posterior approach of presacral lesions

“…Alpha refers to the sacrococcygeal angle between these two lines, L5 fifth lumbar vertebra, S1 first sacral vertebra approach (transsacral) and a combination (abdominal ? transsacral) of these two approaches [8,10,11,15]. The main factors that determine the type of surgical approach include malignancy because of invasion, size of the tumor and location of the tumor with reference to the sacrum [1,13].…”

“…Basically, anterior or combined approaches are preferred for masses above the level of the third sacral vertebra (S3) and for large and malignant masses, whereas the posterior approach is used for relatively smaller and benign masses located at the inferior sacral region (below the level of S3). Detachment of the tumor from its anterior attachment is recommended especially to prevent large vessel injury in the presence of large, invasive tumors extending to the upper levels of the sacrum [5,10,13]. Moreover, the sacrum, as a compact barrier, limits the surgical exposure when using the posterior approach for tumors located particularly at the upper levels and causes a blind zone for the surgeon.…”

“…The presacral region is bounded by the rectum anteriorly, sacrum posteriorly, promontorium of the sacrum and peritoneum superiorly and iliac vessels laterally [1,10]. A wide range of pathological conditions can be seen in the presacral region [2].…”

“…A wide range of pathological conditions can be seen in the presacral region [2]. Congenital masses such as teratomas, chordomas, dermoid or epidermoid tumors; tumors arising from neural elements such as schwannomas, neurofibromas and neuroblastomas; and mass lesions showing distinct features such as infiltrative rectum tumors, metastases, rhabdomyosarcomas and lymphangiomas can be seen in the presacral region [1,3,9,10,13]. Since the presacral region involves several different anatomical structures and related pathologies, it is a common point of interest of different disciplines and generally requires a multidisciplinary approach [2].…”

“…Moreover, the amount of tumor mass removed during the surgical procedure is also an important factor that determines the prognosis [2,10,12]. Therefore, the selection of the most suitable surgical approach for the maximum extent of safe resection is of great importance.…”