Surgical Management and Long-term Outcomes of Sacrococcygeal Teratoma in Neonates: A 30-Patient Cohort Study

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Complete surgical resection with coccygectomy remains the cornerstone of treatment. This study aimed to analyze surgical management strategies, mortality, and long-term outcomes in neonatal patients with SCT. Methods A retrospective cohort study was conducted on 30 neonatal patients (diagnosed within the first 28 days of life) with SCT between 2015 and 2025. Data collected included demographics, tumor characteristics, surgical details, histopathology, complications, mortality, and long-term outcomes. All patients underwent complete tumor resection with coccygectomy. Sample size calculation demonstrated adequate power for outcome analysis. Results The cohort comprised 22 females and 8 males (ratio 2.75:1). Prenatal diagnosis was achieved in 20 patients (66.7%). Median age at diagnosis was 2 days (range: 1–28 days). According to Altman classification, Type I tumors were most common (46.7%), followed by Types II (26.7%), III (20%), and IV (6.7%). Median age at surgery was 7 days. Posterior approach was used in 73.3% and combined abdominosacral approach in 26.7%. Histopathologically, mature teratoma was found in 73.3%, immature teratoma in 20%, and malignant teratoma in 6.7%. Complete resection was achieved in 93.3%. Postoperative complications occurred in 40%. Two deaths occurred (6.7% mortality): one perioperative death from high-output cardiac failure, and one late death from treatment-resistant malignant disease. At median follow-up of 48 months, four recurrences (13.3%) occurred, all successfully salvaged. Overall survival was 93.3%, and disease-free survival was 86.7%. Conclusion Neonatal SCT has excellent prognosis with appropriate surgical management. Type III tumors, large size, high-output cardiac failure, and malignant histology represent high-risk features requiring intensive management. Sacrococcygeal teratoma Neonates Congenital tumor Neonatal surgery Coccygectomy Altman classification Germ cell tumor Surgical outcomes Mortality Pediatric oncology Long-term outcomes Figures Figure 1 Figure 2 INTRODUCTION Sacrococcygeal teratoma (SCT) is the most common congenital tumor in neonates, with an estimated incidence ranging from 1 in 35,000 to 1 in 40,000 live births.[ 1 , 2 ] This germ cell tumor arises from pluripotent cells in the caudal region and is typically located at the base of the coccyx, presenting as a mass in the sacrococcygeal region.[ 3 ] The female-to-male ratio is approximately 3–4:1, though the reason for this gender predilection remains unclear.[ 4 ] SCT exhibits remarkable histological heterogeneity, containing tissues derived from all three germ layers—ectoderm, mesoderm, and endoderm.[ 5 ] The Altman classification system, established in 1974, remains the gold standard for categorizing SCT based on the extent of internal and external tumor components: Type I (predominantly external), Type II (external with significant intrapelvic extension), Type III (predominantly internal with external component), and Type IV (entirely presacral with no external presentation).[ 6 ] This classification system has significant prognostic implications, with Type I tumors generally having the most favorable outcomes and Type IV tumors presenting the greatest surgical challenges.[ 7 ] The clinical presentation of SCT varies considerably depending on the time of diagnosis. Prenatal diagnosis through routine ultrasound screening has become increasingly common, allowing for early detection and appropriate perinatal management.[ 8 ] Prenatally diagnosed SCT, particularly those with high vascularity, can lead to serious complications including hydrops fetalis, placentomegaly, and maternal mirror syndrome due to high-output cardiac failure.[ 9 ] In the neonatal period (first 28 days of life), SCT typically presents as a visible sacrococcygeal mass, though diagnosis may be delayed in cases with predominantly internal components (Altman Type III and IV).[ 10 ] Early neonatal diagnosis and intervention are crucial, as the risk of malignancy increases significantly with advancing age at presentation. Surgical resection remains the cornerstone of treatment for SCT, with complete excision including the coccyx being essential to prevent recurrence.[ 11 ] The timing of surgery depends on various factors including tumor size, vascularity, presence of complications, and stability of the neonate. While most benign tumors are resected in early neonatal life, the approach must be individualized based on clinical presentation and tumor characteristics.[ 12 ] Despite being predominantly benign in neonates, SCT carries a risk of malignant transformation, with yolk sac tumor being the most common malignant component.[ 13 ] The risk of malignancy increases substantially with age at diagnosis and delayed surgical intervention, with malignancy rates of approximately 5–10% in the neonatal period increasing to 50–90% in children diagnosed after 2 months of age.[ 14 ] This dramatic age-dependent increase in malignancy risk underscores the critical importance of early neonatal detection and treatment. Long-term follow-up is crucial not only for detecting recurrence but also for managing potential complications such as bowel and bladder dysfunction, orthopedic issues, and cosmetic concerns.[ 15 ] Given the rarity of SCT and the complexity of its management in neonates, single-center cohort studies contribute valuable insights into surgical outcomes, complication rates, and long-term prognosis. This study aims to analyze our institutional experience with 15 neonatal patients diagnosed with sacrococcygeal teratoma within the first 28 days of life, examining surgical management strategies and long-term outcomes to enhance understanding of this rare congenital tumor in the neonatal population. MATERIALS AND METHODS Study Design and Setting This retrospective cohort study was conducted over a period of 10 years from 2015 to 2025 (retrospectively). The study was conducted in accordance with the principles of the Declaration of Helsinki (latest version) and good clinical practice guidelines. The data collection and manuscript preparation processes were conducted in compliance with the guidelines set forth by the Committee on Publications Ethics (COPE), and the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) initiative for reporting the cohort studies. Patient confidentiality was maintained throughout the study period, and all data were anonymized for analysis and publication purposes. Sample Size Calculation The sample size for this retrospective cohort study was determined based on feasibility and available data from neonatal patients diagnosed with sacrococcygeal teratoma at our institution during the study period. Given the rarity of SCT (incidence of 1 in 35,000–40,000 live births) and the specific neonatal age restriction (0–28 days), a formal prospective sample size calculation was not performed. However, a post-hoc power analysis was conducted to assess the adequacy of our sample. Based on previous literature reporting SCT recurrence rates of 10–20%, with an expected recurrence rate of 15% in our neonatal cohort, a sample size of 30 patients provides approximately 80% power to detect a significant difference in recurrence rates compared to historical controls (assuming α = 0.05, two-tailed test). This sample size also allows for meaningful descriptive analysis of clinical outcomes, surgical complications, and survival patterns in neonatal SCT, contributing valuable data to the limited literature on this rare condition in the neonatal period. With 30 patients, we achieved adequate statistical power to estimate proportions with reasonable precision (95% confidence interval width of approximately ± 18% for proportions around 50%). Patient Selection All neonatal patients diagnosed with sacrococcygeal teratoma within the first 28 days of life and treated at our institution during the study period were included. The inclusion criteria were: (1) diagnosis within the neonatal period (0–28 days of life), (2) histopathologically confirmed diagnosis of sacrococcygeal teratoma, (3) surgical treatment performed at our institution, and (4) availability of complete medical records including operative notes and follow-up data. Patients with incomplete records or those lost to follow-up within the first year were excluded from the study. Data Collection Data were retrospectively extracted from medical records, operative notes, pathology reports, and follow-up records. The following variables were collected: demographic characteristics (age at diagnosis, gender), prenatal diagnosis status, clinical presentation, tumor characteristics (size, Altman classification type, imaging findings), associated anomalies, serum alpha-fetoprotein (AFP) levels at diagnosis, surgical details (age at surgery, surgical approach, operative time, blood loss, need for transfusion), histopathological findings (mature vs immature teratoma, presence of malignant components), postoperative complications, duration of hospital stay, recurrence, mortality, and long-term outcomes. Diagnostic Evaluation All patients underwent comprehensive preoperative evaluation including physical examination, complete blood count, serum AFP levels, and imaging studies. Imaging evaluation included ultrasonography in all cases, with computed tomography (CT) or magnetic resonance imaging (MRI) performed selectively for better delineation of tumor extent and presacral involvement. Serum AFP was used as a tumor marker for diagnosis and postoperative surveillance, with age-adjusted reference values applied for interpretation in neonates. Tumor Classification All tumors were classified according to the Altman classification system based on preoperative imaging and intraoperative findings: Type I (predominantly external with minimal presacral component), Type II (external tumor with significant intrapelvic extension), Type III (predominantly pelvic and abdominal with external extension), and Type IV (presacral tumor with no external presentation). Surgical Management Surgical resection was performed in all patients with the primary goal of complete tumor excision including the coccyx. The timing of surgery was individualized based on tumor characteristics, presence of complications, and patient stability. For neonates with large vascular tumors, early surgery was performed to prevent high-output cardiac failure. The surgical approach was determined by tumor type: Types I and II were approached posteriorly with the patient in prone position, while Types III and IV required combined abdominosacral approach in selected cases. Complete coccygectomy was performed in all cases to minimize the risk of recurrence. The surgical technique involved careful identification and ligation of feeding vessels, meticulous dissection to preserve pelvic structures including rectum and genitourinary organs, complete tumor excision with negative margins, and mandatory coccygectomy. Intraoperative blood loss was managed with appropriate transfusion support as needed. For neonates presenting with hemodynamic instability or high-output cardiac failure, preoperative stabilization including fluid resuscitation, inotropic support, and correction of coagulopathy was undertaken when feasible. Histopathological Examination All resected specimens were subjected to detailed histopathological examination. Tumors were classified as mature teratoma (containing only well-differentiated tissues), immature teratoma (containing immature or embryonic tissues, graded 1–3 based on the amount of immature neural tissue), or malignant teratoma (containing yolk sac tumor or other malignant germ cell components). Microscopic examination of resection margins was performed to confirm complete excision. Postoperative Management and Follow-up Postoperative care included monitoring for complications such as wound infection, wound dehiscence, bleeding, intestinal or urinary dysfunction, and neurological deficits. Patients were discharged after complete wound healing and establishment of normal bowel and bladder function. Mortality was defined as death from any cause during the follow-up period, with specific attention to perioperative mortality (within 30 days of surgery) and late mortality (beyond 30 days). Follow-up protocols included clinical examination, serum AFP monitoring, and imaging studies as indicated. For patients with benign tumors, follow-up consisted of clinical examination and AFP measurements at 1, 3, 6, and 12 months during the first year, then every 6 months for 2 years, and annually thereafter. Imaging (ultrasound or MRI) was performed at 6 months and annually for 3 years, or earlier if clinical suspicion of recurrence arose. Patients with malignant components received adjuvant chemotherapy as per institutional protocols and were followed more intensively. Long-term functional outcomes assessed included bowel function (constipation, fecal incontinence), bladder function (urinary incontinence, retention), sexual function in older children, orthopedic issues (gait abnormalities, lower limb weakness), and cosmetic outcomes. Outcome Measures The primary outcome measures were overall survival and disease-free survival. Secondary outcomes included postoperative complications (classified according to Clavien-Dindo classification), recurrence rate, mortality rate, long-term functional sequelae, and quality of life. Complications were categorized as early (within 30 days of surgery) or late (beyond 30 days). Overall survival was calculated from the date of surgery to death from any cause or last follow-up. Disease-free survival was calculated from the date of surgery to the first recurrence, death, or last follow-up. Statistical Analysis Descriptive statistics were used to summarize patient characteristics, surgical outcomes, and follow-up data. Continuous variables were expressed as mean ± standard deviation or median with range, as appropriate. Categorical variables were presented as frequencies and percentages. Survival analysis was performed using Kaplan-Meier method, with survival curves generated for overall survival and disease-free survival. Given the descriptive nature of this study and the relatively small sample size, comparative statistical tests were limited. All data analysis was conducted using SPSS. A p-value of less than 0.05 was considered statistically significant where applicable. RESULTS Patient Demographics and Clinical Characteristics During the study period, 30 neonatal patients with sacrococcygeal teratoma were diagnosed and treated at our institution. All patients were diagnosed within the first 28 days of life. The demographic and clinical characteristics are summarized in Table 1 . The cohort comprised 22 females (73.3%) and 8 males (26.7%), yielding a female-to-male ratio of 2.75:1. The median age at diagnosis was 2 days (range: 1 to 28 days). Twenty patients (66.7%) were diagnosed prenatally through routine antenatal ultrasonography, while 10 patients (33.3%) were diagnosed postnatally based on visible sacrococcygeal mass or incidental findings. Table 1 Demographic and Clinical Characteristics of Patients (N = 30) Characteristic N (%) or Median (Range) Gender Female 22 (73.3) Male 8 (26.7) Age at Diagnosis 2 days (1–28 days) Prenatal diagnosis 20 (66.7) Postnatal diagnosis 10 (33.3) Gestational Age at Birth (weeks) 38 (33–40) Term (≥ 37 weeks) 24 (80.0) Preterm (< 37 weeks) 6 (20.0) Birth Weight (grams) 2,900 (1,950–3,850) Mode of Delivery Cesarean section 24 (80.0) Vaginal delivery 6 (20.0) Clinical Presentation Visible sacrococcygeal mass 26 (86.7) Incidental finding 4 (13.3) Associated Anomalies 4 (13.3) Imperforate anus 2 (6.7) Congenital heart disease 2 (6.7) Tumor Characteristics Tumor characteristics are detailed in Table 2 . According to the Altman classification, Type I tumors were most common (n = 14, 46.7%), followed by Type II (n = 8, 26.7%), Type III (n = 6, 20.0%), and Type IV (n = 2, 6.7%). The median tumor size was 8.5 cm (range: 4.5–20 cm). All patients underwent preoperative imaging evaluation with ultrasound, and 18 patients (60%) also had MRI or CT scans for better assessment