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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

Purpose:

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.

Methods:

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.

Results:

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.

Conclusion:

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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