V61 - Robotic Excision of a Low Presacral Cyst Via Anterior Approach

Saturday, May 9, 2026

On-Demand

Video Presentation(s)

JR

Jordan Roy, MD

Research Resident
Icahn School of Medicine at Mount Sinai Hospital
Icahn School of Medicine at Mount Sinai Hospital New York, NY
staten island, NY, United States

All of the relevant financial relationships listed below have been mitigated.
This individual has no financial relationships with ineligible companies.

Author(s)

Katherine W. Lam, MD

Colorectal Surgery Research Fellow
Icahn School of Medicine at Mount Sinai
Westchester Medical Center
New York, NY, United States

All of the relevant financial relationships listed below have been mitigated.
This individual has no financial relationships with ineligible companies.
DR

Daniela I. Ramos-Delgado, M.D.

Research Resident
Icahn School of Medicine at Mount Sinai Hospital
Hoboken, New Jersey, United States

Disclosure information not submitted.
RM

Roxanne Mistry, BA

Clinical Research Coordinator II
Mount Sinai Hospital
New York, New York, United States

Disclosure information not submitted.
KM

Kate Micallef, B.S.

Research Assistant
Mount Sinai Hospital
New York, New York, United States

Disclosure information not submitted.
Patricia Sylla, MD, FACS, FASCRS (she/her/hers)

System Chief of Colon and Rectal Surgery
Mount Sinai Hospital
Icahn School of Medicine at Mount Sinai
New York, New York, United States

All of the relevant financial relationships listed below have been mitigated.
Activ Surgical: Consultant (Ongoing); Ethicon: Consultant (Ongoing); Medtronic: Consultant (Ongoing); Moon Surgical: Consultant (Ongoing); Safeheal: Consultant (Ongoing); Stryker: Consultant (Ongoing)
Alex J. Ky, MD (she/her/hers)

Professor of Surgery
Mount Sinai Hospital
Mount Sinai Hospital
New York, New York, United States

Disclosure information not submitted.

Senior Author(s)

TL

Tianyi Lu, MD

Assistant Professor
Mount Sinai Hospital
New York, New York, United States

Disclosure information not submitted.

All of the relevant financial relationships listed below have been mitigated.

Jordan Roy, MD: This individual has no financial relationships with ineligible companies.

Katherine W. Lam, MD: This individual has no financial relationships with ineligible companies.

Patricia Sylla, MD, FACS, FASCRS: Activ Surgical: Consultant (Ongoing); Ethicon: Consultant (Ongoing); Medtronic: Consultant (Ongoing); Moon Surgical: Consultant (Ongoing); Safeheal: Consultant (Ongoing); Stryker: Consultant (Ongoing)

Purpose/Background: Presacral masses can occur for a variety of reasons with multiple differential diagnoses including duplication cyst, Tarlov cyst, and meningocele. These presacral or retrorectal masses present a unique dilemma in the approach for excision due to their location. Masses below S3 are traditionally removed via a posterior approach due to the challenges one faces when operating in the lower presacral space from an anterior transabdominal approach. Robotic surgery, however, provides a way for minimally invasive surgery to prevail while operating via an anterior approach within the deep pelvis.

Methods/Interventions: We present a case involving a 33-year-old female with no significant past medical history who was referred to colorectal surgery clinic after her gynecologist incidentally found a pelvic cyst on transvaginal ultrasound. The patient had an MRI confirming a presacral mass arising from the S3/S4 foramina. There was concern about it being a duplication cyst versus another pathology such as a Tarlov cyst. The patient underwent an IR biopsy of the mass, which showed keratinaceous debris consistent with an epidermoid cyst. Ultimately, the decision was made to proceed to the operating room for robotic excision of this presacral mass. As seen in the video, after mobilization of bowel upon entry, a right-sided pelvic mass was encountered. The mass proved difficult to manipulate, and so a cystotomy was created in order to drain cyst contents. As some of the keratinaceous debris was removed, the cyst became easier to mobilize and the capsule was dissected bluntly and sharply from the mesorectum and the lateral pelvic side wall. The contents and most of the cyst capsule were then excised and placed into Endo Catch bags. However, the posterior wall of the cyst proved difficult to excise as it was in close communication with the presacral veins. Therefore, this portion of capsule was fulgurated with adequate hemostasis achieved thereafter. After cyst excision was complete, the peritoneum was closed and the case was concluded.

Results/Outcomes: This video exhibits the feasibility of an anterior approach to excising ultra-low presacral masses. The patient was discharged the same day and presented to clinic for her postoperative visit without complaints. She has been doing well since her surgery. The final pathology came back as a benign squamous epithelial-lined cyst.

Conclusion/Discussion: Presacral or retrorectal masses remain rare in presentation, yet the standard of practice has been a posterior approach for masses below S3. However, this case exemplifies anterior approach using robotic surgery in order to carefully and precisely excise these low masses without complication and with same day discharge. It is of utmost importance to take all factors into account when considering the right approach for excision, yet this case provides an example of an option available and feasible in certain cases.