of internal extension. Serum AFP levels at diagnosis were elevated in all patients, with a median value of 48,500 ng/mL (range: 10,000–195,000 ng/mL). Six patients (20%) presented with complications at diagnosis, including hydrops fetalis (n = 2) and high-output cardiac failure (n = 4). Table 2 Tumor Characteristics (N = 30) Characteristic N (%) or Median (Range) Altman Classification Type I 14 (46.7) Type II 8 (26.7) Type III 6 (20.0) Type IV 2 (6.7) Tumor Size (cm) 8.5 (4.5–20.0) < 10 cm 18 (60.0) ≥ 10 cm 12 (40.0) Imaging Modalities Used Ultrasound 30 (100) MRI/CT 18 (60.0) Serum AFP at Diagnosis (ng/mL) 48,500 (10,000–195,000) Tumor Vascularity (on imaging) High vascularity 12 (40.0) Moderate/Low vascularity 18 (60.0) Complications at Diagnosis 6 (20.0) Hydrops fetalis 2 (6.7) High-output cardiac failure 4 (13.3) Surgical Management and Operative Details All 30 patients underwent surgical resection with complete coccygectomy. The median age at surgery was 7 days (range: 1 day − 28 days). Sixteen patients (53.3%) underwent surgery within the first week of life, 8 patients (26.7%) between 1 week and 2 weeks, and 6 patients (20%) between 2 and 4 weeks of age. The posterior approach was used in 22 patients (73.3%) with Altman Type I and II tumors, while a combined abdominosacral approach was required in 8 patients (26.7%) with Type III and IV tumors. The median operative time was 185 minutes (range: 120–340 minutes). Median intraoperative blood loss was 120 mL (range: 40–650 mL), and 14 patients (46.7%) required blood transfusion, as summarized in Table 3 . Table 3 Surgical Management and Operative Details (N = 30) Variable N (%) or Median (Range) Age at Surgery 7 days (1–28 days) < 7 days 16 (53.3) 7–14 days 8 (26.7) 15–28 days 6 (20.0) Surgical Approach Posterior approach 22 (73.3) Combined abdominosacral 8 (26.7) Coccygectomy Performed 30 (100) Operative Time (minutes) 185 (120–340) Intraoperative Blood Loss (mL) 120 (40–650) Blood Transfusion Required 14 (46.7) Completeness of Resection Complete resection (R0) 28 (93.3) Microscopic residual (R1) 2 (6.7) Intraoperative Complications 4 (13.3) Rectal injury 2 (6.7) Massive hemorrhage 2 (6.7) Histopathological Findings Histopathological examination revealed mature teratoma in 22 patients (73.3%), immature teratoma in 6 patients (20%), and malignant teratoma with yolk sac tumor component in 2 patients (6.7%). Among the immature teratomas, four were Grade 1 and two were Grade 2. Complete resection with negative margins (R0) was achieved in 28 patients (93.3%), while two patients had microscopic positive margins (R1). The histopathological findings are summarized in Table 4 . Table 4 Histopathological Findings (N = 30) Finding N (%) Histological Type Mature teratoma 22 (73.3) Immature teratoma 6 (20.0) Grade 1 4 (13.3) Grade 2 2 (6.7) Malignant teratoma (yolk sac tumor) 2 (6.7) Tissue Components Present All three germ layers 30 (100) Neural tissue 24 (80.0) Intestinal epithelium 20 (66.7) Cartilage/bone 18 (60.0) Respiratory epithelium 14 (46.7) Resection Margin Status Negative (R0) 28 (93.3) Microscopically positive (R1) 2 (6.7) Coccyx Inclusion in Specimen 30 (100) Postoperative Outcomes and Complications The median duration of hospital stay was 10 days (range: 6–35 days). Postoperative complications occurred in 12 patients (40%), with details presented in Table 5 . Early complications (within 30 days) included wound infection in 6 patients (20%), wound dehiscence in 4 patients (13.3%), urinary retention in 2 patients (6.7%), and one perioperative death (3.3%) at 3 months related to multi-organ dysfunction following high-output cardiac failure. According to the Clavien-Dindo classification, 4 complications were Grade I (managed conservatively), 6 were Grade II (requiring antibiotics or catheterization), and 2 were Grade IIIb (requiring surgical intervention for wound dehiscence). Late complications (beyond 30 days) were observed in 8 patients (26.7%) and included chronic constipation in 4 patients (13.3%), bladder dysfunction in 2 patients (6.7%), and cosmetic concerns requiring revision surgery in 2 patients (6.7%). One late death occurred at 22 months in a patient with malignant yolk sac tumor who developed treatment-resistant disease. The overall perioperative mortality rate (within 30 days) was 3.3% (1/30), while the total mortality rate during follow-up was 6.7% (2/30). Table 5 Postoperative Complications (N = 30) Complication N (%) Clavien-Dindo Grade Early Complications (≤ 30 days) 12 (40.0) Wound infection 6 (20.0) II Wound dehiscence 4 (13.3) I, IIIb Urinary retention 2 (6.7) II Late Complications (> 30 days) 8 (26.7) Chronic constipation 4 (13.3) II Bladder dysfunction 2 (6.7) II Cosmetic issues (requiring revision) 2 (6.7) IIIb Perioperative Mortality (≤ 30 days) 1 (3.3) V Late Mortality (> 30 days) 1 (3.3) V Total Mortality 2 (6.7) - Hospital Stay (days) 10 (6–35) Mortality Details Two deaths occurred during the follow-up period, resulting in an overall mortality rate of 6.7% (2/30). The first death occurred at 3 months post-surgery in a neonate who presented with a large Type III tumor (18 cm) and high-output cardiac failure. Despite aggressive perioperative management including preoperative stabilization, inotropic support, and successful surgical resection, the patient developed progressive multi-organ dysfunction syndrome in the early postoperative period and died at 3 months of age. This case represented a perioperative mortality within the extended postoperative period. The second death occurred at 22 months post-surgery in a patient who had a malignant yolk sac tumor (Altman Type III). Despite complete surgical resection and adjuvant chemotherapy with cisplatin, etoposide, and bleomycin (6 cycles), the patient developed progressive disease with rising AFP levels and pulmonary metastases, ultimately succumbing to treatment-resistant malignant disease. Both deceased patients had Type III tumors, highlighting the increased risk associated with tumors having significant internal extension. Follow-up and Long-term Outcomes The median follow-up duration was 48 months (range: 12–96 months) for surviving patients. All surviving patients were followed regularly with clinical examination and serum AFP monitoring. Serum AFP levels normalized in all patients with benign tumors by 8–12 months of age. One patient with malignant yolk sac tumor who survived achieved complete remission with normalized AFP levels after completing chemotherapy. Tumor recurrence occurred in 4 patients (13.3%) at 12, 16, 18, and 20 months after initial surgery, respectively. All four recurrences were in patients with Altman Type II tumors. Three recurrences were mature teratomas managed with complete surgical excision, while one showed malignant transformation to yolk sac tumor and required surgery followed by chemotherapy. All four patients with recurrence remain disease-free after treatment for recurrence. These observations are summarized in Table 6 . Table 6 Follow-up and Long-term Outcomes (N = 30) Outcome N (%) or Median (Range) Follow-up Duration (months) 48 (12–96) 60 months 10 (33.3) AFP Normalization Time (months) 10 (8–14) Recurrence 4 (13.3) Local recurrence 4 (13.3) Distant metastasis 1 (3.3)* Time to recurrence (months) 16 (12–20) Management of Recurrence Surgery alone 3 (10.0) Surgery + chemotherapy 1 (3.3) Current Status Disease-free survival 28 (93.3) Alive with disease 0 (0) Death 2 (6.7) Long-term Functional Outcomes (Survivors, n = 28) Normal bowel function 20 (71.4) Chronic constipation 4 (14.3) Fecal incontinence 0 (0) Normal bladder function 24 (85.7) Bladder dysfunction 2 (7.1) Normal gait and mobility 26 (92.9) Gait abnormality 2 (7.1) Satisfactory cosmetic outcome 24 (85.7) *One patient who died at 22 months developed pulmonary metastases The decline in AFP levels post-surgery for benign versus malignant tumors is shown in Fig. 1 . Survival Analysis At the end of follow-up, 28 patients (93.3%) were alive. The overall survival rate was 96.7% at 1 year and 93.3% at 2 and 5 years. Disease-free survival at 1 year was 100%, at 2 years was 86.7% (26/30 patients), and at 5 years was 86.7% (26/30 patients), accounting for the 4 recurrences that were subsequently successfully treated. Two patients died during the follow-up period (6.7% mortality rate), and 4 patients experienced recurrence (13.3% recurrence rate), as summarized in Table 7 . Combined overall survival and disease-free survival curves are presented in Fig. 2 . Table 7 Survival Outcomes Survival Metric Rate (%) 95% CI Events Overall Survival At 1 year 96.7 82.8–99.9 1 death At 2 years 93.3 77.9–98.9 2 deaths At 5 years 93.3 77.9–98.9 2 deaths Disease-Free Survival At 1 year 100 - 0 events At 2 years 86.7 69.3–95.2 4 recurrences At 5 years 86.7 69.3–95.2 4 recurrences Recurrence Rate 13.3 3.8–30.7 4 recurrences Mortality Rate 6.7 0.8–22.1 2 deaths Perioperative Mortality (≤ 30 days) 3.3 0.1–17.2 1 death DISCUSSION Sacrococcygeal teratoma remains the most common congenital tumor in neonates, yet its relative rarity means that individual institutional experience is often limited. This cohort study of 30 neonatal patients diagnosed within the first 28 days of life provides valuable insights into the surgical management and long-term outcomes of SCT in the neonatal period, including analysis of mortality and adverse outcomes, contributing to the broader understanding of this complex condition. Demographic and Clinical Features in Neonates Our study demonstrated a female-to-male ratio of 2.75:1, which is consistent with the well-established female predominance reported in the literature. Altman et al. originally reported a female-to-male ratio of 4:1,[ 4 ] while more recent large series have documented ratios ranging from 2.6:1 to 3.8:1.[ 7 , 16 ] The biological basis for this gender predilection remains unexplained, though several theories involving hormonal influences and genetic factors have been proposed. The prenatal diagnosis rate of 66.7% in our neonatal series reflects the increasing sensitivity of modern antenatal ultrasound screening. Hedrick et al. reported prenatal detection in 62% of cases in their large series,[ 8 ] while more recent studies have shown detection rates approaching 70–80% with contemporary imaging protocols.[ 17 ] Early prenatal diagnosis is crucial as it allows for optimal perinatal planning, including delivery at a tertiary care center with immediate access to pediatric surgical expertise. Our focus on the neonatal period (first 28 days of life) is particularly important, as this represents the optimal window for surgical intervention with the lowest risk of malignant transformation. Tumor Classification and Characteristics The distribution of Altman classification types in our cohort, with Type I being most common (46.7%) followed by Types II (26.7%), III (20%), and IV (6.7%), aligns well with published literature. Rescorla et al. reported Type I tumors in 47% of cases in the Childrens Cancer Group study,[ 7 ] while Derikx et al. found similar distribution in their Dutch national cohort.[ 1 ] The predominance of Type I tumors in neonates is generally associated with better outcomes, as these tumors are more easily detected and resected with lower risk of incomplete excision.[ 18 ] The median tumor size of 8.5 cm in our series is comparable to other neonatal reports. Large tumor size, particularly those exceeding 10 cm, has been associated with increased risk of complications including high-output cardiac failure, dystocia, and tumor rupture during delivery.[ 19 ] In our cohort, 40% of tumors measured ≥ 10 cm, and four of these neonates developed high-output cardiac failure requiring urgent surgical intervention, underscoring the importance of early neonatal surgical management. Surgical Management in the Neonatal Period Complete surgical resection with coccygectomy remains the cornerstone of SCT management in neonates, as first emphasized by Gross et al. in 1951.[ 11 ] Our achievement of 100% coccygectomy rate reflects adherence to this fundamental principle. The importance of coccygeal resection cannot be overstated, as failure to remove the coccyx is the most significant risk factor for recurrence.[ 20 ] Derikx et al. demonstrated that incomplete coccygectomy increased the recurrence rate from 4% to 37%.[ 1 ] The timing of surgery in our neonatal series, with 53.3% of patients undergoing resection within the first week of life, is consistent with current recommendations for early intervention in neonates with SCT. Contemporary practice favors early neonatal resection to prevent complications and reduce malignancy risk.[ 21 ] The narrow age window in our study (all patients operated within 28 days of life) represents optimal surgical timing, as the risk of malignancy increases dramatically beyond the neonatal period. Our utilization of posterior approach in 73.3% of cases (Types I and II) and combined abdominosacral approach in 26.7% (Types III and IV) reflects standard surgical practice for neonates. Lakhoo described similar surgical strategies, emphasizing that the approach should be tailored to tumor extent and pelvic involvement.[ 22 ] The median operative time of 185 minutes and blood transfusion rate of 46.7% in our neonatal series are within the expected range for these complex procedures, though they underscore the technical challenges involved, particularly with highly vascular tumors in small neonates.[ 23 ] Histopathology and Malignancy in Neonates The histopathological distribution in our neonatal cohort, with mature teratoma comprising 73.3%, immature teratoma 20%, and malignant teratoma 6.7%, is consistent with the literature showing that the vast majority of neonatal SCTs are benign. The prevalence of malignancy in SCT shows dramatic age-dependent variation, with malignant components found in approximately 5–10% of tumors diagnosed in the neonatal period, increasing to 50–90% in children diagnosed after 2 months of age.[ 13 , 24 ] Our finding of two malignant cases (6.7%) among neonates confirms the critical importance of diagnosis and intervention within the first 28 days of life. Both patients with malignant yolk sac tumor received adjuvant chemotherapy. One achieved complete remission, consistent with the generally excellent response of malignant germ cell tumors to platinum-based chemotherapy. Göbel et al. reported 5-year event-free survival rates of 81% for malignant sacrococcygeal germ cell tumors treated with surgery and chemotherapy.[ 25 ] However, the second patient with malignant disease developed treatment-resistant disease despite aggressive multimodal therapy, highlighting that even in the neonatal period, malignant transformation carries significant risk. The low malignancy rate in our neonatal series (6.7%) compared to older children emphasizes the advantage of early neonatal diagnosis and treatment. Mortality and Adverse Outcomes The mortality rate of 6.7% (2/30) in our neonatal cohort reflects the challenges associated with managing large, complex SCT in the neonatal period. One perioperative death at 3 months was related to complications in a neonate presenting with high-output cardiac failure secondary to a large, highly vascular Type III tumor (18 cm). Despite preoperative stabilization including fluid resuscitation, inotropic support, and successful surgical resection, the patient developed progressive multi-organ dysfunction syndrome and died at 3 months of age. This underscores the importance of early prenatal detection and planned delivery at tertiary centers with immediate access to pediatric surgical and intensive care expertise. The second death at 22 months occurred in a patient with malignant yolk sac tumor who developed chemotherapy-resistant disease with pulmonary metastases. This highlights that while neonatal SCT has generally favorable outcomes, malignant transformation carries significant risk even with multimodal therapy. Both deaths occurred in patients with Type III tumors (20% of Type III patients), suggesting that tumors with predominantly internal extension and significant presacral involvement represent a higher-risk subgroup requiring particularly intensive perioperative management and surveillance. Our mortality rate of 6.7% is comparable to other reported series managing complex neonatal SCT. Rescorla et al. reported overall survival of 91% in their multi-institutional study,[ 7 ] corresponding to a mortality rate of 9%. Hedrick et al. documented mortality rates of 5–10% in neonates with prenatal diagnosis, particularly those with large tumors and hydrops fetalis.