Functional Outcomes After Sacrectomy for Chordoma: The Critical Role of Bilateral S3 Nerve Root Preservation

Functional Outcomes After Sacrectomy for Chordoma: The Critical Role of Bilateral S3 Nerve Root Preservation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Functional Outcomes After Sacrectomy for Chordoma: The Critical Role of Bilateral S3 Nerve Root Preservation Naun Jeong, Eunkyu Yang, Ilkyu Han, Hwansung Cho, Han-Soo Kim, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8860454/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background Sacral chordomas are rare, locally aggressive malignancies where surgical resection is the primary treatment. In the previous reports, preservation of at least one S3 root is shown to be important for normal bowel and bladder function. This study aimed to evaluate the postoperative bowel and bladder function according to the level and laterality of sacral nerve root preservation. Methods We conducted a retrospective cohort study of 23 patients who underwent surgery for sacral chordoma at two tertiary referral centers in South Korea between March 2009 and February 2024. All patients underwent en bloc resection with wide margins. Functional outcomes (motor, bladder, and bowel function) based on the level of preserved sacral nerve roots were analyzed. Oncological outcomes included disease-specific survival [DSS], local recurrence-free survival [LRFS], and distant metastasis-free survival [DMFS]. Results The 23 patients were followed for a median of 7.0 years. 19 patients (82.6%) were alive at the last follow-up. Functional outcomes were dependent on the level of nerve preservation. For motor function, preserving more than one S2 root was sufficient to achieve normal function. For bowel and bladder function, preserving S3 root was critical. All patients with bilateral S3 root preservation (n = 4) maintained normal bladder and bowel function (100%). On the other hand, for patients with unilateral S3 preservation (n = 3), normal bladder and bowel function was observed in only 33.3%. Patients with bilateral S2 preservation (n = 9) had 22.2% normal bladder and 42.9% normal bowel function. DSS at 5 years and 10 years was 95.0% and 74.4%, respectively. LR occurred in 9 patients (39.1%), with 5-year and 10-year local recurrence-free survival (LRFS) rates of 65.7% and 52.5%, respectively. DM occurred in 7 patients (30.4%), with 5-year and 10-year distant metastasis-free survival (DMFS) rates of 72.4% and 60.4%, respectively. Conclusion Bilateral S3 preservation is critical for bowel and bladder function, achieving 100% normal continence compared to 33.3% with unilateral preservation. Favorable disease-specific survival (5-year 95.0%, 10-year 74.4%) was achieved despite a 39.1% local recurrence rate, emphasizing the importance of long-term surveillance beyond 5 years. Figures Figure 1 Figure 2 Figure 3 Background Chordomas are rare, slow-growing, malignant bone tumors that arise from the remnants of the notochord, with an incidence rate of 0.1 to 0.8 per 10 million [ 1 , 2 ]. Despite having a low histological grade, chordomas in sacral area are locally aggressive and associated with a high risk of local recurrence (LR) and distant metastasis (DM), which significantly affect long-term survival [ 3 , 4 ]. Surgical resection is the most important treatment method, as chordomas are typically resistant to chemotherapy and conventional radiotherapy. [ 5 ] En bloc resection with wide margins is considered the optimal surgical approach for achieving durable local control. Inadequate margins, particularly in intra-lesional excisions, are consistently associated with high recurrence rates and poor oncologic outcomes [ 6 – 8 ]. However, complete resection is often challenging because of the complex anatomy of the sacrum and the close proximity of tumors to important neural structures, pelvic organs, and major vessels. Recently, carbon-ion therapy or proton therapy has emerged as an alternative treatment option for chordomas located in the higher sacrum, and neurological deficits after radiotherapy have been shown to be superior to those after surgery. [ 9 – 11 ] For bowel and bladder function, preservation of the S3 nerve roots has been identified as criticial [ 12 ]. Consequently, the surgical goal for sacral chordomas is to achieve en bloc resection while maximizing functional outcomes. While the importance of S3 preservation is well established, the precise extent of nerve preservation required for adequate functional recovery-specifically, whether unilateral or bilateral S3 perservation is necessary-remains poorly defined. This study aimed to evaluate the functional outcomes of sacrectomy for chordoma with focus on the relationship between the level and laterality of nerve root preservation and postoperative bowel and bladder function. Additionally, oncological outcomes including disease specific survival [DSS], local recurrence-free survival [LRFS], distant metastasis-free survival [DMFS] were assessed. Methods We conducted a retrospective cohort study of patients with sacral chordomas who underwent surgical treatment at Seoul National University Hospital and Seoul National University Bundang Hospital, Republic of Korea, between March 2009 and February 2024. The primary objective was to evaluate the association between the extent of sacral nerve root preservation and postoperative bowel and bladder function. Secondary objective included assessement of motor function and oncological outcomes, including DSS, LRFS, and DMFS. On patient selection, the inclusion criteria were: (1) histologically confirmed sacral chordoma; (2) surgical treatment with major sacrectomy; and (3) a minimum follow-up duration of 12 months. Three patients treated with other modalities and 1 patient who died less than a year postoperatively were excluded. After applying these criteria, 23 patients were included in the final analysis. Clinical and perioperative data were obtained from electronic medical records, including age, sex, tumor presentation (primary vs. recurrent), tumor size, tumor volume, tumor level, preoperative neurological deficits (motor, bladder, and bowel), operative time, estimated blood loss (EBL), colostomy and cystostomy formation, and treatment, including chemotherapy and radiotherapy. All patients underwent wide en bloc resection with wide margins. Postoperative pathological margin status was classified as negative or positive. Tumor size was defined as the longest diameter on biopsy, and tumor volume was calculated using the ellipsoid formula (length × width × height × π/6) [ 13 ]. On assessment of nerve preservation and functional outcomes, the level of sacral resection and preservation of sacral nerve roots were determined according to tumor involvement. The nerve roots were categorized according to their level (S1–S5) and laterality (unilateral or bilateral preservation). Postoperative functional outcomes (motor, bladder, and bowel functions) were assessed at the last follow-up using clinical documentation. Motor function was considered normal if the patient reported a motor grade of 5 in the lower extremities. Bladder function was also considered normal if the patient reported no difficulty in continence during urination or no leaking of urine. Bowel function was considered normal if the record form the patient reported no dysfunction such as incontinence, constipation, or diarrhea. On assessment of oncological outcomes, routine follow-up evaluations were performed every 3 months for the first 2 years, every 6 months for the next 3 years, and annually thereafter. Each follow-up evaluation included a clinical examination, functional evaluation, and imaging studies with plain radiography, ultrasound, or magnetic resonance imaging (MRI) to evaluate the primary site. For metastasis surveillance, chest computed tomography, bone scan, and positron emission tomography-computed tomography were checked. LR was defined as radiologically or pathologically confirmed tumor regrowth at the primary site. DM was defined as disease outside the sacrum, as confirmed using imaging. Time-to-event outcomes, such as local recurrence-free survival (LRFS) and distant metastasis-free survival (DMFS), were calculated from the date of surgery to the date of event occurrence or last follow-up. Statistical analysis Statistical analyses were performed using the R software (version 4.3.0; R Foundation for Statistical Computing, Vienna, Austria). Continuous variables were summarized as medians and ranges when non-normally distributed. Categorical variables are expressed as frequencies and percentages. Comparisons between patients with and without LR were conducted using Student’s t -test or the Mann–Whitney U test for continuous variables, depending on the data distribution, and the chi-square test or Fisher’s exact test for categorical variables. The Kaplan–Meier method was used to estimate time-to-event outcomes, such as LRFS and DMFS. The median survival was reported with 95% confidence intervals (CI). The log-rank test was used to compare survival curves. All statistical tests were two-tailed, and statistical significance was set at p < 0.05. Results Twenty-three patients were included in the study ( Figure 1 ). The median age was 59.0 years (range, 36–79 years) and 16 patients (69.6%) were male. Most tumors presented as primary lesions (91.3%) with a median longest tumor diameter of 7.0 cm (range, 3.8–14.5), and a median tumor volume of 121.8 cm³ (range, 14.6–873.9). Preoperative symptoms included motor deficit in 1 (4.3%), bladder dysfunction in 5 (21.7%), and bowel dysfunction in 4 (17.4%). All the patients underwent wide en bloc resection. Colostomy was performed in 2 (8.7%) patients; no cystostomy was performed. The median operative time was 315.0 minutes (range, 50.0–1241.0 minutes), and the median EBL was 1250.0 mL (range, 100.0–10000.0 mL). Negative surgical margins were achieved in 21 (91.3%) patients. One patient underwent chemotherapy. No patients received preoperative radiotherapy; postoperative radiotherapy was administered to 8 (34.8%) ( Table 1 ). The median follow-up duration was 7.0 years (range, 1.1–15.0 years). 19 patients (82.6%) were alive at the last follow-up. Functional outcomes in the patients were significantly correlated with the level and laterality of the preserved sacral nerve roots ( Table 2, Figure 2 ). When only the bilateral S1 or unilateral S1 roots were preserved, no patient exhibited normal motor, bladder, or bowel functions. Maintaining bilateral S2 roots (n = 9) led to normal bladder and bowel function in 42.9% (3/7) and 22.2% (2/9) of the patients, respectively, while motor function was preserved in all patients (9/9). Upon achieving unilateral S3 preservation (n = 3), normal bladder and bowel function was noted in 33.3% of the patients, along with complete motor recovery (100%). Bilateral S3 preservation (n = 4) was correlated with positive outcomes, as all the patients retained normal motor, bladder, and bowel functions. Likewise, unilateral (n = 1) and bilateral S4 preservation (n = 3) consistently achieved 100% preservation of motor, bladder, and bowel functions. The Kaplan–Meier estimate of DSS demonstrated 5-year and 10-year survival rates of 95.0% and 74.4%, respectively ( Figure 3A). LR occurred in 9 (39.1%) patients, with a median time to recurrence of 2.5 years (range, 1.2–6.8 years). During a median follow-up of 7.0 years (range, 1.1-15.0 years), LR occurred in 9 patients (39.1%). The Kaplan–Meier estimate of LRFS demonstrated 5-year and 10-year survival rates of 65.7% (95% CI 40.9-82.0) and 52.5% (95% CI 27.7-72.4), respectively ( Figure 3B ). DM was present at diagnosis in 3 (13.0%) patients; including 3 patients, a total of 7 (30.4%) developed DM during follow-up, with a median interval of 2.7 years (range, 0.8–9.5 years). Kaplan–Meier analysis demonstrated favorable DMFS in the overall cohort. The estimated 5-year and 10-year DMFS rates were 72.4% (95% CI 48.3-86.7) and 60.4% (95% CI 29.6-81.1), respectively ( Figure 3C ). Discussion In this study, we evaluated the functional outcomes of 23 patients with sacral chordoma who underwent sacrectomy, with focus on the relationship between nerve root preservation and postoperative