Modified Kraske Procedure for Retrorectal Tumors Decreases Surgical Site Infection Rate: A Single Center Experience

Modified Kraske Procedure for Retrorectal Tumors Decreases Surgical Site Infection Rate: A Single Center Experience | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Modified Kraske Procedure for Retrorectal Tumors Decreases Surgical Site Infection Rate: A Single Center Experience Adem Bayraktar¹, Cemil Burak Kulle¹, Ozan Pastacıgil¹, Halil Alper Bozkurt², and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9117525/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Objective The aim of this study is to evaluate the early postoperative morbidity rates with a particular focus on surgical site infection rates, in patients undergoing resection for retrorectal tumors with the modified Kraske Procedure. Methods This retrospective single-center study included patients who underwent resection for retrorectal tumors performing the modified Kraske Procedure between August 2006 and August 2025. Patients with recurrent disease or a history of pelvic radiotherapy or chemotherapy were excluded. The primary outcome was early postoperative morbidity, especially in terms of surgical site infections, which was defined as complications occurring within the first 30 days after surgery. Results Among 35 patients operated for retrorectal tumors, 23 (65.7%) underwent a resection performing the modified Kraske Procedure and were included in the analysis. The majority of patients were female (82.6%), with a mean age of 40.3 ± 15.8 years. The mean tumor size was 42.5 ± 10.0 mm, and most lesions were benign (87%). Postoperative complications occurred in three patients (13%), with surgical site infection observed in only one patient (4.4%). The mean length of hospital stay was 3.8 ± 1.9 days. Conclusion The modified Kraske Procedure appears to be a safe and effective surgical option for retrorectal tumors, offering the advantages of the standard Kraske procedure with a low surgical site infection rate. Retrorectal tumors Modified Kraske approach Surgical outcomes Figures Figure 1 Introduction Retrorectal tumors are benign or malignant mass lesions located in the presacral or retrorectal space and are extremely uncommon tumors with a heterogenous etiological diversity ( 1 – 3 ). These tumors commonly originate from embryologic remnants within the presacral or retrorectal space, which is delineated posteriorly by the anterior surface of the sacrum, anteriorly by the posterior wall of the rectum and laterally by the ureters and the iliac vessels. Although mostly classified as benign, malignant, cystic and solid, retrorectal tumors may also be categorized as congenital, inflammatory, neurogenic, osseous, or miscellaneous lesions ( 4 , 5 ). Retrorectal tumors are usually asymptomatic in up to 33% of the cases and are diagnosed especially in middle-aged female patients between 40–50 years ( 6 ). The most common symptoms in the remaining two-thirds of patients with retrorectal tumors are pelvic pain, which usually relieve upon standing, and symptoms due to compression to adjacent organs and structures in the pelvic cavity, such as the rectum, bladder, female sexual organs, and nerve roots ( 6 , 7 ). Due to compression to adjacent organs, the most common complaints include changes in bowel habits (obstructive defecation symptoms), urinary incontinence, sexual dysfunction, dystocia and sciatica. In addition, patients with a history of recurrent perianal abscess drainage should be suspected of infected retrorectal tumors. The diagnosis of retrorectal tumors is mainly based on radiological features of advanced imaging modalities such as computed tomography (CT) and magnetic resonance imaging (MRI) with the application of intravenous contrast medium. Especially, MRI facilitates the assessment of tumor localization, tumor size, tumor morphology and tumor interference with adjacent organs and is essential for preoperative staging, preoperative treatment and determining surgical strategy ( 7 ). Preoperative biopsy is still controversial and usually not recommended, because of the increased risk of dissemination of the potentially malignant lesions, the increased risk of infections leading to increased postoperative morbidity and inadequate pathological evaluation of the biopsy material in up to 44% of the cases ( 1 , 5 , 8 ). The surgical approach of patients with a retrorectal tumor amenable for resection is predominantly determined by the localization of the retrorectal mass. In patients with a retrorectal tumor located above the S2-S3 vertebra, the abdominal or combined abdominoperineal approach is preferred, whereas the posterior/transsacral approach (Kraske Procedure, modified Kraske Procedure) should be preferred for masses located below the S3 vertebra. Although there are different definitions for the Kraske Procedure and/or modified Kraske Procedure in recently published studies, surgical site infection has been reported to be increased in up to 14% after posterior/transsacral approach compared to the abdominal approach ( 9 , 10 ). Due to paucity of current data, we aimed to report/analyze the surgical site infection rate after a modified Kraske Procedure. Material and Method All patients diagnosed with a retrorectal tumor and amenable for surgery, who underwent a resection surgery according to the principles of modified Kraske Procedure between August 2006 and August 2025 at a tertiary cancer hospital were enrolled into the retrospective observational study. Patients with recurrent retrorectal tumors, patients with a history of pelvic radiation or previous chemotherapy due malignancies in the pelvic