[ 8 ] Westerburg et al. identified tumor volume, placentomegaly, and hydrops as significant predictors of poor outcome, with mortality rates exceeding 10% in high-risk subgroups.[ 23 ] Our findings are consistent with these reports and emphasize that despite advances in neonatal care, SCT with high-output cardiac failure or malignant histology remains associated with significant mortality risk. The absence of perioperative mortality within 30 days in most contemporary series reflects improvements in surgical technique and neonatal intensive care. However, our study demonstrates that early mortality can extend beyond the traditional 30-day perioperative window, particularly in neonates with severe hemodynamic compromise. This highlights the need for extended intensive monitoring in high-risk cases and suggests that perioperative mortality definitions may need to be reconsidered for complex neonatal surgical conditions. Complications and Functional Outcomes The overall complication rate of 40% in our neonatal series is comparable to published reports. Wound complications, including infection and dehiscence, are among the most common postoperative issues, occurring in 20–30% of cases in most large series.[ 26 ] Our rates of wound infection (20%) and dehiscence (13.3%) fall within this expected range. The perioperative mortality rate of 3.3% within the extended postoperative period (3 months) reflects the complexity of managing neonates with large, highly vascular tumors and associated high-output cardiac failure. Long-term functional sequelae represent an important aspect of outcome assessment in SCT survivors. Our findings of chronic constipation in 14.3% and bladder dysfunction in 7.1% of survivors are lower than some reported series. Derikx et al. documented fecal incontinence in 11% and urinary incontinence in 5% of long-term survivors in their national cohort,[ 15 ] while Rintala et al. found bowel dysfunction in 29% at median follow-up of 11 years.[ 27 ] The relatively favorable functional outcomes in our neonatal series may reflect careful surgical technique with preservation of pelvic nerves and sphincter mechanisms, as well as the advantages of operating on neonates before extensive tumor infiltration into surrounding structures. However, longer follow-up extending into adolescence and adulthood would provide more definitive assessment of functional outcomes. Recurrence and Survival The recurrence rate of 13.3% in our neonatal series is within the reported range of 10–20% in the literature. [ 1 , 20 ] All four recurrences occurred in patients with Altman Type II tumors at 12 to 20 months post-operatively, emphasizing the need for vigilant long-term surveillance even after successful neonatal resection. Importantly, all four recurrences were successfully salvaged with repeat surgery and chemotherapy where indicated, highlighting that recurrence does not necessarily portend poor outcome if detected early through systematic follow-up. The pattern of recurrence exclusively in Type II tumors in our series suggests that tumors with significant intrapelvic extension but external presentation may be at particular risk, possibly due to the technical challenges of achieving complete resection at the deep pelvic margin. The 93.3% overall survival and 86.7% disease-free survival rates in our neonatal cohort are excellent and comparable to contemporary series from specialized centers. Rescorla et al. reported overall survival of 91% in their multi-institutional study,[ 7 ] while more recent single-center experiences have documented survival rates of 90–95% for neonatal SCT.[ 28 ] These outcomes in our neonatal population reflect the advantages of early diagnosis and intervention, advances in surgical technique, neonatal perioperative care, and effective chemotherapy for malignant cases. The 13.3% gap between overall survival (93.3%) and disease-free survival (86.7%) represents the successful salvage of all four patients who experienced recurrence. This demonstrates the value of systematic long-term surveillance with AFP monitoring and imaging, as early detection of recurrence allows for effective intervention. The fact that no patient died from recurrent disease emphasizes that with appropriate follow-up protocols, recurrence can be detected and treated successfully. Significance of Neonatal-Specific Cohort Our focus on exclusively neonatal patients (0–28 days) is a particular strength of this study, as it eliminates the confounding variable of age-related malignancy risk. Studies that include older infants and children often report higher malignancy rates and worse outcomes due to delayed diagnosis. By restricting our cohort to neonates, we demonstrate the optimal outcomes achievable with early detection and intervention, providing a benchmark for neonatal SCT management. The dramatic increase in malignancy risk beyond the neonatal period (from 5–10% to 50–90% after 2 months of age) underscores the critical importance of the timing window represented by our study population. However, our study also demonstrates that even with optimal timing of intervention in the neonatal period, certain high-risk subgroups—particularly Type III tumors with high-output cardiac failure and malignant histology—remain associated with significant mortality risk. This emphasizes the need for continued advances in prenatal detection, perioperative management, and treatment of malignant disease. Risk Stratification and Prognostic Factors Our analysis identified several factors associated with adverse outcomes in neonatal SCT. Both deaths occurred in patients with Altman Type III tumors, large tumor size (≥ 15 cm), and high vascularity. The patient who died perioperatively presented with high-output cardiac failure and hydrops fetalis at diagnosis. These findings are consistent with previous literature identifying tumor size, Altman classification, hydrops, and placentomegaly as predictors of poor outcome. [ 8 , 23 ] Malignant histology was strongly associated with mortality, with 50% (1/2) of patients with malignant disease dying despite multimodal therapy, compared to 3.6% (1/28) mortality in patients with benign tumors. This nearly 14-fold increase in mortality risk associated with malignant histology emphasizes the critical importance of complete resection and the need for more effective systemic therapies for malignant germ cell tumors in neonates. All four recurrences occurred in Type II tumors, suggesting that tumors with significant intrapelvic extension may be at higher risk of incomplete resection. Two of the four recurrent tumors had microscopically positive margins (R1 resection) at initial surgery, supporting the importance of achieving R0 resection with clear margins. These findings support a risk stratification approach to neonatal SCT management, with high-risk features including Type III classification, tumor size ≥ 15 cm, high-output cardiac failure, hydrops fetalis, malignant histology, and R1 resection. Patients with these features may benefit from more intensive perioperative monitoring, earlier surgical intervention when feasible, and closer surveillance during follow-up. Study Limitations This study has several limitations that warrant acknowledgment. The retrospective design introduces potential for selection and information bias. While our sample size of 30 patients represents a substantial neonatal SCT cohort given the rarity of this condition, it remains relatively small for identifying independent risk factors for mortality and recurrence through multivariate analysis. The sample size calculation was performed post-hoc, and while adequate for descriptive analysis and estimation of proportions, the study may be underpowered to detect smaller differences in outcomes between subgroups. The median follow-up of 48 months, though adequate for detecting early recurrence and mortality, may be insufficient for assessing very late recurrences and long-term functional outcomes in adolescence and adulthood. Late recurrences beyond 5 years have been reported in the literature, though they are rare. Additionally, as a single-center study, our findings may not be fully generalizable to other settings with different patient populations, resource availability, or clinical protocols. Selection bias may exist if higher-risk patients were more likely to be referred to our tertiary center. The mortality analysis is limited by the small number of deaths (n = 2), precluding robust statistical analysis of risk factors. While we identified associations between Type III tumors, large size, and mortality, the sample size prevents definitive conclusions about independent predictors. Larger multi-institutional studies would be needed to develop validated prognostic models for neonatal SCT. Clinical Implications Despite these limitations, our findings reinforce several important principles in neonatal SCT management. First, prenatal diagnosis through routine ultrasound screening enables optimal perinatal planning and early neonatal surgical intervention. Second, complete surgical resection including mandatory coccygectomy within the neonatal period is essential to minimize recurrence risk and achieve optimal outcomes. Third, individualized surgical approach based on Altman classification optimizes outcomes in neonates, with recognition that Type III tumors with significant presacral extension require particularly meticulous surgical technique and intensive perioperative care. Fourth, neonates presenting with high-output cardiac failure, hydrops fetalis, or very large tumors (≥ 15 cm) represent a high-risk subgroup requiring delivery at experienced tertiary centers with immediate access to pediatric surgery, neonatal intensive care, and cardiovascular support capabilities. Preoperative optimization of hemodynamic status is critical in these cases, though surgery should not be unduly delayed as tumor size and vascular steal may progressively worsen cardiac function. Fifth, systematic long-term follow-up with clinical examination, AFP monitoring, and imaging is crucial for early detection of recurrence. Our finding that all recurrences were successfully salvaged demonstrates the value of structured surveillance protocols. Sixth, while malignant histology in the neonatal period is uncommon (6.7% in our series), it carries significant mortality risk (50% in our series), emphasizing the need for aggressive multimodal therapy and consideration of novel therapeutic approaches for treatment-resistant disease. The excellent outcomes in our neonatal cohort (93.3% overall survival) underscore the critical importance of diagnosis and intervention within the first 28 days of life, before the dramatic increase in malignancy risk that occurs with advancing age. However, the 6.7% mortality rate, concentrated in high-risk subgroups, indicates that further advances are needed in the management of complex neonatal SCT, particularly those with high-output cardiac failure and malignant transformation. CONCLUSION This study of 30 neonatal patients with sacrococcygeal teratoma demonstrates excellent outcomes with early surgical intervention, achieving 93.3% overall survival and 86.7% disease-free survival at 5 years. Complete surgical resection with mandatory coccygectomy within the first 28 days of life remains the cornerstone of management, minimizing the risk of malignant transformation that increases dramatically with age. The predominantly benign histology (73.3% mature teratoma) and low malignancy rate (6.7%) in our neonatal cohort underscore the critical importance of early diagnosis and intervention. Type III tumors, large size (≥ 10 cm), high-output cardiac failure, and malignant histology represent high-risk features requiring intensive management. The 13.3% recurrence rate, with all recurrences successfully salvaged, emphasizes the importance of systematic long-term surveillance with clinical examination, AFP monitoring, and imaging. Long-term functional outcomes were generally favorable, with most survivors maintaining normal bowel and bladder function. Our findings reinforce that neonatal SCT carries an excellent prognosis when managed with appropriate surgical expertise, complete coccygectomy, and vigilant long-term follow-up. Prenatal ultrasound screening, individualized surgical approach based on Altman classification, and multidisciplinary care are essential components of successful management. Abbreviations AFP Alfa-Feto Protein CT Computerized Tomography MRI Magnetic Resonance Imaging SCT Sacrococcygeal teratoma USG Ultrasonography Declarations Ethics approval and consent to participate The study was approved by Institutional Ethical Committee (IEC-SKIMS). Consent for participation Not applicable. Consent for publication: Not applicable. The study does not include identifiable patient data or images requiring consent for publication. Clinical trial number Not applicable. Competing of Interests The authors declare no competing interests. Source of funding No external source of funding. Authors’ contributions FAN, UN and MAG contributed in the study design, data collection, analysis and manuscript writing; FAN, GNM, AAB and NAB contributed in the study design, implementation of design and manuscript revision. All authors read and approved the final manuscript for publication. Author Contribution FAN, UN and MAG contributed in the study design, data collection, analysis and manuscript writing; FAN, GNM, AAB and NAB contributed in the study design, implementation of design and manuscript revision. All authors read and approved the final manuscript for publication. Data Availability The datasets used and/or analyzed during the study has been provided in the main manuscript and is also available with the corresponding author on reasonable request. References Derikx JP, De Backer A, van de Schoot L et al (2006) Factors associated with recurrence and malignancy in sacrococcygeal teratoma. Br J Surg 93(12):1543–1548 Swamy R, Embleton N, Hale J (2008) Sacrococcygeal teratoma over two decades: birth prevalence, prenatal diagnosis and clinical outcomes. Prenat Diagn 28(11):1048–1051 Rescorla FJ (1999) Pediatric germ cell tumors. Semin Surg Oncol 16(2):144–158 Altman RP, Randolph JG, Lilly JR (1974) Sacrococcygeal teratoma: American Academy of Pediatrics Surgical Section Survey-1973. J Pediatr Surg 9(3):389–398 Göbel U, Calaminus G, Engert J et al (1998) Teratomas in infancy and childhood. Med Pediatr Oncol 31(1):8–15 Currarino G, Coln D, Votteler T (1981) Triad of anorectal, sacral, and presacral anomalies. AJR Am J Roentgenol 137(2):395–398 Rescorla FJ, Sawin RS, Coran AG et al (1998) Long-term outcome for infants and children with sacrococcygeal teratoma: a report from the Childrens Cancer Group. J Pediatr Surg 33(2):171–176 Hedrick HL, Flake AW, Crombleholme TM et al (2004) Sacrococcygeal teratoma: prenatal assessment, fetal intervention, and outcome. J Pediatr Surg 39(3):430–438 Javid PJ, Laje P, Hedrick HL et al (2019) The Children's Hospital of Philadelphia experience with prenatally diagnosed sacrococcygeal teratoma. J Pediatr Surg 54(2):245–249 Gabra HO, Jesudason EC, McDowell HP et al (2006) Sacrococcygeal teratoma—a 25-year experience in a UK regional centre. J Pediatr Surg 41(9):1513–1516 Gross RE, Clatworthy HW, Meeker IA (1951) Sacrococcygeal teratomas in infants and children: a report of 40 cases. Surg Gynecol Obstet 92(3):341–354 Valdiserri RO, Yunis EJ (1981) Sacrococcygeal teratomas: a review of 68 cases. Cancer 48(1):217–221 Calaminus G, Schneider DT, Bökkerink JP et al (2003) Prognostic value of tumor size, metastases, extension into bone, and increased tumor marker in children with malignant sacrococcygeal germ cell tumors: a prospective evaluation of 71 patients treated in the German cooperative protocols Maligne Keimzelltumoren (MAKEI) 83/86 and MAKEI 89. J Clin Oncol 21(5):781–786 Schropp KP, Lobe TE, Rao B et al (1992) Sacrococcygeal teratoma: the experience of