bowel and bladder function. Our result showed that bilateral S3 preservation achieved 100% normal bladder and bowel function, compared to only 33.3% with unilateral S3 preservation. Additionally, despite en bloc resection with wide margins, local recurrence rate remained high at 39.1% over a median follow-up of 7.0 years. The most favorable outcomes were observed in patients with bilateral S3 preservation (n = 4), as all patients maintained normal bladder and bowel function. Similarly, preservation of the unilateral (n = 1) or bilateral S4 roots (n = 3) was consistently associated with complete recovery of bladder and bowel function. In contrast, unilateral S3 preservation resulted in normal bladder and bowel function in only 33.3%. This disparity suggests that while preservation of at least one S3 root is necessary for continence, it may not be sufficient and bilateral preservation confers a significant functional advantage. This finding may be consistent with neurophysiological evidence that parasympathetic innervation of the bladder relies on a balanced contribution from both sacral roots. Carlucci et al. [24] demonstrated that although S3 roots invariably contribute to detrusor contraction, bladder control typically requires input from multiple sacral roots in combination rather than from a single root alone, underscoring the variability and redundancy of sacral innervation. Similarly, experimental data by Su et al. [25] showed that bilateral stimulation of the sacral nerves produced a more effective modulation of bladder activity than unilateral stimulation, even at lower stimulus intensities, suggesting that bilateral inputs provide synergistic effects in maintaining normal bladder function. Taken together, these findings support our clinical observation that the preservation of both S3 roots is critical for optimizing bladder function after sacral chordoma resection. In our cohort, the bowel and bladder outcomes after sacral resection were generally comparable with those reported in previous studies ( Table 3 ). When preservation was limited to the bilateral S1 or unilateral S1 roots, no patient achieved normal bladder or bowel function. These findings are comparable to those of previous studies. With bilateral S2 preservation (n = 9), normal bladder and bowel functions were observed in 42.9% and 22.2% of patients, respectively. Regarding unilateral S3 preservation, our result with 33.3% normal function was lower than those reported in previous reports. Xia et al. [21] reported that postoperative bowel or bladder dysfunction (BBD) was occurred in 50% of patients with unilateral S3 preservation. Ji et al. [22] analyzed the postoperative neurological function using a newly designed scoring system. Among the patients with unilateral preservation of the S3 nerve root, 37.5% achieved a perfect bladder score. Guo et al. [12] retrospectively analyzed 50 patients who underwent sacrectomy; in 32 patients with non–rectal cancer without colostomy, bowel function was normal 62.5% after unilateral S3 resection, with concordant bowel and bladder function in 94% of the cases. Todd et al. [23] reported that normal bladder/bowel function was retained in 60%/66.6% of patients, respectively with preservation of at least one S3. The small sample size in our study may have contributed to the slightly worse functional outcomes observed with unilateral S3 preservation (US3). Notably, one patient with unilateral S3 preservation had preoperative bladder and bowel dysfunction, but showed postoperative improvement, achieving self-voiding and adequate sphincter control. This finding suggests the potential for functional recovery after surgery, possibly due to neural plasticity or compensation from preserved contralateral roots. Regarding oncological outcomes, the LR rate of 39.1% in our cohort was comparable to previous reports ranging from 14.5% to 44.4%. ( Table 4 ). Xia et al. [14] reported a retrospective cohort of 101 patients with spinal and sacral chordomas treated with definitive surgery, with a mean follow-up of 6.0 years and an LR rate of 24.8%. Borkowska et al. [8] retrospectively analyzed 48 patients with sacral chordomas, and LR occurred in 33.3% of patients. In a pooled analysis by Kerekes et al. [15], LR occurred in 42.6% of patients. The median time to LR in our study was 2.5 years ranging from 1.2 to 6.8 years, whereas previous studies have shown a broader interval, from as early as 0.87 years to as long as 6.2 years. In our cohort, LR occurred even at 6.8 years (81 months) after surgery, highlighting the importance of long-term surveillance. Unlike many malignancies that are routinely followed up for 5 years, sacral chordomas are slow-growing tumors, and late recurrence remains a significant concern. Similarly, Zuckerman et al. [6] reported a median time to LR of 6.2 years, further highlighting the need for follow-up beyond the conventional 5-year period. Distant metastasis occurred in 30.4% of patients, with a median time of 2.7 years. All patients with DM developed pulmonary metastases. Notably, two patients had multifocal disease: one with multiple cutaneous metastases and the other with prostate involvement. The incidence of DM in sacral chordomas varies from 0% to 29.6%, with the lungs identified as the predominant metastatic site, and infrequent involvement of the liver or bone. [15] These results underscore the need for regular chest imaging during postoperative surveillance. In our analysis, no statistically significant risk factors for LR were identified, possibly owing to the small sample size(Table 5). Moreover, although en bloc resection was successfully performed in all cases with a negative margin rate of 91.3%, LR occurred in 39.1% of cases. Interestingly, even cases with positive margins did not always result in LR in our cohort. Nonetheless, current literature consistently identifies incomplete excision as a poor prognostic factor. In a pooled analysis by Kerekes et al.[15], the most consistent prognostic determinant for both LR and DM in sacral chordomas was the surgical margin, with wide margins significantly reducing the risk compared to marginal, intralesional, or contaminated resections. Recently, Goumenos et al. [16] analyzed 27 surgically treated sacral chordomas and reported that inadequate (<2 mm) or positive margins were strongly associated with recurrence. Additional reported prognostic factors include tumor volume ≥100 cm³ [14], soft tissue invasion [7], [17], tumor location above S3[7], and prior sacral surgery[15]. Despite the high LR rate with long interval, the overall oncological prognosis of sacral chordoma remains favorable. In our cohort, the 5-year and 10-year DSS were 95.0% and 74.4%, respectively, which are comparable to or better than those reported in previous studies[6], [14], [15]. This relatively favorable survival despite high LR rate, can be attributed to the slow-growing nature of chordomas. These findings suggest that early detection of recurrence through regular surveillance enables timely intervention, which may translate into improved survival outcomes. Therefore regular surveillance beyond 5 years is essential for early detection of recurrence and timely intervention. This study had several limitations. First, its retrospective design may have introduced inherent selection and information bias. Second, the sample size was small (n = 23) due to the rarity of sacral chordomas, which limited the statistical power to identify significant prognostic factors. Third, as in most previous studies, bowel and bladder dysfunction were assessed based on patient reports documented in clinical records, which may have underestimated subtle deficits. Ji et al. [22] used a 27-point scoring system with four subdomains that examined bladder function: dysuria, urinary incontinence, bladder sensation, and overall bladder function. The use of scoring systems may be helpful in objectively evaluating functional outcomes. Future research with larger multicenter cohorts and standardized functional scoring systems is needed to provide a more objective and comprehensive assessment of long-term bowel and bladder function after major sacrectomy in patients with sacral chordoma. Conclusion This study demonstrated that bilateral S3 nerve root preservation is critical for achieving optimal bowel and bladder function after sacrectomy for sacral chordoma, with 100% of patients maintaining normal continence compared to only 33.3% with unilateral S3 preservation. This finding suggests that when oncologically feasible, preservation of S3 preservation should be considered to optimize postoperative bowel and bladder function. Despite high local recurrence rate of 39.1%, favorable disease-specific survival was achieved (5-year 95.0%, 10-year 74.4%), suggesting vigilant long-term surveillance beyond 5 years can lead to excellent oncological outcomes through early detection and timely intervention. Abbreviations BBD: Bowel or Bladder Dysfunction BS: Bilateral Sparing CI: Confidence Interval CT: Chemotherapy DM: Distant Metastasis DMFS: Distant Metastasis-Free Survival DSS: Disease-Specific Survival EBL: Estimated Blood Loss IRB: Institutional Review Board LR: Local Recurrence LRFS: Local Recurrence-Free Survival MRI: Magnetic Resonance Imaging RM: Resection Margin RT: Radiotherapy US: Unilateral Sparing Declarations Ethical approval The study was conducted in accordance with the principles of the Declaration of Helsinki. Institutional Institutional Review Board approval was obtained from the Institutional Review Board of Seoul National University Hospital (IRB No. H-2509-181-1683) and the Institutional Review Board of Seoul National University Bundang Hospital (IRB No. B-2509-999-101). The requirement for informed consent was waived by the Institutional Review Board of Seoul National University Hospital and the Institutional Review Board of Seoul National University Bundang Hospital due to the retrospective nature of the study and the use of anonymized data. All patient information has been handled with strict confidentiality. Consent for publication Not applicable Availability of data and materials The datasets generated and/or analysed during the current study are not publicly available due to patient confidentiality but are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This work was supported by the National Research Foundation of Korea(NRF) grant funded by the Korea government(MSIT)(No. NRF-2018R1D1A1A02042717, No.RS-2023-00251198). Authors' contributions N.J. conceived and designed the study, collected and analyzed the data, and drafted the manuscript. E.K.Y. assisted with data organization and management. I.H., H.S.K., and H.C. performed the surgeries and contributed to clinical data acquisition. Y.K. supervised the study and critically revised the manuscript for important intellectual content. All authors read and approved the final manuscript. Acknowledgements The authors would like to thank Editage (www.editage.co.kr) for the English language editing of this manuscript. Use of AI-assisted technologies During the preparation of this manuscript, the authors used Gemini 3 Pro and ChatGPT 5.0 in order to improve the English language and readability of the manuscript. After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the published article. References Smoll, N.R., et al., Incidence and relative survival of chordomas: the standardized mortality ratio and the impact of chordomas on a population. Cancer, 2013. 119 (11): p. 2029-37. McMaster, M.L., et al., Chordoma: incidence and survival patterns in the United States, 1973-1995. Cancer Causes Control, 2001. 12 (1): p. 1-11. Walcott, B.P., et al., Chordoma: current concepts, management, and future directions. Lancet Oncol, 2012. 13 (2): p. e69-76. Wedekind, M.F., B.C. Widemann, and G. Cote, Chordoma: Current status, problems, and future directions. Current Problems in Cancer, 2021. 45 (4): p. 100771. Dial, B.L., et al., The Role of Radiotherapy for Chordoma Patients Managed With Surgery: Analysis of the National Cancer Database. Spine (Phila Pa 1976), 2020. 45 (12): p. E742-e751. 