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Urologic Co-Morbidities Associated with Sacrococcygeal Teratoma and a Rational Plan for Urologic Surveillance

Sunday, October 21, 2012: 8:06 AM
Grand Ballroom B (Hilton Riverside)
Nicholas G. Cost, M.D.1, Louis D. Le, M.D.2, Timothy M. Crombleholme, MD, FACS, FAAP3, James I. Geller, M.D.4, Sundeep G. Keswani, MD2, Foong-Yen Lim, MD2 and Shumyle Alam, MD5, (1)Division of Urology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, (2)Department of Pediatric General & Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, (3)Department of Pediatric General & Thoracic Surgery, Children's Hospital Colorado, Aurora, CO, (4)Division of Pediatric Oncology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, (5)Division of Pediatric Urology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH


Sacrococcygeal teratoma (SCT) is one of the most common neonatal and fetal tumors.  They are typically recognized prenatally or immediately post-partum and are resected promptly.  However, because of pelvic mass effect or the need for aggressive surgical resection, there is potential for urologic co-morbidity.  The presence of urologic co-morbidities has been traditionally under-recognized, partly because of a lack of surveillance or investigation.  We reviewed our institutional experience with SCTs in order to propose a rational plan for urologic surveillance.


We retrospectively reviewed all SCT patients evaluated at our institution from 2004-2012.  We collected data on the Altman Classification, presence or absence of early urologic evaluation, hydronephrosis, vesicoureteral reflux (VUR), neurogenic bladder (NGB), and chronic kidney disease (CKD).  Associated urologic co-morbidity observed after resection was defined as: hydronephrosis, VUR, NGB or ≥CKD Stage 2.  We collected data on the need for reconstructive surgery related to the urologic co-morbidity, the time to detection of urologic co-morbidity, and the length of follow-up.  A Kaplan-Meier curve was constructed to assess time-to-event data related to the detection of urologic co-morbidity.


We identified 28 patients (20F:8M) evaluated during the study period with a median follow-up of 3.1yrs (Range 0.14-13.4).  The Altman Classifications were: I 7(25%), II 15(53.6%) and III 6(21.4%).  Eighteen (64.3%) patients had an associated urologic co-morbidity during the study period: 11 (39.3%) patients had hydronephrosis, 10(35.7%) with VUR, 12(42.9%) had NGB, and 2(7.1%) developed ≥CKD2.  Eleven (39.3%) patients had delayed urologic evaluation, and 5 (17.9%) required later reconstructive surgery for their associated urologic condition.

We observed a median time to detection of urologic co-morbidity of 1.28 years (95%CI 0.33-2.23) (Figure 1A).  When comparing Altman Classification via log-rank test, there was a trend towards more urologic co-morbidity in Altman II/III patients, p=0.06 (Figure 1B).  We observed that 4 of the 11 (36.4%) patients that underwent delayed urologic evaluation required reconstructive surgery as opposed to 1 of 17 (5.7%) receiving prompt evaluation, p=0.06.


Urologic co-morbidities are common in children with SCT and appear most common in patients with more pelvic tumor involvement (≥Altman II).  Given this risk, we recommend renal-bladder ultrasound (RBUS) at delivery and 2 weeks after SCT resection.  For patients with structural abnormalities on RBUS or those with ≥Altman II lesions, we also recommend fluoroscopic VCUG (fVCUG) after resection.  All patients are followed until toilet training and clinical evaluations should include calculation of Glomerular Filtration Rate.  Altman I patients or those without structural abnormalities on RBUS may be followed with annual RBUS.  Patients with ≥Altman II lesions or with structural abnormalities also receive annual fVCUG.  In the setting of delayed toilet training, we recommend urodynamics.

Figure 1: Time to the Detection of Urologic Co-morbidity (A) Overall Population, (B) Compared by Altman Classification.

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