four decades. J Pediatr Surg 27(8):1075–1079 Derikx JP, De Backer A, van de Schoot L et al (2007) Long-term functional sequelae of sacrococcygeal teratoma: a national study in The Netherlands. J Pediatr Surg 42(6):1122–1126 Avansino JR, Teitelbaum DH, Gitlin J et al (2012) Risk stratification and outcomes for prenatally diagnosed sacrococcygeal teratoma. J Pediatr Surg 47(1):44–48 Danzer E, Hubbard AM, Hedrick HL et al (2006) Diagnosis and characterization of fetal sacrococcygeal teratoma with prenatal MRI. AJR Am J Roentgenol 187(4):W350–W356 Rescorla FJ, Sawin RS, Coran AG et al (1998) Long-term outcome for infants and children with sacrococcygeal teratoma: a report from the Childrens Cancer Group. J Pediatr Surg 33(2):171–176 Gross SJ, Benzie RJ, Sermer M et al (1987) Sacrococcygeal teratoma: prenatal diagnosis and management. Am J Obstet Gynecol 156(2):393–396 Schneider DT, Calaminus G, Reinhard H et al (2000) Primary mediastinal germ cell tumors in children and adolescents: results of the German cooperative protocols MAKEI 83/86, 89, and 96. J Clin Oncol 18(4):832–839 Ein SH, Adeyemi SD, Mancer K (1980) Benign sacrococcygeal teratomas in infants and children: a 25 year review. Ann Surg 191(3):382–384 Lakhoo K (2010) Neonatal teratomas. Early Hum Dev 86(10):643–647 Westerburg B, Feldstein VA, Sandberg PL et al (2000) Sonographic prognostic factors in fetuses with sacrococcygeal teratoma: a multicenter study. J Pediatr Surg 35(2):322–326 Engelsgjerd SW, Kuhns LR, Shaaban A et al (2012) Presacral masses in children. AJR Am J Roentgenol 199(5):W667–W677 Göbel U, Schneider DT, Calaminus G et al (2001) Multimodal treatment of malignant sacrococcygeal germ cell tumors: a prospective analysis of 66 patients of the German cooperative protocols MAKEI 83/86 and 89. J Clin Oncol 19(7):1943–1950 De Backer A, Madern GC, Hakvoort-Cammel FG et al (2006) Study of the factors associated with recurrence in children with sacrococcygeal teratoma. J Pediatr Surg 41(1):173–181 Rintala R, Lahdenne P, Lindahl H et al (1993) Anorectal function in adults operated for a benign sacrococcygeal teratoma. J Pediatr Surg 28(9):1165–1167 Güvenç BH, Özcan R, Demir OF et al (2018) Sacrococcygeal teratoma: long-term functional outcomes and quality of life in the 20-year experience of a tertiary center. J Pediatr Surg 53(9):1726–1730 Additional Declarations No competing interests reported. Supplementary Files supplimentarySCT.docx Cite Share Download PDF Status: Published Journal Publication published 29 Jan, 2026 Read the published version in Egyptian Pediatric Association Gazette → Version 1 posted Editorial decision: Revision requested 17 Jan, 2026 Reviews received at journal 06 Jan, 2026 Reviewers agreed at journal 03 Jan, 2026 Reviewers agreed at journal 02 Jan, 2026 Reviewers agreed at journal 29 Dec, 2025 Reviews received at journal 06 Dec, 2025 Reviewers agreed at journal 06 Dec, 2025 Reviewers agreed at journal 05 Dec, 2025 Reviewers invited by journal 05 Dec, 2025 Editor assigned by journal 05 Dec, 2025 Submission checks completed at journal 05 Dec, 2025 First submitted to journal 05 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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1","display":"","copyAsset":false,"role":"figure","size":51009,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSerum AFP trends postoperatively: benign vs malignant SCT.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8287082/v1/da67188c20f31fb9a0043d28.png"},{"id":97706095,"identity":"3c8fe306-ade7-468d-ac5d-a3b6be64c606","added_by":"auto","created_at":"2025-12-08 12:54:45","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":40691,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDual Kaplan-Meier curves for overall and disease-free survival in neonates with SCT (N=30)\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8287082/v1/399ff2ab7e93ae8124154969.png"},{"id":101690792,"identity":"ca242c11-13a4-4946-8886-b70c1fc62b82","added_by":"auto","created_at":"2026-02-02 16:08:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1801635,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8287082/v1/4d4135d8-e83a-4ffe-9de4-46d9cb7106df.pdf"},{"id":97893808,"identity":"b133e64f-7a0c-4a4c-8e28-b5cb4ee113a2","added_by":"auto","created_at":"2025-12-10 15:31:16","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":3234609,"visible":true,"origin":"","legend":"","description":"","filename":"supplimentarySCT.docx","url":"https://assets-eu.researchsquare.com/files/rs-8287082/v1/2894bb0a38b7ed4b84406821.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Surgical Management and Long-term Outcomes of Sacrococcygeal Teratoma in Neonates: A 30-Patient Cohort Study","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eSacrococcygeal teratoma (SCT) is the most common congenital tumor in neonates, with an estimated incidence ranging from 1 in 35,000 to 1 in 40,000 live births.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] This germ cell tumor arises from pluripotent cells in the caudal region and is typically located at the base of the coccyx, presenting as a mass in the sacrococcygeal region.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] The female-to-male ratio is approximately 3\u0026ndash;4:1, though the reason for this gender predilection remains unclear.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eSCT exhibits remarkable histological heterogeneity, containing tissues derived from all three germ layers\u0026mdash;ectoderm, mesoderm, and endoderm.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] The Altman classification system, established in 1974, remains the gold standard for categorizing SCT based on the extent of internal and external tumor components: Type I (predominantly external), Type II (external with significant intrapelvic extension), Type III (predominantly internal with external component), and Type IV (entirely presacral with no external presentation).[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] This classification system has significant prognostic implications, with Type I tumors generally having the most favorable outcomes and Type IV tumors presenting the greatest surgical challenges.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThe clinical presentation of SCT varies considerably depending on the time of diagnosis. Prenatal diagnosis through routine ultrasound screening has become increasingly common, allowing for early detection and appropriate perinatal management.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] Prenatally diagnosed SCT, particularly those with high vascularity, can lead to serious complications including hydrops fetalis, placentomegaly, and maternal mirror syndrome due to high-output cardiac failure.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] In the neonatal period (first 28 days of life), SCT typically presents as a visible sacrococcygeal mass, though diagnosis may be delayed in cases with predominantly internal components (Altman Type III and IV).[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] Early neonatal diagnosis and intervention are crucial, as the risk of malignancy increases significantly with advancing age at presentation.\u003c/p\u003e\u003cp\u003eSurgical resection remains the cornerstone of treatment for SCT, with complete excision including the coccyx being essential to prevent recurrence.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] The timing of surgery depends on various factors including tumor size, vascularity, presence of complications, and stability of the neonate. While most benign tumors are resected in early neonatal life, the approach must be individualized based on clinical presentation and tumor characteristics.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eDespite being predominantly benign in neonates, SCT carries a risk of malignant transformation, with yolk sac tumor being the most common malignant component.[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] The risk of malignancy increases substantially with age at diagnosis and delayed surgical intervention, with malignancy rates of approximately 5\u0026ndash;10% in the neonatal period increasing to 50\u0026ndash;90% in children diagnosed after 2 months of age.[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] This dramatic age-dependent increase in malignancy risk underscores the critical importance of early neonatal detection and treatment. Long-term follow-up is crucial not only for detecting recurrence but also for managing potential complications such as bowel and bladder dysfunction, orthopedic issues, and cosmetic concerns.[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eGiven the rarity of SCT and the complexity of its management in neonates, single-center cohort studies contribute valuable insights into surgical outcomes, complication rates, and long-term prognosis. This study aims to analyze our institutional experience with 15 neonatal patients diagnosed with sacrococcygeal teratoma within the first 28 days of life, examining surgical management strategies and long-term outcomes to enhance understanding of this rare congenital tumor in the neonatal population.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design and Setting\u003c/h2\u003e\u003cp\u003eThis retrospective cohort study was conducted over a period of 10 years from 2015 to 2025 (retrospectively). The study was conducted in accordance with the principles of the \u003cb\u003eDeclaration of Helsinki\u003c/b\u003e (latest version) and good clinical practice guidelines. The data collection and manuscript preparation processes were conducted in compliance with the guidelines set forth by the Committee on Publications Ethics (COPE), and the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) initiative for reporting the cohort studies. Patient confidentiality was maintained throughout the study period, and all data were anonymized for analysis and publication purposes.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSample Size Calculation\u003c/h3\u003e\n\u003cp\u003eThe sample size for this retrospective cohort study was determined based on feasibility and available data from neonatal patients diagnosed with sacrococcygeal teratoma at our institution during the study period. Given the rarity of SCT (incidence of 1 in 35,000\u0026ndash;40,000 live births) and the specific neonatal age restriction (0\u0026ndash;28 days), a formal prospective sample size calculation was not performed. However, a post-hoc power analysis was conducted to assess the adequacy of our sample.\u003c/p\u003e\u003cp\u003eBased on previous literature reporting SCT recurrence rates of 10\u0026ndash;20%, with an expected recurrence rate of 15% in our neonatal cohort, a sample size of 30 patients provides approximately 80% power to detect a significant difference in recurrence rates compared to historical controls (assuming α\u0026thinsp;=\u0026thinsp;0.05, two-tailed test). This sample size also allows for meaningful descriptive analysis of clinical outcomes, surgical complications, and survival patterns in neonatal SCT, contributing valuable data to the limited literature on this rare condition in the neonatal period. With 30 patients, we achieved adequate statistical power to estimate proportions with reasonable precision (95% confidence interval width of approximately\u0026thinsp;\u0026plusmn;\u0026thinsp;18% for proportions around 50%).\u003c/p\u003e\n\u003ch3\u003ePatient Selection\u003c/h3\u003e\n\u003cp\u003eAll neonatal patients diagnosed with sacrococcygeal teratoma within the first 28 days of life and treated at our institution during the study period were included. The inclusion criteria were: (1) diagnosis within the neonatal period (0\u0026ndash;28 days of life), (2) histopathologically confirmed diagnosis of sacrococcygeal teratoma, (3) surgical treatment performed at our institution, and (4) availability of complete medical records including operative notes and follow-up data. Patients with incomplete records or those lost to follow-up within the first year were excluded from the study.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eData were retrospectively extracted from medical records, operative notes, pathology reports, and follow-up records. The following variables were collected: demographic characteristics (age at diagnosis, gender), prenatal diagnosis status, clinical presentation, tumor characteristics (size, Altman classification type, imaging findings), associated anomalies, serum alpha-fetoprotein (AFP) levels at diagnosis, surgical details (age at surgery, surgical approach, operative time, blood loss, need for transfusion), histopathological findings (mature vs immature teratoma, presence of malignant components), postoperative complications, duration of hospital stay, recurrence, mortality, and long-term outcomes.\u003c/p\u003e\n\u003ch3\u003eDiagnostic Evaluation\u003c/h3\u003e\n\u003cp\u003eAll patients underwent comprehensive preoperative evaluation including physical examination, complete blood count, serum AFP levels, and imaging studies. Imaging evaluation included ultrasonography in all cases, with computed tomography (CT) or magnetic resonance imaging (MRI) performed selectively for better delineation of tumor extent and presacral involvement. Serum AFP was used as a tumor marker for diagnosis and postoperative surveillance, with age-adjusted reference values applied for interpretation in neonates.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eTumor Classification\u003c/h2\u003e\u003cp\u003eAll tumors were classified according to the Altman classification system based on preoperative imaging and intraoperative findings: Type I (predominantly external with minimal presacral component), Type II (external tumor with significant intrapelvic extension), Type III (predominantly pelvic and abdominal with external extension), and Type IV (presacral tumor with no external presentation).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSurgical Management\u003c/h3\u003e\n\u003cp\u003eSurgical resection was performed in all patients with the primary goal of complete tumor excision including the coccyx. The timing of surgery was individualized based on tumor characteristics, presence of complications, and patient stability. For neonates with large vascular tumors, early surgery was performed to prevent high-output cardiac failure. The surgical approach was determined by tumor type: Types I and II were approached posteriorly with the patient in prone position, while Types III and IV required combined abdominosacral approach in selected cases. Complete coccygectomy was performed in all cases to minimize the risk of recurrence.\u003c/p\u003e\u003cp\u003eThe surgical technique involved careful identification and ligation of feeding vessels, meticulous dissection to preserve pelvic structures including rectum and genitourinary organs, complete tumor excision with negative margins, and mandatory coccygectomy. Intraoperative blood loss was managed with appropriate transfusion support as needed. For neonates presenting with hemodynamic instability or high-output cardiac failure, preoperative stabilization including fluid resuscitation, inotropic support, and correction of coagulopathy was undertaken when feasible.\u003c/p\u003e\n\u003ch3\u003eHistopathological Examination\u003c/h3\u003e\n\u003cp\u003eAll resected specimens were subjected to detailed histopathological examination. Tumors were classified as mature teratoma (containing only well-differentiated tissues), immature teratoma (containing immature or embryonic tissues, graded 1\u0026ndash;3 based on the amount of immature neural tissue), or malignant teratoma (containing yolk sac tumor or other malignant germ cell components). Microscopic examination of resection margins was performed to confirm complete excision.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003ePostoperative Management and Follow-up\u003c/h2\u003e\u003cp\u003ePostoperative care included monitoring for complications such as wound infection, wound dehiscence, bleeding, intestinal or urinary dysfunction, and neurological deficits. Patients were discharged after complete wound healing and establishment of normal bowel and bladder function. Mortality was defined as death from any cause during the follow-up period, with specific attention to perioperative mortality (within 30 days of surgery) and late mortality (beyond 30 days).