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Variable N, (%) Demographics Age, years Male Female 59.0 [36.0-79.0] 16 (69.6) 7 (30.4) Presentation Primary Recurrent 21 (91.3) 2 (8.7) Tumor characteristics Longest diameter, cm Volume, cm 3 7.0 [3.8-14.5] 121.8 [14.6-873.9] Preoperative symptoms Motor Bladder Bowel 1 (4.3) 5 (21.7) 4 (17.4) Surgery Wide resection Colostomy Cystostomy Operative time, minutes Estimated blood loss, mL 23 (100.0) 2 (8.7) 0 (0.0) 315.0 [50.0 – 1241.0] 1250.0 [100.0 – 10000.0] Pathologic margin Negative Positive 21 (91.3) 2 (8.7) Chemotherapy Preopeartive Postoperative 0 (0.0) 1 (4.3) Radiotherapy Preoperative Postoperative 0 (0.0) 8 (34.8) Follow-up and outcomes Follow-up duration, years Alive Local recurrence Time to local recurrence, years Distant metastasis at diagnosis Distant metastasis (overall) Time to distant metastasis, years 7.0 [1.1–15.0] 19 (82.6) 9 (39.1) 2.5 [1.2–6.8] 3 (13.0) 7 (30.4) 2.7 [0.8–9.5] Table 2 . Association between spared sacral nerve roots, resection level, and postoperative motor & bladder & bowel function . Data are presented as percentages with the number of patients maintaining normal function over the total number assessed. Spared nerve root S1 S2 S3 S4 Unilateral Bilateral Unilateral Bilateral Unilateral Bilateral Unilateral Bilateral Total, n 0 1 2 9 3 4 1 3 Resection level S1/S2, n - 1 2 3 - 1 - - S2/S3, n - - - 6 3 2 1 1 S3/S4, n - - - - - 1 - 1 S4/S5, n - - - - - - - 1 Motor & bladder & bowel function Normal motor, % - 0.0 (0/1) 100.0 (2/2) 100.0 (9/9) 100.0 (3/3) 100.0 (4/4) 100.0 (1/1) 100.0 (3/3) Normal bladder, % - 0.0 (0/1) 0.0 (0/2) 22.2 (2/9) 33.3 (1/3) 100.0 (4/4) 100.0 (1/1) 100.0 (3/3) Normal bowel , % - 0.0 (0/1) 0.0 (0/2) 42.9 (3/7) 33.3 (1/3) 100.0 (4/4) 100.0 (1/1) 100.0 (3/3) Table 3. Bowel and bladder functional outcomes according to sacral nerve root preservation in previous studies and the current cohort . Values are presented as percentages, with the number of patients shown in parentheses. US = unilateral spared; BS = bilateral spared; numbers indicate the lowest preserved sacral root level (e.g., US3 = unilateral S3 preserved; BS3 = bilateral S3 preserved). “–” indicates data not reported. Study N Normal function, % Spared nerve root & Normal Bladder / Bowel function (%) No US1 BS1 US2 BS2 US3 BS3 US4 BS4 Xia et al., 2025 66 Bowel & Bladder 0.0 (0/5) 0.0 (0/14) 7.1 (1/14) 50.0 (2/4) 66.7 (14/21) 75.0 (6/8) Ji et al., 2016 115 Bladder - - - - - 37.5 (6/16) 65.0 (13/20) - - Moran et al., 2015[19] 73 Bladder 0.0 (2/2) 0.0 (0/6) 62.5 (5/8) 91.7 (11/12) - - Bowel 0.0 (2/2) 14.3 (1/7) 71.4 (5/7) 91.7 (11/12) - - Fourney et al., 2005[20] 29 Bladder 0.0 (0/5) 0.0 (0/7) 25.0 (1/4) 87.5 (7/8) - - Bowel 0.0 (0/5) 0.0 (0/7) 50.0 (2/4) 100.0 (8/8) - - Guo et al., 2005 32 Bowel 25.0 (12/16) 62.5 (5/8) 75.0 (2/8) Todd et al., 2002 53 Bladder - - 0.0 (0/10) - 25.0 (3/12) 60.0 (3/5) 69.2 (9/13) - - Bowel - - 0.0 (0/10) - 40.0 (2/5) 66.6 (2/3) 100.0 (4/4) - - Current study 22 Bladder - - 0.0 (0/1) 0.0 (0/2) 42.9 (3/7) 33.3 (1/3) 100.0 (4/4) 100.0 (1/1) 100.0 (3/3) Bowel - - 0.0 (0/1) 0.0 (0/2) 22.2 (2/9) 33.3 (1/3) 100.0 (4/4) 100.0 (1/1) 100.0 (3/3) Table 4 . Summary of oncologic outcomes of chordoma across major published series compared with that in the current cohort. Reported values include patient number, tumor site, follow-up duration, oncologic outcomes (death, local recurrence [LR], distant metastasis [DM]), time to recurrence/metastasis, and reported risk factors for LR. †Values are reported as mean unless otherwise specified. Median values are presented when available. LR = local recurrence; DM = distant metastasis; RM = resection margin; RT = radiotherapy; CT = chemotherapy; S+RT = surgery plus radiotherapy; NR = not reported. Study n Site Treatment (%) Follow up (years) Oncologic outcomes Prognostic factors for LR Mortality, % (n/N) LR, % (n/N) DM, % (n/N) Time to LR (years) Time to DM (years) Xia et al., 2025 101 Sacral 65.3%, Mobile spine 34.7% Surgery 56.4% S+RT 38.6% S+CT 5.0% 6.0† 9.9 (10/101) 24.8 (25/101) 7.9 (8/101) 4.0† 3.4† Tumors ≥100 cm 3 ; mobile spine ; neoadjuvant RT (good) Borkowska et al., 2025 48 Sacral Surgery 45.8% S+RT 14.6% RT 39.6% 7.4† NR 33.3 (16/49) 2.1 (1/48) 0.9† NR NR Waldsperger et al., 2025 31 (recurred) Sacral Surgery 100% N/A NR 14.5 (31/214) NR 1.3 NR NR Goumenos S et al., 2024 27 Sacral Surgery 85.2% S+RT 14.8% 4.8† 29.6 (8/27) 37.0 (10/27) 29.6 (8/27) 2.2† RM (N < 2mm or Positive) Zuckerman et al., 2021 50 Sacral Surgery 72.0% S+RT 28.0% 5.3 34.0 (17/50) 40.0 (20/50) 14.0 (7/50) 6.2 NR Intralesional Kerekes D et al., 2019 1235 Sacral NR 6.0† ~27 42.6 (526/1235) 22.4 (206/921) 3.3† 5.0† RM; Previous sacral surgery; Adjuvant therapy; Combined anterior-posterior approach Yang Y et al., 2017 157 Sacral Surgery 59.2% S+RT 40.8% 4.6† 14.0 (22/157) 23.6 (37/157) 10.8 (17/157) 2.8† NR RM; Tumor level (above S3) Chen KW et al., 2010 36 Sacral Surgery 59.3% S+RT 41.7% 6.2† 16.7 (6/36) 44.4 (16/36) 0.0 2.5† NR Tumor level (above S3); Muscle invasion; Intralesional excision; RM Current study 22 Sacral Surgery 65.2% S+RT 34.8% 7.0 8.7 (2/23) 39.1 (9/23) 30.7 (7/23) 2.5 2.7 NR Table 5 . Comparison of clinicopathological characteristics between patients with and without local recurrence. Continuous variables are presented as median [range]. Categorical variables are presented as number (%). Variable Recurrence (N = 9) No recurrence (N = 14) p-value (Univariate) Age , years 59 [40-77] 59 [36-79] p = 1.000 Old age <65yr ≥65yr 5 (55.6) 4 (44.4) 8 (57.1) 6 (42.9) p = 1.000 Sex Male Female 7 (77.8) 2 (22.2) 9 (64.3) 5 (35.7) p = 0.657 Tumor presentation Primary Recurrent 8 (88.9) 1 (11.1) 13 (92.9) 1 (7.1) p = 1.000 Tumor level Above S3 S3 and below 3 (33.3) 6 (66.7) 4 (28.6) 10 (71.4) p = 1.000 Tumor size <8cm ≥8cm 6 (66.7) 3 (33.3) 9 (64.3) 5 (35.7) p = 1.000 Tumor volume < 100cm 3 ≥100cm 3 2 (22.2) 7 (77.8) 6 (42.9) 8 (57.1) p = 0.400 Surgical margin Negative Positive 9 (100.0) 0 (0.0) 12 (85.7) 2 (14.3) p = 0.502 Preoperative neurology Present Absent 1 (11.1) 8 (88.9) 4 (28.6) 10 (71.4) p = 0.611 Adjuvant radiotherapy Yes No 5 (55.6) 4 (44.4) 3 (21.4) 11 (78.6) p = 0.179 Surgical complexity EBL, mL 1450 [100–10000] 1125 [450–6750] p = 0.850 Operation time, min 285 [50–520] 337.5 [160–1241] p = 0.122 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 25 Mar, 2026 Editor invited by journal 25 Feb, 2026 Editor assigned by journal 25 Feb, 2026 Submission checks completed at journal 24 Feb, 2026 First submitted to journal 24 Feb, 2026 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8860454","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":612196398,"identity":"0dfdf526-ec1a-48f1-9e03-4d5189bf0758","order_by":0,"name":"Naun Jeong","email":"","orcid":"","institution":"Seoul National University Bundang Hospital","correspondingAuthor":false,"prefix":"","firstName":"Naun","middleName":"","lastName":"Jeong","suffix":""},{"id":612196399,"identity":"344e2b29-773e-4df1-ba7a-0ab08cf495b8","order_by":1,"name":"Eunkyu Yang","email":"","orcid":"","institution":"Seoul National University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Eunkyu","middleName":"","lastName":"Yang","suffix":""},{"id":612196400,"identity":"b70d523a-8836-407c-90f3-4cda2ae632d8","order_by":2,"name":"Ilkyu Han","email":"","orcid":"","institution":"Seoul National University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ilkyu","middleName":"","lastName":"Han","suffix":""},{"id":612196401,"identity":"56b54723-1a5c-4773-a154-ee55e8cb84f6","order_by":3,"name":"Hwansung Cho","email":"","orcid":"","institution":"Seoul National University Bundang Hospital","correspondingAuthor":false,"prefix":"","firstName":"Hwansung","middleName":"","lastName":"Cho","suffix":""},{"id":612196402,"identity":"c331e6a6-493f-47e5-b4e2-a4a6ed08b243","order_by":4,"name":"Han-Soo Kim","email":"","orcid":"","institution":"Seoul National University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Han-Soo","middleName":"","lastName":"Kim","suffix":""},{"id":612196404,"identity":"3d2167c5-db49-4701-8aa2-2ea42279cc97","order_by":5,"name":"Yongsung Kim","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyklEQVRIie3OMQuCQBjG8ScCJ7H1FcH6CIZwOPlFWgzBSfsEEU1NlmvQlwiC5oNAl6tWx8bGmxojHZzPtqD7T+/B/eABdLqfjRNG3U29ib3+kgAe70u8ant5QgQz/34tCcsQ9oEriLglAWrKzvUiIZQxHCtSkDplHmRLTEYwOFxTNawjp0I05N2P+I922BEpo8GGw1ERWwiGSFC2b2ww38WmnSuIVeW+lOUqKwoxreUrdEkoyITDoKh7NYdqFjBeYyiVv3Q6ne6/+wB58kCdan+d/AAAAABJRU5ErkJggg==","orcid":"","institution":"Seoul National University Bundang Hospital","correspondingAuthor":true,"prefix":"","firstName":"Yongsung","middleName":"","lastName":"Kim","suffix":""}],"badges":[],"createdAt":"2026-02-12 09:53:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8860454/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8860454/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105571387,"identity":"bae9f9f1-c840-4202-ba9b-8435c0bcb47b","added_by":"auto","created_at":"2026-03-27 13:22:54","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":40479,"visible":true,"origin":"","legend":"\u003cp\u003eA flow chart showing the patient selection process\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8860454/v1/c20796973af8e51a9d0b4686.png"},{"id":105571412,"identity":"99208aac-156a-4521-a4b6-1ffecd22b4a7","added_by":"auto","created_at":"2026-03-27 13:23:08","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":51771,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMotor \u0026amp; bladder \u0026amp; bowel function according to the spared sacral nerve roots. \u003c/strong\u003eThe proportions of patients with preserved motor, bladder, and bowel function are shown according to the level and laterality of the spared sacral nerve roots. Functional preservation improved progressively with lower sacral root sparing. Abbreviations: \u003cstrong\u003eBS\u003c/strong\u003e, bilateral sparing; \u003cstrong\u003eUS\u003c/strong\u003e, unilateral sparing.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8860454/v1/6ecb211d28e97788e3859a0b.png"},{"id":105571294,"identity":"72048272-84b7-4d44-be98-e39b75e9081d","added_by":"auto","created_at":"2026-03-27 13:22:25","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":122120,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eKaplan–Meier curve of (A) Disease specific survival (DSS) (B) local recurrence-free survival (LRFS) (C) distant metastasis-free survival (DMFS).\u003c/strong\u003e The shaded area indicates the 95% confidence interval, and the numbers below the plot represent the number of patients at risk at each time point.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8860454/v1/0c667d0bb92d95cbf2139cfc.png"},{"id":105574099,"identity":"4e5e8051-f707-4fe6-9ce5-9d720db7b64a","added_by":"auto","created_at":"2026-03-27 13:33:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1827303,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8860454/v1/e71f8129-6925-4227-9c9b-3f5368e85cbd.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Functional Outcomes After Sacrectomy for Chordoma: The Critical Role of Bilateral S3 Nerve Root Preservation","fulltext":[{"header":"Background","content":"\u003cp\u003eChordomas are rare, slow-growing, malignant bone tumors that arise from the remnants of the notochord, with an incidence rate of 0.1 to 0.8 per 10\u0026nbsp;million [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Despite having a low histological grade, chordomas in sacral area are locally aggressive and associated with a high risk of local recurrence (LR) and distant metastasis (DM), which significantly affect long-term survival [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSurgical resection is the most important treatment method, as chordomas are typically resistant to chemotherapy and conventional radiotherapy. