VM56 - Robot-Assisted Excision of Presacral Cysts

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Purpose/Background: Although their true incidence is unknown, presacral masses are considered relatively rare tumors, accounting for approximately one in 40,000 admissions per year in the U.S. They are often located between the sacrum and rectum and can involve adjacent pelvic floor structures including the rectum and anal sphincter. Despite the majority of these being benign, symptomatic presacral masses can significantly degrade patients’ quality of life. Surgical resection is the mainstay of treatment and can be challenging given the complex, dense anatomy and variety of structures in the pelvis. This video presents a robot assisted excision of presacral cysts located on the levator ani muscles.

Methods/Interventions: The patient presented is a 35-year-old female with a history of endometriosis status-post endometrial cystectomy in 2012. She had initially presented to her gynecologist with acute on chronic pelvic pain worse with bowel movements; and urinary urgency, dysmenorrhea, and dyspareunia despite medical management. Her MRI was remarkable for several endometrial implants around the bilateral ovaries and uterus, multiple fibroids, and most notably two complex presacral masses posterior to and to the left of the lower rectum, abutting the levator ani muscles. After discussing the patient at a multidisciplinary tumor board, it was determined that the presacral masses were most consistent with cysts. A robot-assisted endometrial implant removal by gynecology and presacral mass removal by the colorectal surgery team was recommended. This video demonstrates the latter portion of the case.

Results/Outcomes: This video demonstrates a robot-assisted excision of two presacral cysts in a 35-year-old female with endometriosis presenting with acute on chronic abdominal pain exacerbated by bowel movements. The case and the patient’s recovery were uncomplicated, and the patient reported improvement in her symptoms post-operatively. The final surgical pathology showed fibroadipose tissue with chronic inflammation.

Conclusion/Discussion: Surgical resection is the mainstay of treatment for patients presenting with symptomatic presacral cysts. This video demonstrates that robotic surgery is a safe and effective approach when addressing resections in anatomically challenging areas such as the pelvis.