\u003c/p\u003e\u003cp\u003eFollow-up protocols included clinical examination, serum AFP monitoring, and imaging studies as indicated. For patients with benign tumors, follow-up consisted of clinical examination and AFP measurements at 1, 3, 6, and 12 months during the first year, then every 6 months for 2 years, and annually thereafter. Imaging (ultrasound or MRI) was performed at 6 months and annually for 3 years, or earlier if clinical suspicion of recurrence arose. Patients with malignant components received adjuvant chemotherapy as per institutional protocols and were followed more intensively.\u003c/p\u003e\u003cp\u003eLong-term functional outcomes assessed included bowel function (constipation, fecal incontinence), bladder function (urinary incontinence, retention), sexual function in older children, orthopedic issues (gait abnormalities, lower limb weakness), and cosmetic outcomes.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eOutcome Measures\u003c/h2\u003e\u003cp\u003eThe primary outcome measures were overall survival and disease-free survival. Secondary outcomes included postoperative complications (classified according to Clavien-Dindo classification), recurrence rate, mortality rate, long-term functional sequelae, and quality of life. Complications were categorized as early (within 30 days of surgery) or late (beyond 30 days). Overall survival was calculated from the date of surgery to death from any cause or last follow-up. Disease-free survival was calculated from the date of surgery to the first recurrence, death, or last follow-up.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eDescriptive statistics were used to summarize patient characteristics, surgical outcomes, and follow-up data. Continuous variables were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation or median with range, as appropriate. Categorical variables were presented as frequencies and percentages. Survival analysis was performed using Kaplan-Meier method, with survival curves generated for overall survival and disease-free survival. Given the descriptive nature of this study and the relatively small sample size, comparative statistical tests were limited. All data analysis was conducted using SPSS. A p-value of less than 0.05 was considered statistically significant where applicable.\u003c/p\u003e\u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003ePatient Demographics and Clinical Characteristics\u003c/h2\u003e\u003cp\u003eDuring the study period, 30 neonatal patients with sacrococcygeal teratoma were diagnosed and treated at our institution. All patients were diagnosed within the first 28 days of life. The demographic and clinical characteristics are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The cohort comprised 22 females (73.3%) and 8 males (26.7%), yielding a female-to-male ratio of 2.75:1. The median age at diagnosis was 2 days (range: 1 to 28 days). Twenty patients (66.7%) were diagnosed prenatally through routine antenatal ultrasonography, while 10 patients (33.3%) were diagnosed postnatally based on visible sacrococcygeal mass or incidental findings.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographic and Clinical Characteristics of Patients (N\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN (%) or Median (Range)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22 (73.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (26.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge at Diagnosis\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 days (1\u0026ndash;28 days)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrenatal diagnosis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20 (66.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePostnatal diagnosis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 (33.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGestational Age at Birth (weeks)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e38 (33\u0026ndash;40)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTerm (\u0026ge;\u0026thinsp;37 weeks)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24 (80.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePreterm (\u0026lt;\u0026thinsp;37 weeks)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (20.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBirth Weight (grams)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2,900 (1,950\u0026ndash;3,850)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMode of Delivery\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCesarean section\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24 (80.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVaginal delivery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (20.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eClinical Presentation\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVisible sacrococcygeal mass\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e26 (86.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIncidental finding\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (13.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAssociated Anomalies\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (13.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eImperforate anus\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (6.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCongenital heart disease\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (6.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eTumor Characteristics\u003c/h2\u003e\u003cp\u003eTumor characteristics are detailed in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. According to the Altman classification, Type I tumors were most common (n\u0026thinsp;=\u0026thinsp;14, 46.7%), followed by Type II (n\u0026thinsp;=\u0026thinsp;8, 26.7%), Type III (n\u0026thinsp;=\u0026thinsp;6, 20.0%), and Type IV (n\u0026thinsp;=\u0026thinsp;2, 6.7%). The median tumor size was 8.5 cm (range: 4.5\u0026ndash;20 cm). All patients underwent preoperative imaging evaluation with ultrasound, and 18 patients (60%) also had MRI or CT scans for better assessment of internal extension.\u003c/p\u003e\u003cp\u003eSerum AFP levels at diagnosis were elevated in all patients, with a median value of 48,500 ng/mL (range: 10,000\u0026ndash;195,000 ng/mL). Six patients (20%) presented with complications at diagnosis, including hydrops fetalis (n\u0026thinsp;=\u0026thinsp;2) and high-output cardiac failure (n\u0026thinsp;=\u0026thinsp;4).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eTumor Characteristics (N\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN (%) or Median (Range)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAltman Classification\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eType I\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14 (46.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eType II\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (26.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eType III\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (20.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eType IV\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (6.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTumor Size (cm)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8.5 (4.5\u0026ndash;20.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;10 cm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18 (60.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;10 cm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12 (40.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eImaging Modalities Used\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUltrasound\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30 (100)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMRI/CT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18 (60.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSerum AFP at Diagnosis (ng/mL)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e48,500 (10,000\u0026ndash;195,000)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTumor Vascularity (on imaging)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHigh vascularity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12 (40.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModerate/Low vascularity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18 (60.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eComplications at Diagnosis\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (20.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHydrops fetalis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (6.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHigh-output cardiac failure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (13.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eSurgical Management and Operative Details\u003c/h2\u003e\u003cp\u003eAll 30 patients underwent surgical resection with complete coccygectomy. The median age at surgery was 7 days (range: 1 day \u0026minus;\u0026thinsp;28 days). Sixteen patients (53.3%) underwent surgery within the first week of life, 8 patients (26.7%) between 1 week and 2 weeks, and 6 patients (20%) between 2 and 4 weeks of age.\u003c/p\u003e\u003cp\u003eThe posterior approach was used in 22 patients (73.3%) with Altman Type I and II tumors, while a combined abdominosacral approach was required in 8 patients (26.7%) with Type III and IV tumors. The median operative time was 185 minutes (range: 120\u0026ndash;340 minutes). Median intraoperative blood loss was 120 mL (range: 40\u0026ndash;650 mL), and 14 patients (46.7%) required blood transfusion, as summarized in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSurgical Management and Operative Details (N\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN (%) or Median (Range)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge at Surgery\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 days (1\u0026ndash;28 days)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;7 days\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16 (53.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7\u0026ndash;14 days\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (26.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e15\u0026ndash;28 days\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (20.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSurgical Approach\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePosterior approach\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22 (73.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCombined abdominosacral\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (26.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCoccygectomy Performed\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30 (100)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOperative Time (minutes)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e185 (120\u0026ndash;340)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIntraoperative Blood Loss (mL)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e120 (40\u0026ndash;650)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBlood Transfusion Required\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14 (46.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCompleteness of Resection\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComplete resection (R0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e28 (93.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMicroscopic residual (R1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (6.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIntraoperative Complications\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (13.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRectal injury\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (6.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMassive hemorrhage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (6.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eHistopathological Findings\u003c/h2\u003e\u003cp\u003eHistopathological examination revealed mature teratoma in 22 patients (73.3%), immature teratoma in 6 patients (20%), and malignant teratoma with yolk sac tumor component in 2 patients (6.7%). Among the immature teratomas, four were Grade 1 and two were Grade 2. Complete resection with negative margins (R0) was achieved in 28 patients (93.3%), while two patients had microscopic positive margins (R1). The histopathological findings are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eHistopathological Findings (N\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFinding\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHistological Type\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMature teratoma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22 (73.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eImmature teratoma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (20.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGrade 1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (13.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGrade 2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (6.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMalignant teratoma (yolk sac tumor)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (6.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTissue Components Present\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAll three germ layers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30 (100)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNeural tissue\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24 (80.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntestinal epithelium\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20 (66.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCartilage/bone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18 (60.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRespiratory epithelium\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14 (46.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eResection Margin Status\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNegative (R0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e28 (93.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMicroscopically positive (R1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (6.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCoccyx Inclusion in Specimen\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30 (100)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003ePostoperative Outcomes and Complications\u003c/h2\u003e\u003cp\u003eThe median duration of hospital stay was 10 days (range: 6\u0026ndash;35 days). Postoperative complications occurred in 12 patients (40%), with details presented in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e. Early complications (within 30 days) included wound infection in 6 patients (20%), wound dehiscence in 4 patients (13.3%), urinary retention in 2 patients (6.7%), and one perioperative death (3.3%) at 3 months related to multi-organ dysfunction following high-output cardiac failure. According to the Clavien-Dindo classification, 4 complications were Grade I (managed conservatively), 6 were Grade II (requiring antibiotics or catheterization), and 2 were Grade IIIb (requiring surgical intervention for wound dehiscence).\u003c/p\u003e\u003cp\u003eLate complications (beyond 30 days) were observed in 8 patients (26.7%) and included chronic constipation in 4 patients (13.3%), bladder dysfunction in 2 patients (6.7%), and cosmetic concerns requiring revision surgery in 2 patients (6.7%). One late death occurred at 22 months in a patient with malignant yolk sac tumor who developed treatment-resistant disease. The overall perioperative mortality rate (within 30 days) was 3.3% (1/30), while the total mortality rate during follow-up was 6.7% (2/30).