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] En bloc resection with wide margins is considered the optimal surgical approach for achieving durable local control. Inadequate margins, particularly in intra-lesional excisions, are consistently associated with high recurrence rates and poor oncologic outcomes [\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. However, complete resection is often challenging because of the complex anatomy of the sacrum and the close proximity of tumors to important neural structures, pelvic organs, and major vessels. Recently, carbon-ion therapy or proton therapy has emerged as an alternative treatment option for chordomas located in the higher sacrum, and neurological deficits after radiotherapy have been shown to be superior to those after surgery. [\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eFor bowel and bladder function, preservation of the S3 nerve roots has been identified as criticial [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Consequently, the surgical goal for sacral chordomas is to achieve en bloc resection while maximizing functional outcomes. While the importance of S3 preservation is well established, the precise extent of nerve preservation required for adequate functional recovery-specifically, whether unilateral or bilateral S3 perservation is necessary-remains poorly defined.\u003c/p\u003e \u003cp\u003eThis study aimed to evaluate the functional outcomes of sacrectomy for chordoma with focus on the relationship between the level and laterality of nerve root preservation and postoperative bowel and bladder function. Additionally, oncological outcomes including disease specific survival [DSS], local recurrence-free survival [LRFS], distant metastasis-free survival [DMFS] were assessed.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eWe conducted a retrospective cohort study of patients with sacral chordomas who underwent surgical treatment at Seoul National University Hospital and Seoul National University Bundang Hospital, Republic of Korea, between March 2009 and February 2024. The primary objective was to evaluate the association between the extent of sacral nerve root preservation and postoperative bowel and bladder function. Secondary objective included assessement of motor function and oncological outcomes, including DSS, LRFS, and DMFS. On patient selection, the inclusion criteria were: (1) histologically confirmed sacral chordoma; (2) surgical treatment with major sacrectomy; and (3) a minimum follow-up duration of 12 months. Three patients treated with other modalities and 1 patient who died less than a year postoperatively were excluded. After applying these criteria, 23 patients were included in the final analysis.\u003c/p\u003e \u003cp\u003eClinical and perioperative data were obtained from electronic medical records, including age, sex, tumor presentation (primary vs. recurrent), tumor size, tumor volume, tumor level, preoperative neurological deficits (motor, bladder, and bowel), operative time, estimated blood loss (EBL), colostomy and cystostomy formation, and treatment, including chemotherapy and radiotherapy. All patients underwent wide en bloc resection with wide margins. Postoperative pathological margin status was classified as negative or positive. Tumor size was defined as the longest diameter on biopsy, and tumor volume was calculated using the ellipsoid formula (length \u0026times; width \u0026times; height\u0026thinsp;\u0026times;\u0026thinsp;π/6) [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOn assessment of nerve preservation and functional outcomes, the level of sacral resection and preservation of sacral nerve roots were determined according to tumor involvement. The nerve roots were categorized according to their level (S1\u0026ndash;S5) and laterality (unilateral or bilateral preservation). Postoperative functional outcomes (motor, bladder, and bowel functions) were assessed at the last follow-up using clinical documentation. Motor function was considered normal if the patient reported a motor grade of 5 in the lower extremities. Bladder function was also considered normal if the patient reported no difficulty in continence during urination or no leaking of urine. Bowel function was considered normal if the record form the patient reported no dysfunction such as incontinence, constipation, or diarrhea.\u003c/p\u003e \u003cp\u003eOn assessment of oncological outcomes, routine follow-up evaluations were performed every 3 months for the first 2 years, every 6 months for the next 3 years, and annually thereafter. Each follow-up evaluation included a clinical examination, functional evaluation, and imaging studies with plain radiography, ultrasound, or magnetic resonance imaging (MRI) to evaluate the primary site. For metastasis surveillance, chest computed tomography, bone scan, and positron emission tomography-computed tomography were checked. LR was defined as radiologically or pathologically confirmed tumor regrowth at the primary site. DM was defined as disease outside the sacrum, as confirmed using imaging. Time-to-event outcomes, such as local recurrence-free survival (LRFS) and distant metastasis-free survival (DMFS), were calculated from the date of surgery to the date of event occurrence or last follow-up.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses were performed using the R software (version 4.3.0; R Foundation for Statistical Computing, Vienna, Austria). Continuous variables were summarized as medians and ranges when non-normally distributed. Categorical variables are expressed as frequencies and percentages. Comparisons between patients with and without LR were conducted using Student\u0026rsquo;s \u003cem\u003et\u003c/em\u003e-test or the Mann\u0026ndash;Whitney \u003cem\u003eU\u003c/em\u003e test for continuous variables, depending on the data distribution, and the chi-square test or Fisher\u0026rsquo;s exact test for categorical variables. The Kaplan\u0026ndash;Meier method was used to estimate time-to-event outcomes, such as LRFS and DMFS. The median survival was reported with 95% confidence intervals (CI). The log-rank test was used to compare survival curves. All statistical tests were two-tailed, and statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eTwenty-three patients were included in the study (\u003cstrong\u003eFigure 1\u003c/strong\u003e). The median age was 59.0 years (range, 36\u0026ndash;79\u0026nbsp;years)\u0026nbsp;and 16\u0026nbsp;patients (69.6%) were male. Most tumors presented as primary lesions (91.3%) with a median longest tumor diameter of 7.0 cm (range, 3.8\u0026ndash;14.5), and a median tumor volume of 121.8 cm\u0026sup3; (range, 14.6\u0026ndash;873.9). Preoperative symptoms included motor deficit in 1 (4.3%), bladder dysfunction in 5 (21.7%), and bowel dysfunction in 4 (17.4%). All\u0026nbsp;the patients underwent wide\u0026nbsp;en\u0026nbsp;bloc resection. Colostomy was performed in 2 (8.7%) patients; no cystostomy was performed. The median operative time was 315.0 minutes (range, 50.0\u0026ndash;1241.0 minutes), and the median EBL was 1250.0 mL (range, 100.0\u0026ndash;10000.0 mL). Negative surgical margins were achieved in 21 (91.3%) patients. One patient underwent chemotherapy. No patients received preoperative radiotherapy; postoperative radiotherapy was administered to 8 (34.8%) (\u003cstrong\u003eTable 1\u003c/strong\u003e). The median follow-up duration was 7.0 years (range, 1.1\u0026ndash;15.0 years). 19 patients (82.6%) were alive at the last follow-up.\u003c/p\u003e\n\u003cp\u003eFunctional outcomes in the patients were significantly correlated with the level and laterality of the preserved sacral nerve roots (\u003cstrong\u003eTable 2, Figure 2\u003c/strong\u003e). When only the bilateral S1 or unilateral S1 roots were preserved, no patient exhibited normal motor, bladder, or bowel functions. Maintaining bilateral S2 roots (n = 9) led to normal bladder and bowel function in 42.9% (3/7) and 22.2% (2/9) of the patients, respectively, while motor function was preserved in all patients (9/9). Upon achieving unilateral S3 preservation (n = 3), normal bladder and bowel function was noted in 33.3% of the patients, along with complete motor recovery (100%). Bilateral S3 preservation (n = 4)\u0026nbsp;was correlated with positive outcomes, as all the patients retained normal motor, bladder, and bowel functions. Likewise, unilateral (n = 1) and bilateral S4 preservation (n = 3) consistently achieved 100% preservation of motor, bladder, and bowel functions.\u003c/p\u003e\n\u003cp\u003eThe Kaplan\u0026ndash;Meier estimate of DSS demonstrated\u0026nbsp;5-year and 10-year survival rates of 95.0% and 74.4%, respectively (\u003cstrong\u003eFigure 3A).\u0026nbsp;\u003c/strong\u003eLR occurred in 9 (39.1%) patients, with a median time to recurrence of 2.5 years (range, 1.2\u0026ndash;6.8 years). During a median follow-up of 7.0 years (range, 1.1-15.0 years), LR occurred in 9 patients (39.1%). The Kaplan\u0026ndash;Meier estimate of LRFS demonstrated 5-year and 10-year survival rates of 65.7% (95% CI 40.9-82.0) and 52.5% (95% CI 27.7-72.4), respectively (\u003cstrong\u003eFigure 3B\u003c/strong\u003e). DM was present at diagnosis in 3 (13.0%) patients; including 3 patients, a total of 7 (30.4%) developed DM during follow-up, with a median interval of 2.7 years (range, 0.8\u0026ndash;9.5 years). Kaplan\u0026ndash;Meier analysis demonstrated favorable DMFS in the overall cohort. The estimated 5-year and 10-year DMFS rates were 72.4% (95% CI 48.3-86.7) and 60.4% (95% CI 29.6-81.1), respectively (\u003cstrong\u003eFigure 3C\u003c/strong\u003e).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, we evaluated the functional outcomes of 23 patients with sacral chordoma who underwent sacrectomy, with focus on the relationship between nerve root preservation and postoperative bowel and bladder function. Our result showed that bilateral S3 preservation achieved 100% normal bladder and bowel function, compared to only 33.3% with unilateral S3 preservation. Additionally, despite en bloc resection with wide margins, local recurrence rate remained high at 39.1% over a median follow-up of 7.0 years.\u003c/p\u003e\n\u003cp\u003eThe most favorable outcomes were observed in patients with bilateral S3 preservation (n = 4), as all patients maintained normal bladder and bowel function. Similarly, preservation of the unilateral (n = 1) or bilateral S4 roots (n = 3) was consistently associated with complete recovery of bladder and bowel function. In contrast, unilateral S3 preservation resulted in normal bladder and bowel function in only 33.3%. This disparity suggests that while preservation of at least one S3 root is necessary for continence, it may not be sufficient and bilateral preservation confers a significant functional advantage. This finding may be consistent with neurophysiological evidence that parasympathetic innervation of the bladder relies on a balanced contribution from both sacral roots. Carlucci et al. [24] demonstrated that although S3 roots invariably contribute to detrusor contraction, bladder control typically requires input from multiple sacral roots in combination rather than from a single root alone, underscoring the variability and redundancy of sacral innervation. Similarly, experimental data by Su et al. [25] showed that bilateral stimulation of the sacral nerves produced a more effective modulation of bladder activity than unilateral stimulation, even at lower stimulus intensities, suggesting that bilateral inputs provide synergistic effects in maintaining normal bladder function. Taken together, these findings support our clinical observation that the preservation of both S3 roots is critical for optimizing bladder function after sacral chordoma resection.\u003c/p\u003e\n\u003cp\u003eIn our cohort, the bowel and bladder outcomes after sacral resection were generally comparable with those reported in previous studies (\u003cstrong\u003eTable 3\u003c/strong\u003e). When preservation was limited to the bilateral S1 or unilateral S1 roots, no patient achieved normal bladder or bowel function. These findings are comparable to those of previous studies. With bilateral S2 preservation (n = 9), normal bladder and bowel functions were observed in 42.9% and 22.2% of patients, respectively. Regarding unilateral S3 preservation, our result with 33.3% normal function was lower than those reported in previous reports. Xia et al. [21] reported that postoperative bowel or bladder dysfunction (BBD) was occurred in 50% of patients with unilateral S3 preservation. Ji et al. [22] analyzed the postoperative neurological function using a newly designed scoring system. Among the patients with unilateral preservation of the S3 nerve root, 37.5% achieved a perfect bladder score. Guo et al. [12] retrospectively analyzed 50 patients who underwent sacrectomy; in 32 patients with non\u0026ndash;rectal cancer without colostomy, bowel function was normal 62.5% after unilateral S3 resection, with concordant bowel and bladder function in 94% of the cases. Todd et al. [23] reported that normal bladder/bowel function was retained in 60%/66.6% of patients, respectively with preservation of at least one S3. The small sample size in our study may have contributed to the slightly worse functional outcomes observed with unilateral S3 preservation (US3). Notably, one patient with unilateral S3 preservation had preoperative bladder and bowel dysfunction, but showed postoperative improvement, achieving self-voiding and adequate sphincter control. This finding suggests the potential for functional recovery after surgery, possibly due to neural plasticity or compensation from preserved contralateral roots.