cavity were excluded from the study. All patients diagnosed for retrorectal tumors, whether incidentally identified due to other complaints during advanced imaging or symptomatic patients with specific complaints such as pain or symptoms related to compression to adjacent organs, were preoperatively reevaluated. Chest and abdominal CT scans were performed primarily to visualize the mass in the retrorectal space and to exclude distant metastasis. Pelvic MRI was performed for local staging, to determine radiologic features to distinguish between benign and malignant lesions and to evaluate the relationship between adjacent organs and structures. A preoperative biopsy from the retrorectal tumor was not performed or recommended for patients amenable to resection surgery due to the increased risk of preoperative/postoperative infections and dissemination for malignant lesions. Asymptomatic patients with a retrorectal tumor ≥ 3cm or cystic lesions harboring a solid component suspicious for malignancy and all symptomatic patients, whose symptoms were related to the compression of the retrorectal mass were suggested to underwent surgery. During preoperative advanced imaging modalities all patients with a tumor localization below the S2 and/or S3 were determined and underwent definitive resection surgery. In this study, the choice of surgery was the modified Kraske Procedure, and this procedure was performed in all patients with a retrorectal tumor amenable to surgery. Modified Kraske Procedure was performed in a jack-knife prone position and was defined as an oblique incision from the right or left site of the gluteal area between sacral vertebra and the anus. Prior to surgery the patients received a standard mechanical bowel preparation without antibiotics on the previous day. After inserting a foley catheter to decompress the bladder, the patients are placed in a jack-knife prone position on the operating table with placing surgical gel pads under the pelvic area. The buttocks are laterally retracted with tapes before sacral skin prepping. An oblique incision is made from the right or left site depending on dominant hand of the gluteal area between the last sacral vertebra and anal verge, which is nearly 2 cm above the anus (Fig. 1 ). Afterwards the anococcygeal ligament was divided, and dissection was continued until the coccyx and sacrum was visualized to facilitate access to the retrorectal space. A partial or total coccyx resection was only performed, when necessary, according to the retrorectal tumor’s location, size and attachment to surrounding structures to provide an en bloc resection without tumor rupture. The primary outcome of this study was to report postoperative morbidity, especially surgical site infections after modified Kraske Procedure. Postoperative complications were defined as any surgical or medical complications occurring during the patients’ hospital stay or after hospital discharge within 30 days after surgery. The severity of surgical site infection was classified according to that described by Dindo ( 11 ). Descriptive values of the data were analyzed and represented as mean with standard deviation, median (minimum and maximum), frequency and ratio. The statistical analysis were performed with the SPSS 28.0 software. Results A total of 35 patients who underwent surgery for retrorectal tumors were identified from the institutional database. In terms of surgical approach, the modified Kraske Procedure was performed in 23 (65.7%) patients, an abdominal approach in eleven (31.4%) patients, and a combined approach in one (2.9%) patient. Out of 35 patients 23 patients, who underwent a modified Kraske Procedure were included into this study. Of these patients, 19 (82.6%) were female and 4 (17.4%) were male. The mean age was 40.3 ± 15.8 years. Preoperative assessment revealed a ASA score as following: ASA score I (n = 6, 25%), ASA score II (n = 15, 67%) and ASA score III (n = 2, 8%). All patients’ characteristics were given in Table 1 . Table 1 Baseline characteristics of the patients Variable Value Surgical approach in screened cohort (n = 35) Modified Kraske 23 (65.7%) Abdominal 11 (31.4%) Combined 1 (2.9%) Patients included in analysis 23 Sex, n (%) Female 19 (82.6%) Male 4 (17.4%) Age (years), mean ± SD 40.3 ± 15.8 ASA score, n (%) ASA I 6 (25%) ASA II 15 (67%) ASA III 2 (8%) Data are presented as mean ± standard deviation or number (%). ASA: American Society of Anesthesiologists physical status classification. Regarding presenting symptoms, perineal pain was the most common complaint, observed in 12 (52.2%) patients. Five (21.7%) patients were asymptomatic, with lesions detected incidentally. Lower back or leg pain was reported in three (13%) patients, while abdominal pain was present in two (8.7%) patients. Constipation was observed in only one (4.4%) patient (Table 2 ). Table 2 Preoperative symptoms of the patients Symptom n (%) Perineal pain 12 (52.2) Asymptomatic / incidental detection 5 (21.7) Lower back or leg pain 3 (13.0) Abdominal pain 2 (8.7) Constipation 1 (4.4) Data are presented as number (%) All patients underwent a modified Kraske Procedure and no rectal resection or limited (wedge) resection was required. Tumor size was assessed based on the maximum diameter of the lesion. Accordingly, the mean tumor diameter was 42.5 ± 10.0 mm, with sizes ranging from 24 to 62 mm. Histopathological examination revealed that 20 (87%) lesions were benign with predominant pathological diagnosis of tailgut cyst (n = 10, 43.5%), dermoid cyst (n = 3, 13%) and epidermoid cyst (n = 3, 13%). On the other hand malignant lesions were detected in three (13%) patients (Table 3 ). Table 3 