Presacral dermoid: now you see it now you don’t

Abstract

In this paper, we describe a presacral dermoid which was not seen at laparoscopy, despite being quite large and causing displacement of the rectum on magnetic resonance imaging (MRI). It later became symptomatic and was removed laparoscopically. Histology confirmed it to be a benign developmental cyst. Keywords Presacral . Dermoid Case reportA 33-year-old white Caucasian woman presented with a three-year history of primary infertility. She had a regular menstrual cycle; however, her periods were quite heavy and painful. Pelvic examination was normal She had a normal hormonal profile indicating an ovulatory cycle. HyCoSy assessment confirmed flow and spill on the right tube, but no flow was seen on the left side, indicating possible left obstruction. A laparoscopy and dye showed a retroverted uterus with extensive endometriosis (Fig. 1). The left ovary was adherent to the back of the uterus. There were large bowel adhesions on both sides. No fill or spill was seen from either tube, indicating possible bilateral tubal obstruction. A suspicion of a left endometrioma was noted. An ultrasound scan, performed four months later, suggested the possibility of a left endometrioma measuring 16 mm and a well defined endometrioma on the right side separate from both ovaries. A laparoscopic treatment of a 3-cm left ovarian endometrioma was subsequently carried out. However, no other cysts were seen. Treatment was carried out, not because of pain, but because of fertility issues.An ultrasound scan carried out following the laparoscopic procedure showed a large cystic area with internal echoes, suggesting an endometrioma measuring 8 cm with a volume of 235 cc. Again, it appeared separate to either ovary. A magnetic resonance imaging (MRI) scan showed a cystic mass displacing the rectum to the left (Fig. 2). The uterus, both ovaries, sigmoid and rectum appeared normal. These findings were discussed at the radiology meeting. It was concluded that this was most likely an epidermoid cyst in the ischiorectal fossa.She was referred to the general surgeons who diagnosed the cyst as a presacral dermoid. Upon examination, the cyst was not encroaching on the rectum, which explained why she remained asymptomatic. A decision was made for conservative management in light of the fact that this cyst had probably been there since birth and had never caused her any symptoms. The indications for removing it were, therefore, minimal and the morbidity from such an extensive surgical procedure could be significant. A plan was made to review her in a year with further imaging studies.However, 10 months later, she had low back pain and sacral pain. We are not sure whether the patient's awareness of having a cyst in the pelvis made her symptoms more noticeable in the 10 months after diagnosis. Certainly, her symptoms were not cyclical endometriosis. Consequently, one would assume that it was more due to the dermoid cyst rather than the endometriosis. A repeat MRI showed that the cyst had not changed in size. In view of her symptoms

Presacral dermoid cyst in a young female patient: A case report

“… 5 , 6 The tumors can be resected using a laparoscope to avoid the considerable morbidity associated with open surgery. 7 , 8 , 9 , 10 As postoperative fistula can occur in up to 3% of the cases, careful dissection away from the rectum must be stressed. 11 Recurrence rates of benign presacral lesions are meager compared to malignant tumors; however, the rates can vary depending on the extent of resection.…”