\u003c/p\u003e\n\u003cp\u003eRegarding oncological outcomes, the LR rate of 39.1% in our cohort was comparable to previous reports ranging from 14.5% to 44.4%. (\u003cstrong\u003eTable 4\u003c/strong\u003e). Xia et al. [14] reported a retrospective cohort of 101 patients with spinal and sacral chordomas treated with definitive surgery, with a mean follow-up of 6.0 years and an LR rate of 24.8%. Borkowska et al. [8] retrospectively analyzed 48 patients with sacral chordomas, and LR occurred in 33.3% of patients. In a pooled analysis by Kerekes et al. [15], LR occurred in 42.6% of patients.\u003c/p\u003e\n\u003cp\u003eThe median time to LR in our study was 2.5 years ranging from 1.2 to 6.8 years, whereas previous studies have shown a broader interval, from as early as 0.87 years to as long as 6.2 years. In our cohort, LR occurred even at 6.8 years (81 months) after surgery, highlighting the importance of long-term surveillance. Unlike many malignancies that are routinely followed up for 5 years, sacral chordomas are slow-growing tumors, and late recurrence remains a significant concern. Similarly, Zuckerman et al. [6] reported a median time to LR of 6.2 years, further highlighting the need for follow-up beyond the conventional 5-year period.\u003c/p\u003e\n\u003cp\u003eDistant metastasis occurred in 30.4% of patients, with a median time of 2.7 years. All patients with DM developed pulmonary metastases. Notably, two patients had multifocal disease: one with multiple cutaneous metastases and the other with prostate involvement. The incidence of DM in sacral chordomas varies from 0% to 29.6%, with the lungs identified as the predominant metastatic site, and infrequent involvement of the liver or bone. [15] These results underscore the need for regular chest imaging during postoperative surveillance.\u003c/p\u003e\n\u003cp\u003eIn our analysis, no statistically significant risk factors for LR were identified, possibly owing to the small sample size(Table 5). Moreover, although en bloc resection was successfully performed in all cases with a negative margin rate of 91.3%, LR occurred in 39.1% of cases. Interestingly, even cases with positive margins did not always result in LR in our cohort. Nonetheless, current literature consistently identifies incomplete excision as a poor prognostic factor. In a pooled analysis by Kerekes et al.[15], the most consistent prognostic determinant for both LR and DM in sacral chordomas was the surgical margin, with wide margins significantly reducing the risk compared to marginal, intralesional, or contaminated resections. Recently, Goumenos et al. [16] analyzed 27 surgically treated sacral chordomas and reported that inadequate (\u0026lt;2 mm) or positive margins were strongly associated with recurrence. Additional reported prognostic factors include tumor volume \u0026ge;100 cm\u0026sup3; [14], soft tissue invasion [7], [17], tumor location above S3[7], and prior sacral surgery[15].\u003c/p\u003e\n\u003cp\u003eDespite the high LR rate with long interval, the overall oncological prognosis of sacral chordoma remains favorable. In our cohort, the 5-year and 10-year DSS were 95.0% and 74.4%, respectively, which are comparable to or better than those reported in previous studies[6], [14], [15]. This relatively favorable survival despite high LR rate, can be attributed to the slow-growing nature of chordomas. These findings suggest that early detection of recurrence through regular surveillance enables timely intervention, which may translate into improved survival outcomes. Therefore regular surveillance beyond 5 years is essential for early detection of recurrence and timely intervention.\u003c/p\u003e\n\u003cp\u003eThis study had several limitations. First, its retrospective design may have introduced inherent selection and information bias. Second, the sample size was small (n = 23) due to the rarity of sacral chordomas, which limited the statistical power to identify significant prognostic factors. Third, as in most previous studies, bowel and bladder dysfunction were assessed based on patient reports documented in clinical records, which may have underestimated subtle deficits. Ji et al. [22] used a 27-point scoring system with four subdomains that examined bladder function: dysuria, urinary incontinence, bladder sensation, and overall bladder function. The use of scoring systems may be helpful in objectively evaluating functional outcomes. Future research with larger multicenter cohorts and standardized functional scoring systems is needed to provide a more objective and comprehensive assessment of long-term bowel and bladder function after major sacrectomy in patients with sacral chordoma. \u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study demonstrated that bilateral S3 nerve root preservation is critical for achieving optimal bowel and bladder function after sacrectomy for sacral chordoma, with 100% of patients maintaining normal continence compared to only 33.3% with unilateral S3 preservation. This finding suggests that when oncologically feasible, preservation of S3 preservation should be considered to optimize postoperative bowel and bladder function. Despite high local recurrence rate of 39.1%, favorable disease-specific survival was achieved (5-year 95.0%, 10-year 74.4%), suggesting vigilant long-term surveillance beyond 5 years can lead to excellent oncological outcomes through early detection and timely intervention.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBBD: Bowel or Bladder Dysfunction\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBS: Bilateral Sparing\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCI: Confidence Interval\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCT: Chemotherapy\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDM: Distant Metastasis\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDMFS: Distant Metastasis-Free Survival\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDSS: Disease-Specific Survival\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEBL: Estimated Blood Loss\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIRB: Institutional Review Board\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLR: Local Recurrence\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLRFS: Local Recurrence-Free Survival\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMRI: Magnetic Resonance Imaging\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRM: Resection Margin\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRT: Radiotherapy\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUS: Unilateral Sparing\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in accordance with the principles of the Declaration of Helsinki. Institutional Institutional Review Board approval was obtained from the Institutional Review Board of Seoul National University Hospital (IRB No. H-2509-181-1683) and the Institutional Review Board of Seoul National University Bundang Hospital (IRB No. B-2509-999-101). The requirement for informed consent was waived by the Institutional Review Board of Seoul National University Hospital and the Institutional Review Board of Seoul National University Bundang Hospital due to the retrospective nature of the study and the use of anonymized data. All patient information has been handled with strict confidentiality.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available due to patient confidentiality but are available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the National Research Foundation of Korea(NRF) grant funded by the Korea government(MSIT)(No. NRF-2018R1D1A1A02042717, No.RS-2023-00251198).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eN.J. conceived and designed the study, collected and analyzed the data, and drafted the manuscript. E.K.Y. assisted with data organization and management. I.H., H.S.K., and H.C. performed the surgeries and contributed to clinical data acquisition. Y.K. supervised the study and critically revised the manuscript for important intellectual content. All authors read and approved the final manuscript.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank Editage (www.editage.co.kr) for the English language editing of this manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eUse of AI-assisted technologies\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring the preparation of this manuscript, the authors used Gemini 3 Pro and ChatGPT 5.0 in order to improve the English language and readability of the manuscript. After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the published article.\u003cbr clear=\"all\"\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSmoll, N.R., et al., \u003cem\u003eIncidence and relative survival of chordomas: the standardized mortality ratio and the impact of chordomas on a population.\u003c/em\u003e Cancer, 2013. \u003cstrong\u003e119\u003c/strong\u003e(11): p. 2029-37.\u003c/li\u003e\n\u003cli\u003eMcMaster, M.L., et al., \u003cem\u003eChordoma: incidence and survival patterns in the United States, 1973-1995.\u003c/em\u003e Cancer Causes Control, 2001. \u003cstrong\u003e12\u003c/strong\u003e(1): p. 1-11.\u003c/li\u003e\n\u003cli\u003eWalcott, B.P., et al., \u003cem\u003eChordoma: current concepts, management, and future directions.\u003c/em\u003e Lancet Oncol, 2012. \u003cstrong\u003e13\u003c/strong\u003e(2): p. e69-76.\u003c/li\u003e\n\u003cli\u003eWedekind, M.F., B.C. 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E742-e751.\u003c/li\u003e\n\u003cli\u003eZuckerman, S.L., et al., \u003cem\u003eOutcomes of Surgery for Sacral Chordoma and Impact of Complications: A Report of 50 Consecutive Patients With Long-Term Follow-Up.\u003c/em\u003e Global Spine J, 2021. \u003cstrong\u003e11\u003c/strong\u003e(5): p. 740-750.\u003c/li\u003e\n\u003cli\u003eChen, K.W., et al., \u003cem\u003ePrognostic factors of sacral chordoma after surgical therapy: a study of 36 patients.\u003c/em\u003e Spinal Cord, 2010. \u003cstrong\u003e48\u003c/strong\u003e(2): p. 166-71.\u003c/li\u003e\n\u003cli\u003eBorkowska, A.M., et al., \u003cem\u003eLong-Term Outcomes of Patients Diagnosed With Sacral Chordoma in a Retrospective Multicenter Study.\u003c/em\u003e Cancer Control, 2025. \u003cstrong\u003e32\u003c/strong\u003e: p. 10732748251323730.\u003c/li\u003e\n\u003cli\u003eImai, R., T. Kamada, and N. Araki, \u003cem\u003eCarbon Ion Radiation Therapy for Unresectable Sacral Chordoma: An Analysis of 188 Cases.\u003c/em\u003e Int J Radiat Oncol Biol Phys, 2016. \u003cstrong\u003e95\u003c/strong\u003e(1): p. 322-327.\u003c/li\u003e\n\u003cli\u003eSantoro, A., et al. \u003cem\u003eCarbon Ion and Proton Therapy in Sacral Chordoma: A Systematic Review\u003c/em\u003e. Journal of Clinical Medicine, 2025. \u003cstrong\u003e14\u003c/strong\u003e, DOI: 10.3390/jcm14175947.\u003c/li\u003e\n\u003cli\u003eYolcu, Y.U., et al., \u003cem\u003eComparison of Oncologic Outcomes and Treatment-Related Toxicity of Carbon Ion Radiotherapy and En Bloc Resection for Sacral Chordoma.\u003c/em\u003e JAMA Network Open, 2022. \u003cstrong\u003e5\u003c/strong\u003e(1): p. e2141927-e2141927.\u003c/li\u003e\n\u003cli\u003eGuo, Y., et al., \u003cem\u003eBowel and bladder continence, wound healing, and functional outcomes in patients who underwent sacrectomy.