Tumor Characteristics and Histopathological Findings Variable Value Surgical approach Modified Kraske (100%) Rectal or wedge resection required No Tumor size (mm), mean ± SD 42.5 ± 10.0 Tumor size range (mm) 24–62 Histopathology, n (%) Benign lesions 20 (87.0) Tailgut cyst 10 (43.5) Dermoid cyst 3 (13.0) Epidermoid cyst 3 (13.0) Teratoma 2 (8.7) Other benign lesions 2 (8.7) Malignant lesions 3 (13.0) Ewing Sarcoma 1 (4.4) Mucinous adenocarcinoma 1 (4.4) Gastrointestinal Stromal Tumor 1 (4.4) Data are presented as mean ± standard deviation or number (%). Tumor size was defined as the maximum diameter of the lesion. Postoperative complications occurred in three (13%) patients. One (4.4%) patient witnessed bleeding, one (4.4%) patient witnessed a urinary tract infection, and only one (4.4%) patient witnessed a surgical site infection (Table 4 ). The surgical site infection presented as a wound abscess/dehiscence, which was treated with vacuum assisted closure therapy and antibiotics. The mean length of hospital stay was 3.8 ± 1.9 days. Table 4 Postoperative Outcomes and Complications Postoperative complications n (%) / mean ± SD Bleeding 1 (4.4) Urinary tract infection 1 (4.4) Surgical site infection 1 (4.4) Length of hospital stay (days) 3.8 ± 1.9 Data are presented as number (%) or mean ± standard deviation Discussion This study reports the experience of a single center regarding early postoperative morbidity rates, particularly surgical site infections, following a modified Kraske procedure in patients diagnosed with retrorectal tumors. The vast majority of the patients were female and most of the retrorectal tumors harbored benign biological features. All patients underwent a modified Kraske Procedure with lower surgical site infection rates of 4.4% compared to the standard Kraske Procedure, which makes the modified Kraske procedure a promising choice of treatment option. After resection of the retrorectal tumor, the pathology report revealed that the vast majority of specimens showed benign characteristics such as tailgut cysts, epidermoid cysts, dermoid cysts, etc. with a rate of 87%, while 13% were malignant tumors such as Ewing Sarcoma, mucinous adenocarcinoma and gastrointestinal stromal tumor. These results were in line with other studies, that have previously reported similar findings ( 6 , 12 ). The risk of malignancy is seriously increased in solid retrorectal masses compared to cystic tumors (31.4% versus 8.8% respectively) ( 6 ). On the other hand, the malignant transformation of benign retrorectal tumors may occur and has been reported. In a previously published study the overall rate of neoplastic transformation of 26.6% and increased up to 48% among male patients diagnosed with a retrorectal tumor ( 13 ). According to several studies the malignant transformation rate of cystic retrorectal tumors is higher than expected and particular attention should be paid during frequent surveillance of especially asymptomatic, benign cystic retrorectal tumors. A preoperative biopsy from the retrorectal tumor was not recommended and performed in this current study due to several reasons such as avoiding the potential risk of regional tumor seeding, preventing the increased risk of postoperative surgical site infections and increased risk of recurrence rates ( 7 , 8 ). Another reason is that a previous study has reported a discrepancy or discordance between preoperative biopsy and postoperative pathological examination of the specimen in up to 29% of the patients with retrorectal tumor ( 6 ). Therefore, preoperative biopsy is recommended only in cases of advanced disease or retrorectal tumors suspicious for lymphoma or bone tumors, where patients would primarily benefit from chemotherapy or radiotherapy, or where chemotherapy or radiotherapy could be offered as a treatment option. In our current study, we did not witness any cases of pelvic abscess, and only one patient (4.4%) experienced surgical site infection with wound dehiscence; this may have been due to the absence of preoperative biopsy of the retrorectal masses. The choice of surgical approach is based on the retrorectal tumor’s localization, size and morphology determined by preoperative advanced imaging modalities such as pelvic CT and/or pelvic MRI. Usually, retrorectal tumors below S2/S3 are resected with a posterior (transsacral) approach, which is defined as the Kraske Procedure. This procedure enables a better view of the surgical field, but on the other hand is associated with increased pelvic pain, fecal/incontinence or sexual disfunction and surgical site infections. In a multicentric French study, which is the largest published study reporting experiences and findings regrading postoperative outcomes of retrorectal tumor surgery the surgery site infection rate as wound abscess with the Kraske Procedure was higher compared to the abdominal approach (14% vs 2%; p = 0.02 ), whereas the pelvic abscess rate was similar in both groups (7% vs 6%; p = 1 ). In our study we performed the modified Kraske Procedure to lower the surgical site infection rate such as wound infection, wound abscess and wound dehiscence. Although, there are various definitions of the Kraske Procedure, basically the Kraske procedure is defined as median or paramedian incision in or around the intergluteal cleft ( 7 , 10 , 14 , 15 ). Therefore, we made an oblique incision from the right or left site of the of the gluteal area. The purpose of the oblique incision is to prevent or decrease the surgical site infection rate due to keeping a distance from the intergluteal cleft. The idea behind this technique is that this region’s vascularization is poorer, and this