# Combined Laparoscopic and Posterior Approach Resection of Presacral Neuroblastoma with Rectobulbar Urethral Fistula

## TL;DR

A 1-year-old boy with a rare tumor and rectobulbar urethral fistula underwent successful combined laparoscopic and posterior surgery, avoiding further treatments and complications.

## Contribution

A combined surgical approach for resecting presacral neuroblastoma and performing PSARP in a complex pediatric case.

## Key findings

- The tumor was completely resected with R0 margins and diagnosed as a differentiating subtype of neuroblastoma.
- The combined approach allowed for successful PSARP without complications and minimal postoperative issues.
- The patient showed no recurrence for 3 years and achieved good functional outcomes.

## Abstract

We herein report a case of presacral neuroblastoma (NB) with a rectobulbar urethral fistula. We successfully resected the tumor with a combined laparoscopic and posterior approach and simultaneously performed posterior sagittal anorectoplasty (PSARP).

A 1-year-old boy underwent laparoscopic surgery. He had a surgical history of transverse colostomy for an imperforate anus (later diagnosed as a rectobulbar urethral fistula) on the 2nd day after birth. Before radical surgery for a rectobulbar urethral fistula at 1 year of age, an imaging study incidentally showed a 28 × 27-mm presacral tumor. After a detailed examination, the tumor was diagnosed as NB, International Neuroblastoma Risk Group (INRG) Stage L1. We decided to perform surgical resection using a combined laparoscopic and posterior approach. The main reason for using the laparoscopic approach was to reduce intraoperative bleeding by ligating the median sacral artery (tumor-feeding artery). We also planned to simultaneously perform PSARP. If PSARP is performed later, postoperative adhesions make it difficult to dissect the rectum and identify the levator ani muscles. Under general anesthesia, the median sacral artery was ligated laparoscopically. The patient was then placed in the jackknife position, and the tumor was completely resected using a posterior approach. PSARP was performed without complications. The pathological diagnosis was NB, a differentiating subtype with R0 resection. The final INRG risk classification was low-risk, and no additional treatments were required. Postoperative complications were not observed, with the exception of urinary incontinence. The patient was discharged on the 16th day after surgery. He had no recurrence for 3 years after surgery. His defecation was well controlled using glycerin enema without soiling. His self-catheterization for urinary incontinence once daily was continued for 1 year and stopped after confirming no residual urine.

In this study, we performed laparoscopic surgery combined with a posterior approach for a presacral NB and successfully resected the tumor with a good laparoscopic view. Furthermore, we simultaneously performed PSARP for the rectobulbar urethral fistula following tumor resection. This approach may be one of the options for treating presacral NB associated with a rectobulbar urethral fistula.