Management of giant presacral schwannoma. Clinical series and literature review

Presacral schwannomas are rare tumors. Due to their benign nature and slow growth, these tumors are often giant and become difficult to treat. Their removal is a surgical challenge with different strategies reported in the literature. This study presents the consecutives cases of presacral schwannomas operated on in our institution, our surgical strategy and literature review.

This retrospective study includes all consecutive patients operated on for a pre-sacral schwannoma in our department between 2006 and 2019, i.e. 6 patients. We report clinical features, pre and post-operative imaging, surgical data and post-operative outcomes.

All patients had symptoms before surgery (constipation, dysuria, radicular or lower back pain) with an average duration of 7.4 months. All patients underwent an MRI and a CT scan before the surgery. Five patients had type III schwannoma according to Klimo classification and one patient had a type II. The average size was 504,9 cm³ (range 53,1-1495,4). All the patients were operated on by an anterior approach in a double team with an mean duration of 246 min. Intraoperative bleeding was less than 500 ml for 4 patients, 2 patients had significant bleeding (2700 and 2900 mL). Excision was total or subtotal in all cases. One patient had an intraoperative complication (air embolism). Follow up at 3 months was excellent with a disappearance of symptoms for all patients except one patient who retained constipation. One patient had a late complication (bowel obstruction due to tissue adhesions). At last follow-up after phone interview, no patient had clinical symptoms that could suggest a recurrence.

The anterior approach with a double surgical team is a great option for the treatment of presacral schwannoma. Combined with adequate preoperative imaging and intraoperative stimulation, it reduces the risk of intra and postoperative complications.