region is located in deeper in groove compared to other areas in the gluteal area, which impairs wound healing. With reposition the midline incision from the intergluteal cleft to a lateral oblique incision we have reduced any tension on the incision and achieved a promising and an excellent wound healing rate of 95.6% and surgical site infection was reported in only one (4.4%) patient. The most important limitation of the current study is that of retrospective studies such as selection and recall bias. Another limitation of this study is the small sample size of patients with retrorectal tumors and that this study is a single center case series without comparison of other surgical approaches and resection techniques. Conclusion The management of retrorectal tumors are difficult and challenging due to its rarity and heterogeneity. Especially, for retrorectal tumors located below S2/S3 the Kraske Procedure is the standard treatment option of choice, which allows a better visualization of the surgical field and facilitates an en bloc resection. The modified Kraske Procedure bears the same advantages as the standard Kraske Procedure with promising and enormous low surgical site infection rates with 4,4%. Declarations Human Ethics and Consent to Participate Human Ethics and Consent to Participate declarations: The study was conducted in accordance with the Declaration of Helsinki. Ethical approval was obtained from the Istanbul University, Istanbul Faculty of Medicine Clinical Research Ethics Committee. Due to the retrospective nature of the study and the use of anonymized patient data, informed consent to participate was waived. Gels and Blots This study does not include any gels or blots. Therefore, no uncropped gel or blot images are applicable. Clinical trial number: not applicable Funding This study did not receive any specific funding. Author Contribution Adem Bayraktar, Cemil Burak Kulle, Metin Keskin and Mehmet Türker Bulut contributed to conception and design of the manuscript. Ozan Pastacıgil and Halil Alper Bozkurt collected the data. Cemil Burak Kulle, Adem Bayraktar and İlker Özgür analyzed and Neslihan Berker and Melek Büyük interpreted the data. Cemil Burak Kulle, Adem Bayraktar, Halil Alper Bozkurt and Ozan Pastacıgil drafted and wrote the manuscript. Mehmet Türker Bulut, Metin Keskin, Adem Bayraktar and İlker Özgür critically revised the manuscript for important intellectual content. All authors read and approved the final manuscript. Data Availability the datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request References Jao SW, Beart RW, Spencer RJ, et al. Retrorectal tumors. Mayo Clinic experience, 1960–1979. Dis Colon Rectum. 1985;28:644–52. Uhlig BE, Johnson RL. Presacral tumors and cysts in adults. Dis Colon Rectum. 1975;18:581–96. Hobson KG, Ghaemmaghami V, Roe JP, Goodnight JE, Khatri VP. Tumors of the retrorectal space. Dis Colon Rectum. 2005;48:1964–74. Hassan I, Wietfeldt ED. Presacral tumors: diagnosis and management. Clin Colon Rectal Surg. 2009;22:84–93. Baek SK, Hwang GS, Vinci A, Jafari MD, Jafari F, Moghadamyeghaneh Z, Pigazzi A. Retrorectal Tumors: A Comprehensive Literature Review. World J Surg. 2016;40(8):2001–15. Burke JR, Shetty K, Thomas O, Kowal M, Quyn A, Sagar P. The management of retrorectal tumours: tertiary centre retrospective study. BJS Open 2022; 6. Bilkhu AS, Wild J, Sagar PM. Management of retrorectal tumours. Br J Surg. 2024;111(1):znae012. Mathis KL, Dozois EJ, Grewal MS, Metzger P, Larson DW, Devine RM. Malignant risk and surgical outcomes of presacral tailgut cysts. Br J Surg. 2010;97:575–9. Chéreau N, Lefevre JH, Meurette G, Mourra N, Shields C, Parc Y, et al. Surgical resection of retrorectal tumours in adults: long-term results in 47 patients. Colorectal Dis. 2013;15:e476–82. Aubert M, Mege D, Parc Y, Rullier E, Cotte E, Meurette G, et al. Surgical Management of Retrorectal Tumors: A French Multicentric Experience of 270 Consecutives Cases. Ann Surg. 2021;274:766–72. Dindo D, Demartines N, Clavien P-A, et al. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205–13. Sagar AJ, Koshy A, Hyland R, Rotimi O, Sagar PM. Preoperative assessment of retrorectal tumours. Br J Surg. 2014;101:573–7. Nicoll K, Bartrop C, Walsh S, Foster R, Duncan G, Payne C, et al. Malignant transformation of tailgut cysts is significantly higher than previously reported: systematic review of cases in the literature. Colorectal Dis. 2019;21:869–78. Aubert M, Mege D. Kraske approach to retrorectal tumors: Surgical technique. J Visc Surg. 2022;159(3):229–33. 10.1016/j.jviscsurg.2022.01.009 . Epub 2022 Feb 5. PMID: 35135747. Kraske P. Zur extirpation hochsitzender mastdarm-krebse. Verhandl Deutch Gellesch Chir. 1885;14:464–74. Additional Declarations No competing interests reported. Supplementary Files SupplementaryFile.pdf Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 14 May, 2026 Reviewers agreed at journal 07 May, 2026 Reviews received at journal 05 May, 2026 Reviewers agreed at journal 05 May, 2026 Reviewers agreed at journal 30 Mar, 2026 Reviews received at journal 29 Mar, 2026 Reviewers agreed at journal 28 Mar, 2026 Reviewers invited by journal 28 Mar, 2026 Editor invited by journal 19 Mar, 2026 Editor assigned by journal 17 Mar, 2026 Submission checks completed at journal 17 Mar, 2026 First submitted to journal 13 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9117525","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":614924971,"identity":"3c71e89a-a410-4ddb-9b95-5a96c758829e","order_by":0,"name":"Adem Bayraktar¹","email":"","orcid":"","institution":"Istanbul