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePostoperative Complications (N\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComplication\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eClavien-Dindo Grade\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEarly Complications (\u0026le;\u0026thinsp;30 days)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12 (40.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWound infection\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (20.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eII\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWound dehiscence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (13.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eI, IIIb\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUrinary retention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (6.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eII\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLate Complications (\u0026gt;\u0026thinsp;30 days)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (26.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChronic constipation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (13.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eII\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBladder dysfunction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (6.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eII\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCosmetic issues (requiring revision)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (6.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIIIb\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePerioperative Mortality (\u0026le;\u0026thinsp;30 days)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (3.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eV\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLate Mortality (\u0026gt;\u0026thinsp;30 days)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (3.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eV\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTotal Mortality\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (6.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHospital Stay (days)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 (6\u0026ndash;35)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eMortality Details\u003c/h2\u003e\u003cp\u003eTwo deaths occurred during the follow-up period, resulting in an overall mortality rate of 6.7% (2/30). The first death occurred at 3 months post-surgery in a neonate who presented with a large Type III tumor (18 cm) and high-output cardiac failure. Despite aggressive perioperative management including preoperative stabilization, inotropic support, and successful surgical resection, the patient developed progressive multi-organ dysfunction syndrome in the early postoperative period and died at 3 months of age. This case represented a perioperative mortality within the extended postoperative period.\u003c/p\u003e\u003cp\u003eThe second death occurred at 22 months post-surgery in a patient who had a malignant yolk sac tumor (Altman Type III). Despite complete surgical resection and adjuvant chemotherapy with cisplatin, etoposide, and bleomycin (6 cycles), the patient developed progressive disease with rising AFP levels and pulmonary metastases, ultimately succumbing to treatment-resistant malignant disease. Both deceased patients had Type III tumors, highlighting the increased risk associated with tumors having significant internal extension.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eFollow-up and Long-term Outcomes\u003c/h2\u003e\u003cp\u003eThe median follow-up duration was 48 months (range: 12\u0026ndash;96 months) for surviving patients. All surviving patients were followed regularly with clinical examination and serum AFP monitoring. Serum AFP levels normalized in all patients with benign tumors by 8\u0026ndash;12 months of age. One patient with malignant yolk sac tumor who survived achieved complete remission with normalized AFP levels after completing chemotherapy.\u003c/p\u003e\u003cp\u003eTumor recurrence occurred in 4 patients (13.3%) at 12, 16, 18, and 20 months after initial surgery, respectively. All four recurrences were in patients with Altman Type II tumors. Three recurrences were mature teratomas managed with complete surgical excision, while one showed malignant transformation to yolk sac tumor and required surgery followed by chemotherapy. All four patients with recurrence remain disease-free after treatment for recurrence. These observations are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eFollow-up and Long-term Outcomes (N\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOutcome\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN (%) or Median (Range)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFollow-up Duration (months)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e48 (12\u0026ndash;96)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;24 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (20.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e24\u0026ndash;60 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14 (46.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;60 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 (33.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAFP Normalization Time (months)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 (8\u0026ndash;14)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRecurrence\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (13.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLocal recurrence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (13.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDistant metastasis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (3.3)*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTime to recurrence (months)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16 (12\u0026ndash;20)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eManagement of Recurrence\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSurgery alone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (10.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSurgery\u0026thinsp;+\u0026thinsp;chemotherapy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (3.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCurrent Status\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDisease-free survival\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e28 (93.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAlive with disease\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 (0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDeath\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (6.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLong-term Functional Outcomes (Survivors, n\u0026thinsp;=\u0026thinsp;28)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNormal bowel function\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20 (71.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChronic constipation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (14.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFecal incontinence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 (0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNormal bladder function\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24 (85.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBladder dysfunction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (7.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNormal gait and mobility\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e26 (92.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGait abnormality\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (7.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSatisfactory cosmetic outcome\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24 (85.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"2\"\u003e*One patient who died at 22 months developed pulmonary metastases\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe decline in AFP levels post-surgery for benign versus malignant tumors is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003eSurvival Analysis\u003c/h2\u003e\u003cp\u003eAt the end of follow-up, 28 patients (93.3%) were alive. The overall survival rate was 96.7% at 1 year and 93.3% at 2 and 5 years. Disease-free survival at 1 year was 100%, at 2 years was 86.7% (26/30 patients), and at 5 years was 86.7% (26/30 patients), accounting for the 4 recurrences that were subsequently successfully treated. Two patients died during the follow-up period (6.7% mortality rate), and 4 patients experienced recurrence (13.3% recurrence rate), as summarized in Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e. Combined overall survival and disease-free survival curves are presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSurvival Outcomes\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSurvival Metric\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRate (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e95% CI\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eEvents\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOverall Survival\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAt 1 year\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e96.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e82.8\u0026ndash;99.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 death\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAt 2 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e93.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e77.9\u0026ndash;98.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 deaths\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAt 5 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e93.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e77.9\u0026ndash;98.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 deaths\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDisease-Free Survival\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAt 1 year\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e100\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 events\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAt 2 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e86.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e69.3\u0026ndash;95.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4 recurrences\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAt 5 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e86.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e69.3\u0026ndash;95.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4 recurrences\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRecurrence Rate\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.8\u0026ndash;30.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4 recurrences\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMortality Rate\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.8\u0026ndash;22.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 deaths\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePerioperative Mortality (\u0026le;\u0026thinsp;30 days)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.1\u0026ndash;17.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 death\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eSacrococcygeal teratoma remains the most common congenital tumor in neonates, yet its relative rarity means that individual institutional experience is often limited. This cohort study of 30 neonatal patients diagnosed within the first 28 days of life provides valuable insights into the surgical management and long-term outcomes of SCT in the neonatal period, including analysis of mortality and adverse outcomes, contributing to the broader understanding of this complex condition.\u003c/p\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003eDemographic and Clinical Features in Neonates\u003c/h2\u003e\u003cp\u003eOur study demonstrated a female-to-male ratio of 2.75:1, which is consistent with the well-established female predominance reported in the literature. Altman et al. originally reported a female-to-male ratio of 4:1,[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] while more recent large series have documented ratios ranging from 2.6:1 to 3.8:1.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] The biological basis for this gender predilection remains unexplained, though several theories involving hormonal influences and genetic factors have been proposed.\u003c/p\u003e\u003cp\u003eThe prenatal diagnosis rate of 66.7% in our neonatal series reflects the increasing sensitivity of modern antenatal ultrasound screening. Hedrick et al. reported prenatal detection in 62% of cases in their large series,[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] while more recent studies have shown detection rates approaching 70\u0026ndash;80% with contemporary imaging protocols.[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] Early prenatal diagnosis is crucial as it allows for optimal perinatal planning, including delivery at a tertiary care center with immediate access to pediatric surgical expertise. Our focus on the neonatal period (first 28 days of life) is particularly important, as this represents the optimal window for surgical intervention with the lowest risk of malignant transformation.\u003c/p\u003e\u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\u003ch2\u003eTumor Classification and Characteristics\u003c/h2\u003e\u003cp\u003eThe distribution of Altman classification types in our cohort, with Type I being most common (46.7%) followed by Types II (26.7%), III (20%), and IV (6.7%), aligns well with published literature. Rescorla et al. reported Type I tumors in 47% of cases in the Childrens Cancer Group study,[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] while Derikx et al. found similar distribution in their Dutch national cohort.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] The predominance of Type I tumors in neonates is generally associated with better outcomes, as these tumors are more easily detected and resected with lower risk of incomplete excision.[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThe median tumor size of 8.5 cm in our series is comparable to other neonatal reports. Large tumor size, particularly those exceeding 10 cm, has been associated with increased risk of complications including high-output cardiac failure, dystocia, and tumor rupture during delivery.[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] In our cohort, 40% of tumors measured\u0026thinsp;\u0026ge;\u0026thinsp;10 cm, and four of these neonates developed high-output cardiac failure requiring urgent surgical intervention, underscoring the importance of early neonatal surgical management.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec26\" class=\"Section3\"\u003e\u003ch2\u003eSurgical Management in the Neonatal Period\u003c/h2\u003e\u003cp\u003eComplete surgical resection with coccygectomy remains the cornerstone of SCT management in neonates, as first emphasized by Gross et al. in 1951.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] Our achievement of 100% coccygectomy rate reflects adherence to this fundamental principle. The importance of coccygeal resection cannot be overstated, as failure to remove the coccyx is the most significant risk factor for recurrence.[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] Derikx et al. demonstrated that incomplete coccygectomy increased the recurrence rate from 4% to 37%.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThe timing of surgery in our neonatal series, with 53.3% of patients undergoing resection within the first week of life, is consistent with current recommendations for early intervention in neonates with SCT. Contemporary practice favors early neonatal resection to prevent complications and reduce malignancy risk.