First in literature intra-neuronal sacral nerve stimulation for fecal incontinence after robotic assisted en-bloc sacrectomy with transection of nerve roots

Abstract En-bloc sacrectomy is the treatment of choice for patients affected by sacral chordoma. It is a radical surgical procedure, which has to face the problem of handling fragile anatomical structures, such as the internal iliac vessels and the sacral nerve roots, with the risk of causing bowel, bladder, and sexual dysfunction. The combined anterior-posterior approach allows for a safer dissection of the tumor from the mesorectal fascia than the mere posterior approach, especially for tumors extending proximally to S3. Robotic surgery can improve the safety of the procedure. Sacral nerve stimulation is an accepted therapeutic option for fecal incontinence and may be used to treat postoperative incontinence. We report on a patient affected by sacral chordoma with en-bloc sacrectomy preceded by a robotic-assisted dissection of the mesorectal fascia, and on managing the postoperative fecal incontinence by implanting a Sacral Nerve Stimulator (SNS) on the first postoperative day. To our knowledge this is the first such procedure in literature. From our experience, robotic anterior approach increases safety for the organs in the pelvis when performing sacrectomy. Moreover, SNS should be considered to manage neurological complications following the transection of nerve roots after sacrectomy .