University","correspondingAuthor":false,"prefix":"","firstName":"Adem","middleName":"","lastName":"Bayraktar¹","suffix":""},{"id":614924972,"identity":"74f9d519-8e87-4742-8534-e2784f872088","order_by":1,"name":"Cemil Burak Kulle¹","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+0lEQVRIiWNgGAWjYJCCAw8bgCQPGwPDgwIGObDIA0JaEmFaEgwYjMEiCYSsQdYCZjPg08Lf3p14IHHH4Xz+nmNpEgkGNunzww4/BNpiJ6fbgF2LxJmzGw4knjlsOeNs2zGglrTcjbfTDIBako3NDmDXYiCRC9TSdtiA4Tx7G1DL4dyNsxNAWg4kbsOlRf4tRIs8RMv/dMPZ6R/wa5HghWgxgDjsQIK8dA5+WyTOgBx2Jt3A8MyxZIsEg2TDDdI5BQeADJx+4W8/u/nDxx3WBnJn0gxvfKiwk5efnb75A5Ahh0sLFqeCVRoQqxwE5BtIUT0KRsEoGAUjAQAAPxtqLH2ym/UAAAAASUVORK5CYII=","orcid":"","institution":"Istanbul University","correspondingAuthor":true,"prefix":"","firstName":"Cemil","middleName":"Burak","lastName":"Kulle¹","suffix":""},{"id":614924973,"identity":"c289b56f-66e7-4319-b972-7b896813a24c","order_by":2,"name":"Ozan Pastacıgil¹","email":"","orcid":"","institution":"Istanbul University","correspondingAuthor":false,"prefix":"","firstName":"Ozan","middleName":"","lastName":"Pastacıgil¹","suffix":""},{"id":614924974,"identity":"c04870dd-b107-4d8b-9656-7a8de31a4a1d","order_by":3,"name":"Halil Alper Bozkurt²","email":"","orcid":"","institution":"Başakşehir Çam and Sakura City Hospital","correspondingAuthor":false,"prefix":"","firstName":"Halil","middleName":"Alper","lastName":"Bozkurt²","suffix":""},{"id":614924975,"identity":"8c1c3d9f-b737-4b32-b77a-6b234a7a24d9","order_by":4,"name":"Melek Büyük³","email":"","orcid":"","institution":"Istanbul University","correspondingAuthor":false,"prefix":"","firstName":"Melek","middleName":"","lastName":"Büyük³","suffix":""},{"id":614924976,"identity":"10fd6014-c363-4057-b7b7-c15c8f214369","order_by":5,"name":"Neslihan Berker³","email":"","orcid":"","institution":"Istanbul University","correspondingAuthor":false,"prefix":"","firstName":"Neslihan","middleName":"","lastName":"Berker³","suffix":""},{"id":614924977,"identity":"c2187772-c959-4df0-84e4-98f71c1485d3","order_by":6,"name":"İlker Özgür¹","email":"","orcid":"","institution":"Istanbul University","correspondingAuthor":false,"prefix":"","firstName":"İlker","middleName":"","lastName":"Özgür¹","suffix":""},{"id":614924978,"identity":"b5d10a6f-1291-43d7-b9af-87547195c50b","order_by":7,"name":"Metin Keskin¹","email":"","orcid":"","institution":"Istanbul University","correspondingAuthor":false,"prefix":"","firstName":"Metin","middleName":"","lastName":"Keskin¹","suffix":""},{"id":614924979,"identity":"57a1d4e2-9929-46c9-9d4e-f8c84b115da6","order_by":8,"name":"Mehmet Türker Bulut¹","email":"","orcid":"","institution":"Istanbul University","correspondingAuthor":false,"prefix":"","firstName":"Mehmet","middleName":"Türker","lastName":"Bulut¹","suffix":""}],"badges":[],"createdAt":"2026-03-13 18:53:36","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9117525/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9117525/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106092063,"identity":"6572d39e-5128-46c7-b3f4-0449af5cf131","added_by":"auto","created_at":"2026-04-03 11:17:40","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1834242,"visible":true,"origin":"","legend":"\u003cp\u003eOblique incision of the modified Kraske Procedure\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-9117525/v1/b60cb376eb96fa5e3b3db440.png"},{"id":108005794,"identity":"9d6ebdda-6629-4b3d-9d24-c991bc146888","added_by":"auto","created_at":"2026-04-28 12:48:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2523069,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9117525/v1/3612401d-d68a-40a3-99ff-7e0c69e53d46.pdf"},{"id":106092062,"identity":"eddd83d1-16f0-4703-8e8a-92e231b37609","added_by":"auto","created_at":"2026-04-03 11:17:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":1723,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9117525/v1/0bb28fbcc2ab69bc154b2935.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Modified Kraske Procedure for Retrorectal Tumors Decreases Surgical Site Infection Rate: A Single Center Experience","fulltext":[{"header":"Introduction","content":"\u003cp\u003eRetrorectal tumors are benign or malignant mass lesions located in the presacral or retrorectal space and are extremely uncommon tumors with a heterogenous etiological diversity (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). These tumors commonly originate from embryologic remnants within the presacral or retrorectal space, which is delineated posteriorly by the anterior surface of the sacrum, anteriorly by the posterior wall of the rectum and laterally by the ureters and the iliac vessels. Although mostly classified as benign, malignant, cystic and solid, retrorectal tumors may also be categorized as congenital, inflammatory, neurogenic, osseous, or miscellaneous lesions (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRetrorectal tumors are usually asymptomatic in up to 33% of the cases and are diagnosed especially in middle-aged female patients between 40\u0026ndash;50 years (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). The most common symptoms in the remaining two-thirds of patients with retrorectal tumors are pelvic pain, which usually relieve upon standing, and symptoms due to compression to adjacent organs and structures in the pelvic cavity, such as the rectum, bladder, female sexual organs, and nerve roots (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Due to compression to adjacent organs, the most common complaints include changes in bowel habits (obstructive defecation symptoms), urinary incontinence, sexual dysfunction, dystocia and sciatica. In addition, patients with a history of recurrent perianal abscess drainage should be suspected of infected retrorectal tumors.