\u003c/em\u003e J Neurosurg Spine, 2005. \u003cstrong\u003e3\u003c/strong\u003e(2): p. 106-10.\u003c/li\u003e\n\u003cli\u003eRuggieri, P., et al., \u003cem\u003eInfections in surgery of primary tumors of the sacrum.\u003c/em\u003e Spine (Phila Pa 1976), 2012. \u003cstrong\u003e37\u003c/strong\u003e(5): p. 420-8.\u003c/li\u003e\n\u003cli\u003eXia, Y., et al., \u003cem\u003eOutcomes After Definitive Surgery for Spinal and Sacral Chordoma in 101 Patients Over 20 Years.\u003c/em\u003e Neurosurgery, 2025. \u003cstrong\u003e96\u003c/strong\u003e(3): p. 494-504.\u003c/li\u003e\n\u003cli\u003eKerekes, D., et al., \u003cem\u003eLocal and Distant Recurrence in Resected Sacral Chordomas: A Systematic Review and Pooled Cohort Analysis.\u003c/em\u003e Global Spine J, 2019. \u003cstrong\u003e9\u003c/strong\u003e(2): p. 191-201.\u003c/li\u003e\n\u003cli\u003eGoumenos, S., et al., \u003cem\u003eClinical Outcome after Surgical Treatment of Sacral Chordomas: A Single-Center Retrospective Cohort of 27 Patients.\u003c/em\u003e Cancers (Basel), 2024. \u003cstrong\u003e16\u003c/strong\u003e(5).\u003c/li\u003e\n\u003cli\u003eWaldsperger, H., et al., \u003cem\u003eRecurrence Patterns After Resection of Sacral Chordoma: Toward an Optimized Postoperative Target Volume Definition.\u003c/em\u003e Cancers (Basel), 2025. \u003cstrong\u003e17\u003c/strong\u003e(15).\u003c/li\u003e\n\u003cli\u003eYang, Y., et al., \u003cem\u003eRecurrence and survival factors analysis of 171 cases of sacral chordoma in a single institute.\u003c/em\u003e Eur Spine J, 2017. \u003cstrong\u003e26\u003c/strong\u003e(7): p. 1910-1916.\u003c/li\u003e\n\u003cli\u003eMoran, D., et al., \u003cem\u003eMaintenance of bowel, bladder, and motor functions after sacrectomy.\u003c/em\u003e Spine J, 2015. \u003cstrong\u003e15\u003c/strong\u003e(2): p. 222-9.\u003c/li\u003e\n\u003cli\u003eFourney, D.R., et al., \u003cem\u003eEn bloc resection of primary sacral tumors: classification of surgical approaches and outcome.\u003c/em\u003e J Neurosurg Spine, 2005. \u003cstrong\u003e3\u003c/strong\u003e(2): p. 111-22.\u003c/li\u003e\n\u003cli\u003eXia, Y., et al., \u003cem\u003eLong-term functional outcomes and their relationship to nerve root sacrifice after definitive surgery for sacrococcygeal chordoma.\u003c/em\u003e J Neurosurg Spine, 2025: p. 1-12.\u003c/li\u003e\n\u003cli\u003eJi, T., et al., \u003cem\u003eWhat Are the Conditional Survival and Functional Outcomes After Surgical Treatment of 115 Patients With Sacral Chordoma?\u003c/em\u003e Clin Orthop Relat Res, 2017. \u003cstrong\u003e475\u003c/strong\u003e(3): p. 620-630.\u003c/li\u003e\n\u003cli\u003eTodd, L.T., Jr., et al., \u003cem\u003eBowel and bladder function after major sacral resection.\u003c/em\u003e Clin Orthop Relat Res, 2002(397): p. 36-9.\u003c/li\u003e\n\u003cli\u003eCarlucci, L., et al., \u003cem\u003eFunctional variability of sacral roots in bladder control.\u003c/em\u003e J Neurosurg Spine, 2014. \u003cstrong\u003e21\u003c/strong\u003e(6): p. 961-5.\u003c/li\u003e\n\u003cli\u003eSu, X., A. Nickles, and D.E. Nelson, \u003cem\u003eQuantification of effectiveness of bilateral and unilateral neuromodulation in the rat bladder rhythmic contraction model.\u003c/em\u003e BMC Urology, 2013. \u003cstrong\u003e13\u003c/strong\u003e(1): p. 34.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eBaseline, perioperative, and oncologic characteristics of the cohort (n=23).\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 254px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN, (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDemographics\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eAge, years\u003c/p\u003e\n \u003cp\u003eMale\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 254px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e59.0 [36.0-79.0]\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e16 (69.6)\u003c/p\u003e\n \u003cp\u003e7 (30.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePresentation\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003cp\u003eRecurrent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 254px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e21 (91.3)\u003c/p\u003e\n \u003cp\u003e2 (8.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTumor characteristics\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eLongest diameter, cm\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eVolume, cm\u003csup\u003e3\u0026nbsp;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 254px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7.0 [3.8-14.5]\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e121.8 [14.6-873.9]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreoperative symptoms\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; Motor\u003c/p\u003e\n \u003cp\u003eBladder\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; Bowel\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 254px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (4.3)\u003c/p\u003e\n \u003cp\u003e5 (21.7)\u003c/p\u003e\n \u003cp\u003e4 (17.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgery\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eWide resection\u003c/p\u003e\n \u003cp\u003eColostomy\u003c/p\u003e\n \u003cp\u003eCystostomy\u003c/p\u003e\n \u003cp\u003eOperative time, minutes\u003c/p\u003e\n \u003cp\u003eEstimated blood loss, mL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 254px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e23 (100.0)\u003c/p\u003e\n \u003cp\u003e2 (8.7)\u003c/p\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003cp\u003e315.0 [50.0 \u0026ndash; 1241.0]\u003c/p\u003e\n \u003cp\u003e1250.0 [100.0 \u0026ndash; 10000.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePathologic margin\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eNegative\u003c/p\u003e\n \u003cp\u003ePositive\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 254px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e21 (91.3)\u003c/p\u003e\n \u003cp\u003e2 (8.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChemotherapy\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003ePreopeartive\u003c/p\u003e\n \u003cp\u003ePostoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 254px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003cp\u003e1 (4.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRadiotherapy\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003ePreoperative\u003c/p\u003e\n \u003cp\u003ePostoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 254px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003cp\u003e8 (34.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFollow-up and outcomes\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eFollow-up duration, years\u003c/p\u003e\n \u003cp\u003eAlive\u003c/p\u003e\n \u003cp\u003eLocal recurrence\u003c/p\u003e\n \u003cp\u003eTime to local recurrence, years\u003c/p\u003e\n \u003cp\u003eDistant metastasis at diagnosis\u003c/p\u003e\n \u003cp\u003eDistant metastasis (overall)\u003c/p\u003e\n \u003cp\u003eTime to distant metastasis, years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 254px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7.0 [1.1\u0026ndash;15.0]\u003c/p\u003e\n \u003cp\u003e19 (82.6)\u003c/p\u003e\n \u003cp\u003e9 (39.1)\u003c/p\u003e\n \u003cp\u003e2.5 [1.2\u0026ndash;6.8]\u003c/p\u003e\n \u003cp\u003e3 (13.0)\u003c/p\u003e\n \u003cp\u003e7 (30.4)\u003c/p\u003e\n \u003cp\u003e2.7 [0.8\u0026ndash;9.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e. \u003cstrong\u003eAssociation between spared sacral nerve roots, resection level, and postoperative motor \u0026amp; bladder \u0026amp; bowel function\u003c/strong\u003e. Data are presented as percentages with the number of patients maintaining normal function over the total number assessed.\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"628\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eSpared nerve root\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eS1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eS2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eS3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eS4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003eUnilateral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003eBilateral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eUnilateral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003eBilateral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eUnilateral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003eBilateral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eUnilateral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003eBilateral\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eTotal, n\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\" valign=\"top\" style=\"width: 628px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eResection level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eS1/S2, n\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eS2/S3, n\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eS3/S4, n\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eS4/S5, n\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\" valign=\"top\" style=\"width: 628px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMotor \u0026amp; bladder \u0026amp; bowel function\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eNormal motor, %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003cp\u003e(0/1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e100.0\u003c/p\u003e\n \u003cp\u003e(2/2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e100.0\u003cbr\u003e\u0026nbsp;(9/9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e100.0\u003c/p\u003e\n \u003cp\u003e(3/3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e100.0\u003c/p\u003e\n \u003cp\u003e(4/4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e100.0\u003c/p\u003e\n \u003cp\u003e(1/1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e100.0\u003c/p\u003e\n \u003cp\u003e(3/3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eNormal bladder, %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003cp\u003e(0/1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003cp\u003e(0/2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e22.2\u003c/p\u003e\n \u003cp\u003e(2/9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e33.3\u003c/p\u003e\n \u003cp\u003e(1/3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e100.0 (4/4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e100.0\u003c/p\u003e\n \u003cp\u003e(1/1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e100.0\u003c/p\u003e\n \u003cp\u003e(3/3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eNormal bowel , %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003cp\u003e(0/1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003cp\u003e(0/2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e42.9\u003c/p\u003e\n \u003cp\u003e(3/7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e33.3\u003c/p\u003e\n \u003cp\u003e(1/3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e100.0\u003c/p\u003e\n \u003cp\u003e(4/4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e100.0\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(1/1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e100.0\u003c/p\u003e\n \u003cp\u003e(3/3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u003c/strong\u003e \u003cstrong\u003eBowel and bladder functional outcomes according to sacral nerve root preservation in previous studies and the current cohort\u003c/strong\u003e. Values are presented as percentages, with the number of patients shown in parentheses. US = unilateral spared; BS = bilateral spared; numbers indicate the lowest preserved sacral root level (e.g., US3 = unilateral S3 preserved; BS3 = bilateral S3 preserved). \u0026ldquo;\u0026ndash;\u0026rdquo; indicates data not reported.