EP653 - Presacral Mass And Cyst: Surgical Management And Outcomes From A Tertiary Referral Center Over 9 Years

Purpose/Background: Presacral masses are rare with most literature limited to case reports and small case series. Clear management guidelines are lacking and outcomes data are sparse. Although usually benign, surgical excision is typically recommended, and multiple operative approaches have been described. Open surgery remains most common, though minimally invasive approaches have been shown to be safe and effective in selected patients based on limited reports. This study characterizes presacral masses, operative strategies, and outcomes at a tertiary referral center over a nine-year period.

Methods/Interventions: We performed a retrospective review of adults (≥18 years) who underwent primary resection of a presacral mass by colorectal surgeons at our tertiary referral center between January 2016 and September 2025. Records were queried using CPT codes, ICD-10 codes, and operative report terms. Patients were included if a colorectal surgeon participated in resection of a primary presacral mass. Exclusion criteria included rectal cancer with presacral extension and metastatic disease to the presacral space. Descriptive statistics were used.

Results/Outcomes: Thirty-nine patients were identified. Median age was 42 years and 87% were female (n=34). Preoperative MRI was obtained in 97.4% of cases (n=38). Posterior resections had 14 specimen perforations (53.9%) and anterior had 6 (54.5%). Complete resection was achieved in 94.9% overall (n=37), 93.9% in open cases (n=31/33), and 100% in robotic or combined cases (n=6/6) (Table). Final pathology was benign in 89.7% (n=35). A posterior approach was most common (66.7%, n=26), followed by abdominal (28.2%, n=11) and combined abdominal-posterior (5.1%, n=2). Robotic resection was used in 5 patients (12.8%), and 1 (2.6%) underwent a staged combined open-robotic procedure. Coccygectomy was performed in 20 patients (51.3%), partial sacrectomy in 5 (12.8%), and complete sacrectomy in 1 (2.6%). Six resections (15.4%) were performed in conjunction with a spine surgeon, and 8 (20.5%) had closure performed by a plastic surgeon. Median length of stay was 2 days for both open (n=33) and robotic (n=5) approaches and 4 days for the combined approach (n=1). No morbidities occurred following robotic resection (n=5). The staged open-robotic case (n=1) required postoperative transfusion. Among open resections (n=33), morbidity occurred in 33.3% of cases (n=11), including wound disruption (22.2%, n=7), deep surgical site or organ-space infection (12.1%, n=4 each), superficial infection (3.0%, n=1), and urinary tract infection (3.0%, n=1). There were no 30-day mortalities. Two recurrences (5.1%) were identified at a mean follow-up of 162 days.

Conclusion/Discussion: Our experience demonstrates that presacral mass resection can be performed safely and with high rates of complete excision using an individualized, multidisciplinary approach. Robotic resection alone was successful in 5 cases, representing one of the largest single-institution robotic series reported to date. Most lesions were benign and managed via a posterior approach. Multidisciplinary collaboration among colorectal, orthopedic, neurosurgery, and plastic surgery was essential for cases requiring sacrectomy or complex wound closure. These findings support the continued application of robotic techniques and multidisciplinary management to optimize outcomes for presacral mass resection at tertiary referral centers.

Table. Operative approach and final pathology for presacral cysts patients stratified by resection type (Tertiary Referral Center, January 2016 - September 2025)