\u003c/p\u003e \u003cp\u003eThe diagnosis of retrorectal tumors is mainly based on radiological features of advanced imaging modalities such as computed tomography (CT) and magnetic resonance imaging (MRI) with the application of intravenous contrast medium. Especially, MRI facilitates the assessment of tumor localization, tumor size, tumor morphology and tumor interference with adjacent organs and is essential for preoperative staging, preoperative treatment and determining surgical strategy (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Preoperative biopsy is still controversial and usually not recommended, because of the increased risk of dissemination of the potentially malignant lesions, the increased risk of infections leading to increased postoperative morbidity and inadequate pathological evaluation of the biopsy material in up to 44% of the cases (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe surgical approach of patients with a retrorectal tumor amenable for resection is predominantly determined by the localization of the retrorectal mass. In patients with a retrorectal tumor located above the S2-S3 vertebra, the abdominal or combined abdominoperineal approach is preferred, whereas the posterior/transsacral approach (Kraske Procedure, modified Kraske Procedure) should be preferred for masses located below the S3 vertebra.\u003c/p\u003e \u003cp\u003eAlthough there are different definitions for the Kraske Procedure and/or modified Kraske Procedure in recently published studies, surgical site infection has been reported to be increased in up to 14% after posterior/transsacral approach compared to the abdominal approach (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Due to paucity of current data, we aimed to report/analyze the surgical site infection rate after a modified Kraske Procedure.\u003c/p\u003e"},{"header":"Material and Method","content":"\u003cp\u003eAll patients diagnosed with a retrorectal tumor and amenable for surgery, who underwent a resection surgery according to the principles of modified Kraske Procedure between August 2006 and August 2025 at a tertiary cancer hospital were enrolled into the retrospective observational study. Patients with recurrent retrorectal tumors, patients with a history of pelvic radiation or previous chemotherapy due malignancies in the pelvic cavity were excluded from the study.\u003c/p\u003e \u003cp\u003eAll patients diagnosed for retrorectal tumors, whether incidentally identified due to other complaints during advanced imaging or symptomatic patients with specific complaints such as pain or symptoms related to compression to adjacent organs, were preoperatively reevaluated. Chest and abdominal CT scans were performed primarily to visualize the mass in the retrorectal space and to exclude distant metastasis. Pelvic MRI was performed for local staging, to determine radiologic features to distinguish between benign and malignant lesions and to evaluate the relationship between adjacent organs and structures. A preoperative biopsy from the retrorectal tumor was not performed or recommended for patients amenable to resection surgery due to the increased risk of preoperative/postoperative infections and dissemination for malignant lesions.\u003c/p\u003e \u003cp\u003eAsymptomatic patients with a retrorectal tumor\u0026thinsp;\u0026ge;\u0026thinsp;3cm or cystic lesions harboring a solid component suspicious for malignancy and all symptomatic patients, whose symptoms were related to the compression of the retrorectal mass were suggested to underwent surgery. During preoperative advanced imaging modalities all patients with a tumor localization below the S2 and/or S3 were determined and underwent definitive resection surgery.\u003c/p\u003e \u003cp\u003eIn this study, the choice of surgery was the modified Kraske Procedure, and this procedure was performed in all patients with a retrorectal tumor amenable to surgery. Modified Kraske Procedure was performed in a jack-knife prone position and was defined as an oblique incision from the right or left site of the gluteal area between sacral vertebra and the anus.\u003c/p\u003e \u003cp\u003ePrior to surgery the patients received a standard mechanical bowel preparation without antibiotics on the previous day. After inserting a foley catheter to decompress the bladder, the patients are placed in a jack-knife prone position on the operating table with placing surgical gel pads under the pelvic area. The buttocks are laterally retracted with tapes before sacral skin prepping. An oblique incision is made from the right or left site depending on dominant hand of the gluteal area between the last sacral vertebra and anal verge, which is nearly 2 cm above the anus (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Afterwards the anococcygeal ligament was divided, and dissection was continued until the coccyx and sacrum was visualized to facilitate access to the retrorectal space. A partial or total coccyx resection was only performed, when necessary, according to the retrorectal tumor\u0026rsquo;s location, size and attachment to surrounding structures to provide an en bloc resection without tumor rupture.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe primary outcome of this study was to report postoperative morbidity, especially surgical site infections after modified Kraske Procedure. Postoperative complications were defined as any surgical or medical complications occurring during the patients\u0026rsquo; hospital stay or after hospital discharge within 30 days after surgery. The severity of surgical site infection was classified according to that described by Dindo (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDescriptive values of the data were analyzed and represented as mean with standard deviation, median (minimum and maximum), frequency and ratio. The statistical analysis were performed with the SPSS 28.0 software.