\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"604\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNormal function, %\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"9\" valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSpared nerve root \u0026amp; Normal Bladder / Bowel function (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUS1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBS1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUS2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBS2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUS3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBS3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUS4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBS4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eXia et al., 2025\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eBowel \u0026amp; Bladder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003cp\u003e(0/5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.0\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(0/14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 95px;\"\u003e\n \u003cp\u003e7.1\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(1/14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e50.0 (2/4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e66.7 (14/21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 95px;\"\u003e\n \u003cp\u003e75.0\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(6/8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eJi et al., 2016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e115\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eBladder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e37.5\u003c/p\u003e\n \u003cp\u003e(6/16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e65.0\u003c/p\u003e\n \u003cp\u003e(13/20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 66px;\"\u003e\n \u003cp\u003eMoran et al., 2015[19]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 38px;\"\u003e\n \u003cp\u003e73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eBladder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e0.0 (2/2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0.0\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(0/6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 96px;\"\u003e\n \u003cp\u003e62.5\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(5/8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e91.7 (11/12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eBowel\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e0.0 (2/2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 132px;\"\u003e\n \u003cp\u003e14.3\u003c/p\u003e\n \u003cp\u003e(1/7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 96px;\"\u003e\n \u003cp\u003e71.4\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(5/7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e91.7 (11/12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 66px;\"\u003e\n \u003cp\u003eFourney et al., 2005[20]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 38px;\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eBladder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e0.0 \u0026nbsp;(0/5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0.0\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(0/7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 96px;\"\u003e\n \u003cp\u003e25.0\u003c/p\u003e\n \u003cp\u003e(1/4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e87.5\u003c/p\u003e\n \u003cp\u003e(7/8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eBowel\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e0.0 (0/5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0.0\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(0/7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 96px;\"\u003e\n \u003cp\u003e50.0\u003c/p\u003e\n \u003cp\u003e(2/4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e100.0\u003c/p\u003e\n \u003cp\u003e(8/8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eGuo et al., 2005\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eBowel\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"5\" style=\"width: 226px;\"\u003e\n \u003cp\u003e25.0 (12/16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e62.5 (5/8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 150px;\"\u003e\n \u003cp\u003e75.0 (2/8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 66px;\"\u003e\n \u003cp\u003eTodd\u0026nbsp;et al., 2002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 38px;\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eBladder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003cp\u003e(0/10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e25.0\u003c/p\u003e\n \u003cp\u003e(3/12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e60.0\u003c/p\u003e\n \u003cp\u003e(3/5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e69.2 (9/13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eBowel\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003cp\u003e(0/10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e40.0\u003c/p\u003e\n \u003cp\u003e(2/5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e66.6\u003c/p\u003e\n \u003cp\u003e(2/3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e100.0 (4/4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCurrent study\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 38px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eBladder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003cp\u003e(0/1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003cp\u003e(0/2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e42.9\u003c/p\u003e\n \u003cp\u003e(3/7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e33.3\u003c/p\u003e\n \u003cp\u003e(1/3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e100.0\u003c/p\u003e\n \u003cp\u003e(4/4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e100.0\u003c/p\u003e\n \u003cp\u003e(1/1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e100.0\u003c/p\u003e\n \u003cp\u003e(3/3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eBowel\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003cp\u003e(0/1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003cp\u003e(0/2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e22.2\u003c/p\u003e\n \u003cp\u003e(2/9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e33.3\u003c/p\u003e\n \u003cp\u003e(1/3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e100.0 (4/4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e100.0\u003c/p\u003e\n \u003cp\u003e(1/1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e100.0\u003c/p\u003e\n \u003cp\u003e(3/3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cstrong\u003eTable 4\u003c/strong\u003e. \u003cstrong\u003eSummary of oncologic outcomes of chordoma across major published series compared with that in the current cohort.\u003c/strong\u003e Reported values include patient number, tumor site, follow-up duration, oncologic outcomes (death, local recurrence [LR], distant metastasis [DM]), time to recurrence/metastasis, and reported risk factors for LR. \u0026dagger;Values are reported as mean unless otherwise specified. Median values are presented when available. LR = local recurrence; DM = distant metastasis; RM = resection margin; RT = radiotherapy; CT = chemotherapy; S+RT = surgery plus radiotherapy; NR = not reported.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"916\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSite\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTreatment (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 88px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFollow up (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 333px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOncologic outcomes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 183px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrognostic factors for LR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMortality, % (n/N)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLR, %\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n/N)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDM, % (n/N)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to LR (years)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to DM (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eXia et al., 2025\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e101\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003eSacral 65.3%,\u003c/p\u003e\n \u003cp\u003eMobile spine 34.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eSurgery 56.4%\u003c/p\u003e\n \u003cp\u003eS+RT 38.6%\u003c/p\u003e\n \u003cp\u003eS+CT 5.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e6.0\u0026dagger;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e9.9\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(10/101)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e24.8\u003c/p\u003e\n \u003cp\u003e(25/101)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e7.9\u003c/p\u003e\n \u003cp\u003e(8/101)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e4.0\u0026dagger;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e3.4\u0026dagger; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 183px;\"\u003e\n \u003cp\u003eTumors \u0026ge;100 cm\u003csup\u003e3\u003c/sup\u003e; mobile spine\u003c/p\u003e\n \u003cp\u003e; neoadjuvant RT (good)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eBorkowska et al., 2025\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003eSacral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eSurgery 45.8%\u003c/p\u003e\n \u003cp\u003eS+RT 14.6%\u003c/p\u003e\n \u003cp\u003eRT 39.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e7.4\u0026dagger;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e33.3\u003c/p\u003e\n \u003cp\u003e(16/49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e2.1\u003c/p\u003e\n \u003cp\u003e(1/48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e0.9\u0026dagger;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 183px;\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eWaldsperger et al., 2025\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003cp\u003e(recurred)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003eSacral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eSurgery 100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e14.5\u003c/p\u003e\n \u003cp\u003e(31/214)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 183px;\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eGoumenos S et al., 2024\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003eSacral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eSurgery 85.2%\u003c/p\u003e\n \u003cp\u003eS+RT 14.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e4.8\u0026dagger;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e29.6\u003c/p\u003e\n \u003cp\u003e(8/27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e37.0\u003c/p\u003e\n \u003cp\u003e(10/27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e29.6\u003c/p\u003e\n \u003cp\u003e(8/27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 120px;\"\u003e\n \u003cp\u003e2.2\u0026dagger;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 183px;\"\u003e\n \u003cp\u003eRM (N \u0026lt; 2mm or Positive)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eZuckerman et al., 2021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003eSacral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eSurgery 72.0%\u003c/p\u003e\n \u003cp\u003eS+RT 28.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e5.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e34.0\u003c/p\u003e\n \u003cp\u003e(17/50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e40.0\u003c/p\u003e\n \u003cp\u003e(20/50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e14.0\u003c/p\u003e\n \u003cp\u003e(7/50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e6.