The patient came to the clinic 19-November-2011  complaining of constipation, urgency and frequency with strange feeling when setting. The patient was operated 02-June-2010 for pelvic mass through laparoscopic approach, but the patient did not feel any improvement. CT-scan of the pelvis done 28-May-2010 before surgery showing huge presacral mass 97x117 mm in dimensions. There is no histologic study, nor postoperative control studies.

MRI of the pelvis done 17-November-2011 showing the same previous mass and a separate mass in the region of the right lumbo-sacral plexus. They are well separated, but adherent to each other.

On examination: There is weak dorsi and planterflexion right foot 4/5.

The patient was sent for MRI of the lumbo-sacral spine and CT-scan of the pelvis, which were done 20-Noveember-2011 ruling out any CSF connection between the masses and the intradural structures of the spinal cord.

Right pelvic rim extraperitoneal approach with extension medially through part of the old caesarian incision. The running lateral femoral cutaneous nerve was dissected and preserved. The dissection was taken over the iliac and psoas muscle. The femoral nerve was identified and was checked with ISIS Inomed HighLine 32 channel Neurosxplorer neuronavigation. The external iliac artery and vein were identified and preserved. The psoas muscle was retracted lateral to expose the obturator nerve. The internal iliac vein with the running below the L4 and L5 roots were identified and check with electrophysiological navigator. There is no tumor there and there is adhesion due to old inflammatory process.  More medial dissection was carried out, but no proper cleavage was seen to resect the huge cyst, which had thick capsule, which was punctured and around 150 yellow-brown thick fluid was obtained and sent for histologic and bacteriologic studies. A cysto-fix was inserted in the coccygeal area anterior to the sacrum and around 400 same color puss was evacuated. 150 ml Renografin was diluted with 500 ml normal saline was used to irrigate the cyst, which was studied using C-arm.  The cystic mass could be identified after filling the cavity with with 400 ml of the mentioned solution. The wall of the cyst was stuck to all anatomical structures and it was impossible to separate it. Some parts of the capsule was sent for histologic studies and swollen lymphnodes also. The cavity then was irrigated with normal saline and complete evacuation of the cyst was achieved and checked by the C-arm. A drain was kept to big cyst and the wound was closed by layers and Ready-vac drain was put under the skin lateral to the wound.

Smooth postoperative recovery with improvement of the power of  the right foot.

The patient was operated 17 months ago and laparoscopic intervention was done. These 2 masses cannot be dealt by this approach.

The smaller mass originating from the neural structures is more important to explore and remove than evacuation the huge cyst.

Retrospectively, it was wise to evacuate the cyst through coccygeal route and inject the die and do studies to evaluate the multilobular cyst. But even when doing this, the neurosurgeon will remain unsure about the mass in the right lumbosacral area until he do proper exploration of this area.

The final histologic result was scarococcygeal teratoma  with no malignant cells. Other elements of germ cell tumour cannot be excluded.

All investigations for tbc were negative and all laboratory findings were not specific.