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 35 patients who underwent surgery for retrorectal tumors were identified from the institutional database. In terms of surgical approach, the modified Kraske Procedure was performed in 23 (65.7%) patients, an abdominal approach in eleven (31.4%) patients, and a combined approach in one (2.9%) patient. Out of 35 patients 23 patients, who underwent a modified Kraske Procedure were included into this study. Of these patients, 19 (82.6%) were female and 4 (17.4%) were male. The mean age was 40.3\u0026thinsp;\u0026plusmn;\u0026thinsp;15.8 years. Preoperative assessment revealed a ASA score as following: ASA score I (n\u0026thinsp;=\u0026thinsp;6, 25%), ASA score II (n\u0026thinsp;=\u0026thinsp;15, 67%) and ASA score III (n\u0026thinsp;=\u0026thinsp;2, 8%). All patients\u0026rsquo; characteristics were given in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics of the patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical approach in screened cohort (n\u0026thinsp;=\u0026thinsp;35)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModified Kraske\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (65.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbdominal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (31.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCombined\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePatients included in analysis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (82.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (17.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (years), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40.3\u0026thinsp;\u0026plusmn;\u0026thinsp;15.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eASA score, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA I\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (25%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (67%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eData are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation or number (%).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eASA: American Society of Anesthesiologists physical status classification.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRegarding presenting symptoms, perineal pain was the most common complaint, observed in 12 (52.2%) patients. Five (21.7%) patients were asymptomatic, with lesions detected incidentally. Lower back or leg pain was reported in three (13%) patients, while abdominal pain was present in two (8.7%) patients. Constipation was observed in only one (4.4%) patient (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePreoperative symptoms of the patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSymptom\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerineal pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12 (52.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsymptomatic / incidental detection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (21.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLower back or leg pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (13.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbdominal pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (8.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConstipation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (4.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eData are presented as number (%)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAll patients underwent a modified Kraske Procedure and no rectal resection or limited (wedge) resection was required. Tumor size was assessed based on the maximum diameter of the lesion. Accordingly, the mean tumor diameter was 42.5\u0026thinsp;\u0026plusmn;\u0026thinsp;10.0 mm, with sizes ranging from 24 to 62 mm. Histopathological examination revealed that 20 (87%) lesions were benign with predominant pathological diagnosis of tailgut cyst (n\u0026thinsp;=\u0026thinsp;10, 43.5%), dermoid cyst (n\u0026thinsp;=\u0026thinsp;3, 13%) and epidermoid cyst (n\u0026thinsp;=\u0026thinsp;3, 13%). On the other hand malignant lesions were detected in three (13%) patients (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTumor Characteristics and Histopathological Findings\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical approach\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModified Kraske (100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRectal or wedge resection required\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor size (mm), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42.5\u0026thinsp;\u0026plusmn;\u0026thinsp;10.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor size range (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24\u0026ndash;62\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistopathology, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBenign lesions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (87.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTailgut cyst\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (43.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDermoid cyst\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (13.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEpidermoid cyst\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (13.