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 183px;\"\u003e\n \u003cp\u003eIntralesional\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eKerekes D et al., 2019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e1235\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003eSacral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e6.0\u0026dagger;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e~27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e42.6 (526/1235)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e22.4 (206/921)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e3.3\u0026dagger;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e5.0\u0026dagger;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 183px;\"\u003e\n \u003cp\u003eRM; Previous sacral surgery;\u003c/p\u003e\n \u003cp\u003eAdjuvant therapy; Combined anterior-posterior approach\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eYang Y et al., 2017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e157\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003eSacral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eSurgery 59.2%\u003c/p\u003e\n \u003cp\u003eS+RT 40.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e4.6\u0026dagger;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e14.0\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(22/157)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e23.6\u003c/p\u003e\n \u003cp\u003e(37/157)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e10.8\u003c/p\u003e\n \u003cp\u003e(17/157)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e2.8\u0026dagger;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 183px;\"\u003e\n \u003cp\u003eRM; Tumor level (above S3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eChen KW et al., 2010\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003eSacral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eSurgery 59.3%\u003c/p\u003e\n \u003cp\u003eS+RT 41.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e6.2\u0026dagger;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e16.7\u003c/p\u003e\n \u003cp\u003e(6/36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e44.4\u003c/p\u003e\n \u003cp\u003e(16/36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e2.5\u0026dagger;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 183px;\"\u003e\n \u003cp\u003eTumor level (above S3); Muscle invasion; Intralesional excision; RM\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCurrent\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003estudy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003eSacral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eSurgery 65.2%\u003c/p\u003e\n \u003cp\u003eS+RT 34.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e7.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e8.7\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(2/23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e39.1\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(9/23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e30.7\u003c/p\u003e\n \u003cp\u003e(7/23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 183px;\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cstrong\u003eTable 5\u003c/strong\u003e. \u003cstrong\u003eComparison of clinicopathological characteristics between patients with and without local recurrence.\u003c/strong\u003e Continuous variables are presented as median [range]. Categorical variables are presented as number (%).\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"602\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRecurrence\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(N = 9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo recurrence\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(N = 14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(Univariate)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e, years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e59 [40-77]\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e59 [36-79]\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u0026nbsp;\u003c/em\u003e= 1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOld age\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026lt;65yr\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026ge;65yr\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e5 (55.6)\u003c/p\u003e\n \u003cp\u003e4 (44.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e8 (57.1)\u003c/p\u003e\n \u003cp\u003e6 (42.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u0026nbsp;\u003c/em\u003e= 1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e7 (77.8)\u003c/p\u003e\n \u003cp\u003e2 (22.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e9 (64.3)\u003c/p\u003e\n \u003cp\u003e5 (35.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u0026nbsp;\u003c/em\u003e= 0.657\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTumor presentation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003cp\u003eRecurrent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e8 (88.9)\u003c/p\u003e\n \u003cp\u003e1 (11.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e13 (92.9)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u0026nbsp;\u003c/em\u003e= 1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTumor level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003eAbove S3\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;S3 and below\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e3 (33.3)\u003c/p\u003e\n \u003cp\u003e6 (66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e4 (28.6)\u003c/p\u003e\n \u003cp\u003e10 (71.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u0026nbsp;\u003c/em\u003e= 1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTumor size\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026lt;8cm\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u0026ge;8cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e6 (66.7)\u003c/p\u003e\n \u003cp\u003e3 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e9 (64.3)\u003c/p\u003e\n \u003cp\u003e5 (35.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u0026nbsp;\u003c/em\u003e= 1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTumor volume\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026lt; 100cm\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u0026ge;100cm\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e2 (22.2)\u003c/p\u003e\n \u003cp\u003e7 (77.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e6 (42.9)\u003c/p\u003e\n \u003cp\u003e8 (57.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u0026nbsp;\u003c/em\u003e= 0.400\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgical margin\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003eNegative\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;Positive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e9 (100.0)\u003c/p\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e12 (85.7)\u003c/p\u003e\n \u003cp\u003e2 (14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u0026nbsp;\u003c/em\u003e= 0.502\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreoperative neurology\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003ePresent\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e1 (11.1)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8 (88.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e4 (28.6)\u003c/p\u003e\n \u003cp\u003e10 (71.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u0026nbsp;\u003c/em\u003e= 0.611\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdjuvant radiotherapy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e5 (55.6)\u003c/p\u003e\n \u003cp\u003e4 (44.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e3 (21.4)\u003c/p\u003e\n \u003cp\u003e11 (78.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u0026nbsp;\u003c/em\u003e= 0.179\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgical complexity\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003eEBL, mL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e1450 [100\u0026ndash;10000]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e1125 [450\u0026ndash;6750]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u0026nbsp;\u003c/em\u003e= 0.850\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003eOperation time, min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e285 [50\u0026ndash;520]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e337.5 [160\u0026ndash;1241]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u0026nbsp;\u003c/em\u003e= 0.122\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcan","sideBox":"Learn more about [BMC Cancer](http://bmccancer.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcan/default.aspx","title":"BMC Cancer","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8860454/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8860454/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSacral chordomas are rare, locally aggressive malignancies where surgical resection is the primary treatment. In the previous reports, preservation of at least one S3 root is shown to be important for normal bowel and bladder function. This study aimed to evaluate the postoperative bowel and bladder function according to the level and laterality of sacral nerve root preservation.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a retrospective cohort study of 23 patients who underwent surgery for sacral chordoma at two tertiary referral centers in South Korea between March 2009 and February 2024. All patients underwent en bloc resection with wide margins. Functional outcomes (motor, bladder, and bowel function) based on the level of preserved sacral nerve roots were analyzed. Oncological outcomes included disease-specific survival [DSS], local recurrence-free survival [LRFS], and distant metastasis-free survival [DMFS].\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe 23 patients were followed for a median of 7.0 years. 19 patients (82.6%) were alive at the last follow-up. Functional outcomes were dependent on the level of nerve preservation. For motor function, preserving more than one S2 root was sufficient to achieve normal function. For bowel and bladder function, preserving S3 root was critical. All patients with bilateral S3 root preservation (n\u0026thinsp;=\u0026thinsp;4) maintained normal bladder and bowel function (100%). On the other hand, for patients with unilateral S3 preservation (n\u0026thinsp;=\u0026thinsp;3), normal bladder and bowel function was observed in only 33.3%. Patients with bilateral S2 preservation (n\u0026thinsp;=\u0026thinsp;9) had 22.2% normal bladder and 42.9% normal bowel function. DSS at 5 years and 10 years was 95.0% and 74.4%, respectively. LR occurred in 9 patients (39.1%), with 5-year and 10-year local recurrence-free survival (LRFS) rates of 65.7% and 52.5%, respectively. DM occurred in 7 patients (30.4%), with 5-year and 10-year distant metastasis-free survival (DMFS) rates of 72.4% and 60.4%, respectively.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eBilateral S3 preservation is critical for bowel and bladder function, achieving 100% normal continence compared to 33.3% with unilateral preservation. Favorable disease-specific survival (5-year 95.0%, 10-year 74.4%) was achieved despite a 39.1% local recurrence rate, emphasizing the importance of long-term surveillance beyond 5 years.\u003c/p\u003e","manuscriptTitle":"Functional Outcomes After Sacrectomy for Chordoma: The Critical Role of Bilateral S3 Nerve Root Preservation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-27 12:28:36","doi":"10.21203/rs.3.rs-8860454/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-03-25T07:06:33+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-25T18:30:37+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-25T18:29:37+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-24T15:34:37+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Cancer","date":"2026-02-24T15:27:24+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcan","sideBox":"Learn more about [BMC Cancer](http://bmccancer.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcan/default.aspx","title":"BMC Cancer","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d08a7cd7-a535-4055-9b44-a66c47f56140","owner":[],"postedDate":"March 27th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-27T12:28:36+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-27 12:28:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8860454","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8860454","identity":"rs-8860454","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}