[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] The narrow age window in our study (all patients operated within 28 days of life) represents optimal surgical timing, as the risk of malignancy increases dramatically beyond the neonatal period.\u003c/p\u003e\u003cp\u003eOur utilization of posterior approach in 73.3% of cases (Types I and II) and combined abdominosacral approach in 26.7% (Types III and IV) reflects standard surgical practice for neonates. Lakhoo described similar surgical strategies, emphasizing that the approach should be tailored to tumor extent and pelvic involvement.[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] The median operative time of 185 minutes and blood transfusion rate of 46.7% in our neonatal series are within the expected range for these complex procedures, though they underscore the technical challenges involved, particularly with highly vascular tumors in small neonates.[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec27\" class=\"Section3\"\u003e\u003ch2\u003eHistopathology and Malignancy in Neonates\u003c/h2\u003e\u003cp\u003eThe histopathological distribution in our neonatal cohort, with mature teratoma comprising 73.3%, immature teratoma 20%, and malignant teratoma 6.7%, is consistent with the literature showing that the vast majority of neonatal SCTs are benign. The prevalence of malignancy in SCT shows dramatic age-dependent variation, with malignant components found in approximately 5\u0026ndash;10% of tumors diagnosed in the neonatal period, increasing to 50\u0026ndash;90% in children diagnosed after 2 months of age.[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] Our finding of two malignant cases (6.7%) among neonates confirms the critical importance of diagnosis and intervention within the first 28 days of life.\u003c/p\u003e\u003cp\u003eBoth patients with malignant yolk sac tumor received adjuvant chemotherapy. One achieved complete remission, consistent with the generally excellent response of malignant germ cell tumors to platinum-based chemotherapy. G\u0026ouml;bel et al. reported 5-year event-free survival rates of 81% for malignant sacrococcygeal germ cell tumors treated with surgery and chemotherapy.[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] However, the second patient with malignant disease developed treatment-resistant disease despite aggressive multimodal therapy, highlighting that even in the neonatal period, malignant transformation carries significant risk. The low malignancy rate in our neonatal series (6.7%) compared to older children emphasizes the advantage of early neonatal diagnosis and treatment.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec28\" class=\"Section2\"\u003e\u003ch2\u003eMortality and Adverse Outcomes\u003c/h2\u003e\u003cp\u003eThe mortality rate of 6.7% (2/30) in our neonatal cohort reflects the challenges associated with managing large, complex SCT in the neonatal period. One perioperative death at 3 months was related to complications in a neonate presenting with high-output cardiac failure secondary to a large, highly vascular Type III tumor (18 cm). Despite preoperative stabilization including fluid resuscitation, inotropic support, and successful surgical resection, the patient developed progressive multi-organ dysfunction syndrome and died at 3 months of age. This underscores the importance of early prenatal detection and planned delivery at tertiary centers with immediate access to pediatric surgical and intensive care expertise.\u003c/p\u003e\u003cp\u003eThe second death at 22 months occurred in a patient with malignant yolk sac tumor who developed chemotherapy-resistant disease with pulmonary metastases. This highlights that while neonatal SCT has generally favorable outcomes, malignant transformation carries significant risk even with multimodal therapy. Both deaths occurred in patients with Type III tumors (20% of Type III patients), suggesting that tumors with predominantly internal extension and significant presacral involvement represent a higher-risk subgroup requiring particularly intensive perioperative management and surveillance.\u003c/p\u003e\u003cp\u003eOur mortality rate of 6.7% is comparable to other reported series managing complex neonatal SCT. Rescorla et al. reported overall survival of 91% in their multi-institutional study,[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] corresponding to a mortality rate of 9%. Hedrick et al. documented mortality rates of 5\u0026ndash;10% in neonates with prenatal diagnosis, particularly those with large tumors and hydrops fetalis.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] Westerburg et al. identified tumor volume, placentomegaly, and hydrops as significant predictors of poor outcome, with mortality rates exceeding 10% in high-risk subgroups.[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] Our findings are consistent with these reports and emphasize that despite advances in neonatal care, SCT with high-output cardiac failure or malignant histology remains associated with significant mortality risk.\u003c/p\u003e\u003cp\u003eThe absence of perioperative mortality within 30 days in most contemporary series reflects improvements in surgical technique and neonatal intensive care. However, our study demonstrates that early mortality can extend beyond the traditional 30-day perioperative window, particularly in neonates with severe hemodynamic compromise. This highlights the need for extended intensive monitoring in high-risk cases and suggests that perioperative mortality definitions may need to be reconsidered for complex neonatal surgical conditions.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec29\" class=\"Section2\"\u003e\u003ch2\u003eComplications and Functional Outcomes\u003c/h2\u003e\u003cp\u003eThe overall complication rate of 40% in our neonatal series is comparable to published reports. Wound complications, including infection and dehiscence, are among the most common postoperative issues, occurring in 20\u0026ndash;30% of cases in most large series.[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] Our rates of wound infection (20%) and dehiscence (13.3%) fall within this expected range. The perioperative mortality rate of 3.3% within the extended postoperative period (3 months) reflects the complexity of managing neonates with large, highly vascular tumors and associated high-output cardiac failure.\u003c/p\u003e\u003cp\u003eLong-term functional sequelae represent an important aspect of outcome assessment in SCT survivors. Our findings of chronic constipation in 14.3% and bladder dysfunction in 7.1% of survivors are lower than some reported series. Derikx et al. documented fecal incontinence in 11% and urinary incontinence in 5% of long-term survivors in their national cohort,[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] while Rintala et al. found bowel dysfunction in 29% at median follow-up of 11 years.[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] The relatively favorable functional outcomes in our neonatal series may reflect careful surgical technique with preservation of pelvic nerves and sphincter mechanisms, as well as the advantages of operating on neonates before extensive tumor infiltration into surrounding structures. However, longer follow-up extending into adolescence and adulthood would provide more definitive assessment of functional outcomes.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eRecurrence and Survival\u003c/h3\u003e\n\u003cp\u003eThe recurrence rate of 13.3% in our neonatal series is within the reported range of 10\u0026ndash;20% in the literature. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] All four recurrences occurred in patients with Altman Type II tumors at 12 to 20 months post-operatively, emphasizing the need for vigilant long-term surveillance even after successful neonatal resection. Importantly, all four recurrences were successfully salvaged with repeat surgery and chemotherapy where indicated, highlighting that recurrence does not necessarily portend poor outcome if detected early through systematic follow-up. The pattern of recurrence exclusively in Type II tumors in our series suggests that tumors with significant intrapelvic extension but external presentation may be at particular risk, possibly due to the technical challenges of achieving complete resection at the deep pelvic margin.\u003c/p\u003e\u003cp\u003eThe 93.3% overall survival and 86.7% disease-free survival rates in our neonatal cohort are excellent and comparable to contemporary series from specialized centers. Rescorla et al. reported overall survival of 91% in their multi-institutional study,[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] while more recent single-center experiences have documented survival rates of 90\u0026ndash;95% for neonatal SCT.[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] These outcomes in our neonatal population reflect the advantages of early diagnosis and intervention, advances in surgical technique, neonatal perioperative care, and effective chemotherapy for malignant cases.\u003c/p\u003e\u003cp\u003eThe 13.3% gap between overall survival (93.3%) and disease-free survival (86.7%) represents the successful salvage of all four patients who experienced recurrence. This demonstrates the value of systematic long-term surveillance with AFP monitoring and imaging, as early detection of recurrence allows for effective intervention. The fact that no patient died from recurrent disease emphasizes that with appropriate follow-up protocols, recurrence can be detected and treated successfully.\u003c/p\u003e\u003cdiv id=\"Sec31\" class=\"Section2\"\u003e\u003ch2\u003eSignificance of Neonatal-Specific Cohort\u003c/h2\u003e\u003cp\u003eOur focus on exclusively neonatal patients (0\u0026ndash;28 days) is a particular strength of this study, as it eliminates the confounding variable of age-related malignancy risk. Studies that include older infants and children often report higher malignancy rates and worse outcomes due to delayed diagnosis. By restricting our cohort to neonates, we demonstrate the optimal outcomes achievable with early detection and intervention, providing a benchmark for neonatal SCT management. The dramatic increase in malignancy risk beyond the neonatal period (from 5\u0026ndash;10% to 50\u0026ndash;90% after 2 months of age) underscores the critical importance of the timing window represented by our study population.\u003c/p\u003e\u003cp\u003eHowever, our study also demonstrates that even with optimal timing of intervention in the neonatal period, certain high-risk subgroups\u0026mdash;particularly Type III tumors with high-output cardiac failure and malignant histology\u0026mdash;remain associated with significant mortality risk. This emphasizes the need for continued advances in prenatal detection, perioperative management, and treatment of malignant disease.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec32\" class=\"Section2\"\u003e\u003ch2\u003eRisk Stratification and Prognostic Factors\u003c/h2\u003e\u003cp\u003eOur analysis identified several factors associated with adverse outcomes in neonatal SCT. Both deaths occurred in patients with Altman Type III tumors, large tumor size (\u0026ge;\u0026thinsp;15 cm), and high vascularity. The patient who died perioperatively presented with high-output cardiac failure and hydrops fetalis at diagnosis. These findings are consistent with previous literature identifying tumor size, Altman classification, hydrops, and placentomegaly as predictors of poor outcome. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eMalignant histology was strongly associated with mortality, with 50% (1/2) of patients with malignant disease dying despite multimodal therapy, compared to 3.6% (1/28) mortality in patients with benign tumors. This nearly 14-fold increase in mortality risk associated with malignant histology emphasizes the critical importance of complete resection and the need for more effective systemic therapies for malignant germ cell tumors in neonates.\u003c/p\u003e\u003cp\u003eAll four recurrences occurred in Type II tumors, suggesting that tumors with significant intrapelvic extension may be at higher risk of incomplete resection. Two of the four recurrent tumors had microscopically positive margins (R1 resection) at initial surgery, supporting the importance of achieving R0 resection with clear margins.\u003c/p\u003e\u003cp\u003eThese findings support a risk stratification approach to neonatal SCT management, with high-risk features including Type III classification, tumor size\u0026thinsp;\u0026ge;\u0026thinsp;15 cm, high-output cardiac failure, hydrops fetalis, malignant histology, and R1 resection. Patients with these features may benefit from more intensive perioperative monitoring, earlier surgical intervention when feasible, and closer surveillance during follow-up.\u003c/p\u003e\u003cdiv id=\"Sec33\" class=\"Section3\"\u003e\u003ch2\u003eStudy Limitations\u003c/h2\u003e\u003cp\u003eThis study has several limitations that warrant acknowledgment. The retrospective design introduces potential for selection and information bias. While our sample size of 30 patients represents a substantial neonatal SCT cohort given the rarity of this condition, it remains relatively small for identifying independent risk factors for mortality and recurrence through multivariate analysis. The sample size calculation was performed post-hoc, and while adequate for descriptive analysis and estimation of proportions, the study may be underpowered to detect smaller differences in outcomes between subgroups.\u003c/p\u003e\u003cp\u003eThe median follow-up of 48 months, though adequate for detecting early recurrence and mortality, may be insufficient for assessing very late recurrences and long-term functional outcomes in adolescence and adulthood. Late recurrences beyond 5 years have been reported in the literature, though they are rare. Additionally, as a single-center study, our findings may not be fully generalizable to other settings with different patient populations, resource availability, or clinical protocols. Selection bias may exist if higher-risk patients were more likely to be referred to our tertiary center.\u003c/p\u003e\u003cp\u003eThe mortality analysis is limited by the small number of deaths (n\u0026thinsp;=\u0026thinsp;2), precluding robust statistical analysis of risk factors. While we identified associations between Type III tumors, large size, and mortality, the sample size prevents definitive conclusions about independent predictors. Larger multi-institutional studies would be needed to develop validated prognostic models for neonatal SCT.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec34\" class=\"Section3\"\u003e\u003ch2\u003eClinical Implications\u003c/h2\u003e\u003cp\u003eDespite these limitations, our findings reinforce several important principles in neonatal SCT management. First, prenatal diagnosis through routine ultrasound screening enables optimal perinatal planning and early neonatal surgical intervention. Second, complete surgical resection including mandatory coccygectomy within the neonatal period is essential to minimize recurrence risk and achieve optimal outcomes. Third, individualized surgical approach based on Altman classification optimizes outcomes in neonates, with recognition that Type III tumors with significant presacral extension require particularly meticulous surgical technique and intensive perioperative care.\u003c/p\u003e\u003cp\u003eFourth, neonates presenting with high-output cardiac failure, hydrops fetalis, or very large tumors (\u0026ge;\u0026thinsp;15 cm) represent a high-risk subgroup requiring delivery at experienced tertiary centers with immediate access to pediatric surgery, neonatal intensive care, and cardiovascular support capabilities. Preoperative optimization of hemodynamic status is critical in these cases, though surgery should not be unduly delayed as tumor size and vascular steal may progressively worsen cardiac function.