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.