Risk factors for rectal perforation during presacral cyst removal: a comparison between transabdominal, perineal, and...

This study aimed to evaluate the risk factors associated with rectal perforation during various surgical interventions for presacral cysts.

This retrospective study included 73 participants from 2013 to 2023 who met the inclusion criteria. Participants underwent surgical treatments through transabdominal, perineal, or combined approaches. Preoperative assessments of presacral cysts were performed using computed tomography (CT) and magnetic resonance imaging (MRI). Biannual postoperative follow-ups involved ultrasound, CT, or MRI scans. Data analysis was conducted using RStudio software.

The incidence of rectal perforation did not differ significantly across surgical approaches [combined 2 (18%) vs. perineal 3 (8.8%) vs. transabdominal 4 (14%), P = 0.7]. Cyst capsule rupture was more frequent in the transabdominal and combined approaches [17 (61%) and 5 (45%), respectively] versus perineal approach [8 (24%), P = 0.011]. The laparoscopic subgroup experienced a higher rate of cyst rupture compared to the robotic subgroup, with rectum perforation cases only correlating with ruptures in the robotic subgroup. Intraoperative complications prompted conversions to open surgery in the laparoscopic group, unlike in the robotic group. Postoperative follow-up revealed no mortalities, with malignant transformation observed in two cases and local recurrences in three. While univariate analysis did not identify significant predictors of rectal wall perforation, multivariate analysis suggested that the risk of perforation increased with cyst rupture and decreased when the cyst was located further from the anal verge.

The study identifies two primary risk factors for rectal wall perforation: the cyst capsule integrity and the cyst-rectum shortest distance, with the latter being accurately determined by MRI. These findings may inform further surgical planning and risk assessment.