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.