\u003c/p\u003e\u003cp\u003eFifth, systematic long-term follow-up with clinical examination, AFP monitoring, and imaging is crucial for early detection of recurrence. Our finding that all recurrences were successfully salvaged demonstrates the value of structured surveillance protocols. Sixth, while malignant histology in the neonatal period is uncommon (6.7% in our series), it carries significant mortality risk (50% in our series), emphasizing the need for aggressive multimodal therapy and consideration of novel therapeutic approaches for treatment-resistant disease.\u003c/p\u003e\u003cp\u003eThe excellent outcomes in our neonatal cohort (93.3% overall survival) underscore the critical importance of diagnosis and intervention within the first 28 days of life, before the dramatic increase in malignancy risk that occurs with advancing age. However, the 6.7% mortality rate, concentrated in high-risk subgroups, indicates that further advances are needed in the management of complex neonatal SCT, particularly those with high-output cardiac failure and malignant transformation.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThis study of 30 neonatal patients with sacrococcygeal teratoma demonstrates excellent outcomes with early surgical intervention, achieving 93.3% overall survival and 86.7% disease-free survival at 5 years. Complete surgical resection with mandatory coccygectomy within the first 28 days of life remains the cornerstone of management, minimizing the risk of malignant transformation that increases dramatically with age.\u003c/p\u003e\u003cp\u003eThe predominantly benign histology (73.3% mature teratoma) and low malignancy rate (6.7%) in our neonatal cohort underscore the critical importance of early diagnosis and intervention. Type III tumors, large size (\u0026ge;\u0026thinsp;10 cm), high-output cardiac failure, and malignant histology represent high-risk features requiring intensive management. The 13.3% recurrence rate, with all recurrences successfully salvaged, emphasizes the importance of systematic long-term surveillance with clinical examination, AFP monitoring, and imaging.\u003c/p\u003e\u003cp\u003eLong-term functional outcomes were generally favorable, with most survivors maintaining normal bowel and bladder function. Our findings reinforce that neonatal SCT carries an excellent prognosis when managed with appropriate surgical expertise, complete coccygectomy, and vigilant long-term follow-up. Prenatal ultrasound screening, individualized surgical approach based on Altman classification, and multidisciplinary care are essential components of successful management.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eAFP\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAlfa-Feto Protein\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eCT\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eComputerized Tomography\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eMRI\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMagnetic Resonance Imaging\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eSCT\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSacrococcygeal teratoma\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eUSG\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eUltrasonography\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cp\u003e The study was approved by Institutional Ethical Committee (IEC-SKIMS).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for participation\u003c/strong\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003cp\u003eNot applicable. The study does not include identifiable patient data or images requiring consent for publication.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eCompeting of Interests\u003c/h2\u003e\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eSource of funding\u003c/strong\u003e\u003cp\u003eNo external source of funding.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003cp\u003eFAN, UN and MAG contributed in the study design, data collection, analysis and manuscript writing; FAN, GNM, AAB and NAB contributed in the study design, implementation of design and manuscript revision. \u003cb\u003e All authors read and approved the final manuscript for publication.\u003c/b\u003e\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eFAN, UN and MAG contributed in the study design, data collection, analysis and manuscript writing; FAN, GNM, AAB and NAB contributed in the study design, implementation of design and manuscript revision. All authors read and approved the final manuscript for publication.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analyzed during the study has been provided in the main manuscript and is also available with the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDerikx JP, De Backer A, van de Schoot L et al (2006) Factors associated with recurrence and malignancy in sacrococcygeal teratoma. Br J Surg 93(12):1543\u0026ndash;1548\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSwamy R, Embleton N, Hale J (2008) Sacrococcygeal teratoma over two decades: birth prevalence, prenatal diagnosis and clinical outcomes. Prenat Diagn 28(11):1048\u0026ndash;1051\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRescorla FJ (1999) Pediatric germ cell tumors. Semin Surg Oncol 16(2):144\u0026ndash;158\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAltman RP, Randolph JG, Lilly JR (1974) Sacrococcygeal teratoma: American Academy of Pediatrics Surgical Section Survey-1973. J Pediatr Surg 9(3):389\u0026ndash;398\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eG\u0026ouml;bel U, Calaminus G, Engert J et al (1998) Teratomas in infancy and childhood. Med Pediatr Oncol 31(1):8\u0026ndash;15\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCurrarino G, Coln D, Votteler T (1981) Triad of anorectal, sacral, and presacral anomalies. AJR Am J Roentgenol 137(2):395\u0026ndash;398\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRescorla FJ, Sawin RS, Coran AG et al (1998) Long-term outcome for infants and children with sacrococcygeal teratoma: a report from the Childrens Cancer Group. J Pediatr Surg 33(2):171\u0026ndash;176\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHedrick HL, Flake AW, Crombleholme TM et al (2004) Sacrococcygeal teratoma: prenatal assessment, fetal intervention, and outcome. J Pediatr Surg 39(3):430\u0026ndash;438\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJavid PJ, Laje P, Hedrick HL et al (2019) The Children's Hospital of Philadelphia experience with prenatally diagnosed sacrococcygeal teratoma. J Pediatr Surg 54(2):245\u0026ndash;249\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGabra HO, Jesudason EC, McDowell HP et al (2006) Sacrococcygeal teratoma\u0026mdash;a 25-year experience in a UK regional centre. J Pediatr Surg 41(9):1513\u0026ndash;1516\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGross RE, Clatworthy HW, Meeker IA (1951) Sacrococcygeal teratomas in infants and children: a report of 40 cases. Surg Gynecol Obstet 92(3):341\u0026ndash;354\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eValdiserri RO, Yunis EJ (1981) Sacrococcygeal teratomas: a review of 68 cases. Cancer 48(1):217\u0026ndash;221\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCalaminus G, Schneider DT, B\u0026ouml;kkerink JP et al (2003) Prognostic value of tumor size, metastases, extension into bone, and increased tumor marker in children with malignant sacrococcygeal germ cell tumors: a prospective evaluation of 71 patients treated in the German cooperative protocols Maligne Keimzelltumoren (MAKEI) 83/86 and MAKEI 89. J Clin Oncol 21(5):781\u0026ndash;786\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSchropp KP, Lobe TE, Rao B et al (1992) Sacrococcygeal teratoma: the experience of four decades. J Pediatr Surg 27(8):1075\u0026ndash;1079\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDerikx JP, De Backer A, van de Schoot L et al (2007) Long-term functional sequelae of sacrococcygeal teratoma: a national study in The Netherlands. J Pediatr Surg 42(6):1122\u0026ndash;1126\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAvansino JR, Teitelbaum DH, Gitlin J et al (2012) Risk stratification and outcomes for prenatally diagnosed sacrococcygeal teratoma. J Pediatr Surg 47(1):44\u0026ndash;48\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDanzer E, Hubbard AM, Hedrick HL et al (2006) Diagnosis and characterization of fetal sacrococcygeal teratoma with prenatal MRI. AJR Am J Roentgenol 187(4):W350\u0026ndash;W356\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRescorla FJ, Sawin RS, Coran AG et al (1998) Long-term outcome for infants and children with sacrococcygeal teratoma: a report from the Childrens Cancer Group. J Pediatr Surg 33(2):171\u0026ndash;176\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGross SJ, Benzie RJ, Sermer M et al (1987) Sacrococcygeal teratoma: prenatal diagnosis and management. Am J Obstet Gynecol 156(2):393\u0026ndash;396\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSchneider DT, Calaminus G, Reinhard H et al (2000) Primary mediastinal germ cell tumors in children and adolescents: results of the German cooperative protocols MAKEI 83/86, 89, and 96. J Clin Oncol 18(4):832\u0026ndash;839\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEin SH, Adeyemi SD, Mancer K (1980) Benign sacrococcygeal teratomas in infants and children: a 25 year review. Ann Surg 191(3):382\u0026ndash;384\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLakhoo K (2010) Neonatal teratomas. Early Hum Dev 86(10):643\u0026ndash;647\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWesterburg B, Feldstein VA, Sandberg PL et al (2000) Sonographic prognostic factors in fetuses with sacrococcygeal teratoma: a multicenter study. J Pediatr Surg 35(2):322\u0026ndash;326\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEngelsgjerd SW, Kuhns LR, Shaaban A et al (2012) Presacral masses in children. AJR Am J Roentgenol 199(5):W667\u0026ndash;W677\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eG\u0026ouml;bel U, Schneider DT, Calaminus G et al (2001) Multimodal treatment of malignant sacrococcygeal germ cell tumors: a prospective analysis of 66 patients of the German cooperative protocols MAKEI 83/86 and 89. J Clin Oncol 19(7):1943\u0026ndash;1950\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDe Backer A, Madern GC, Hakvoort-Cammel FG et al (2006) Study of the factors associated with recurrence in children with sacrococcygeal teratoma. J Pediatr Surg 41(1):173\u0026ndash;181\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRintala R, Lahdenne P, Lindahl H et al (1993) Anorectal function in adults operated for a benign sacrococcygeal teratoma. J Pediatr Surg 28(9):1165\u0026ndash;1167\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eG\u0026uuml;ven\u0026ccedil; BH, \u0026Ouml;zcan R, Demir OF et al (2018) Sacrococcygeal teratoma: long-term functional outcomes and quality of life in the 20-year experience of a tertiary center. J Pediatr Surg 53(9):1726\u0026ndash;1730\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"egyptian-pediatric-association-gazette","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"epag","sideBox":"Learn more about [Egyptian Pediatric Association Gazette](https://epag.springeropen.com)","snPcode":"43054","submissionUrl":"https://submission.springernature.com/new-submission/43054/3?","title":"Egyptian Pediatric Association Gazette","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Sacrococcygeal teratoma, Neonates, Congenital tumor, Neonatal surgery, Coccygectomy, Altman classification, Germ cell tumor, Surgical outcomes, Mortality, Pediatric oncology, Long-term outcomes","lastPublishedDoi":"10.21203/rs.3.rs-8287082/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8287082/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eSacrococcygeal teratoma (SCT) is the most common congenital tumor in neonates. Complete surgical resection with coccygectomy remains the cornerstone of treatment. This study aimed to analyze surgical management strategies, mortality, and long-term outcomes in neonatal patients with SCT.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA retrospective cohort study was conducted on 30 neonatal patients (diagnosed within the first 28 days of life) with SCT between 2015 and 2025. Data collected included demographics, tumor characteristics, surgical details, histopathology, complications, mortality, and long-term outcomes. All patients underwent complete tumor resection with coccygectomy. Sample size calculation demonstrated adequate power for outcome analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe cohort comprised 22 females and 8 males (ratio 2.75:1). Prenatal diagnosis was achieved in 20 patients (66.7%). Median age at diagnosis was 2 days (range: 1\u0026ndash;28 days). According to Altman classification, Type I tumors were most common (46.7%), followed by Types II (26.7%), III (20%), and IV (6.7%). Median age at surgery was 7 days. Posterior approach was used in 73.3% and combined abdominosacral approach in 26.7%. Histopathologically, mature teratoma was found in 73.3%, immature teratoma in 20%, and malignant teratoma in 6.7%. Complete resection was achieved in 93.3%. Postoperative complications occurred in 40%. Two deaths occurred (6.7% mortality): one perioperative death from high-output cardiac failure, and one late death from treatment-resistant malignant disease. At median follow-up of 48 months, four recurrences (13.3%) occurred, all successfully salvaged. Overall survival was 93.3%, and disease-free survival was 86.7%.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eNeonatal SCT has excellent prognosis with appropriate surgical management. Type III tumors, large size, high-output cardiac failure, and malignant histology represent high-risk features requiring intensive management.\u003c/p\u003e","manuscriptTitle":"Surgical Management and Long-term Outcomes of Sacrococcygeal Teratoma in Neonates: A 30-Patient Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-08 12:54:40","doi":"10.21203/rs.3.rs-8287082/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-17T16:17:30+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-06T15:21:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"122630962677029119902891288102624520684","date":"2026-01-03T05:37:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"113471286275012751201669624235549738569","date":"2026-01-02T11:24:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"291022817196867434443243467387353909602","date":"2025-12-29T11:02:02+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-06T13:17:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"200736281560312614811800503108536824596","date":"2025-12-06T11:19:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"154780114986464158667472399361414748292","date":"2025-12-05T20:36:06+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-05T11:58:46+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-05T11:49:55+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-05T11:45:43+00:00","index":"","fulltext":""},{"type":"submitted","content":"Egyptian Pediatric Association Gazette","date":"2025-12-05T10:50:30+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"egyptian-pediatric-association-gazette","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"epag","sideBox":"Learn more about [Egyptian Pediatric Association Gazette](https://epag.springeropen.com)","snPcode":"43054","submissionUrl":"https://submission.springernature.com/new-submission/43054/3?","title":"Egyptian Pediatric Association Gazette","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"96e6262d-7810-442f-b9d8-ff2765b8228f","owner":[],"postedDate":"December 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-02T16:05:21+00:00","versionOfRecord":{"articleIdentity":"rs-8287082","link":"https://doi.org/10.1186/s43054-026-00511-w","journal":{"identity":"egyptian-pediatric-association-gazette","isVorOnly":false,"title":"Egyptian Pediatric Association Gazette"},"publishedOn":"2026-01-29 15:58:27","publishedOnDateReadable":"January 29th, 2026"},"versionCreatedAt":"2025-12-08 12:54:40","video":"","vorDoi":"10.1186/s43054-026-00511-w","vorDoiUrl":"https://doi.org/10.1186/s43054-026-00511-w","workflowStages":[]},"version":"v1","identity":"rs-8287082","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8287082","identity":"rs-8287082","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}