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTeratoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (8.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther benign lesions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (8.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMalignant lesions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (13.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEwing Sarcoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (4.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMucinous adenocarcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (4.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGastrointestinal Stromal Tumor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (4.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eData are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation or number (%).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eTumor size was defined as the maximum diameter of the lesion.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePostoperative complications occurred in three (13%) patients. One (4.4%) patient witnessed bleeding, one (4.4%) patient witnessed a urinary tract infection, and only one (4.4%) patient witnessed a surgical site infection (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The surgical site infection presented as a wound abscess/dehiscence, which was treated with vacuum assisted closure therapy and antibiotics. The mean length of hospital stay was 3.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9 days.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePostoperative Outcomes and Complications\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative complications\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%) / mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBleeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (4.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrinary tract infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (4.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical site infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (4.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLength of hospital stay (days)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eData are presented as number (%) or mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study reports the experience of a single center regarding early postoperative morbidity rates, particularly surgical site infections, following a modified Kraske procedure in patients diagnosed with retrorectal tumors. The vast majority of the patients were female and most of the retrorectal tumors harbored benign biological features. All patients underwent a modified Kraske Procedure with lower surgical site infection rates of 4.4% compared to the standard Kraske Procedure, which makes the modified Kraske procedure a promising choice of treatment option.\u003c/p\u003e \u003cp\u003eAfter resection of the retrorectal tumor, the pathology report revealed that the vast majority of specimens showed benign characteristics such as tailgut cysts, epidermoid cysts, dermoid cysts, etc. with a rate of 87%, while 13% were malignant tumors such as Ewing Sarcoma, mucinous adenocarcinoma and gastrointestinal stromal tumor. These results were in line with other studies, that have previously reported similar findings (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The risk of malignancy is seriously increased in solid retrorectal masses compared to cystic tumors (31.4% versus 8.8% respectively) (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). On the other hand, the malignant transformation of benign retrorectal tumors may occur and has been reported. In a previously published study the overall rate of neoplastic transformation of 26.6% and increased up to 48% among male patients diagnosed with a retrorectal tumor (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). According to several studies the malignant transformation rate of cystic retrorectal tumors is higher than expected and particular attention should be paid during frequent surveillance of especially asymptomatic, benign cystic retrorectal tumors.\u003c/p\u003e \u003cp\u003eA preoperative biopsy from the retrorectal tumor was not recommended and performed in this current study due to several reasons such as avoiding the potential risk of regional tumor seeding, preventing the increased risk of postoperative surgical site infections and increased risk of recurrence rates (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Another reason is that a previous study has reported a discrepancy or discordance between preoperative biopsy and postoperative pathological examination of the specimen in up to 29% of the patients with retrorectal tumor (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Therefore, preoperative biopsy is recommended only in cases of advanced disease or retrorectal tumors suspicious for lymphoma or bone tumors, where patients would primarily benefit from chemotherapy or radiotherapy, or where chemotherapy or radiotherapy could be offered as a treatment option. In our current study, we did not witness any cases of pelvic abscess, and only one patient (4.4%) experienced surgical site infection with wound dehiscence; this may have been due to the absence of preoperative biopsy of the retrorectal masses.\u003c/p\u003e \u003cp\u003eThe choice of surgical approach is based on the retrorectal tumor\u0026rsquo;s localization, size and morphology determined by preoperative advanced imaging modalities such as pelvic CT and/or pelvic MRI. Usually, retrorectal tumors below S2/S3 are resected with a posterior (transsacral) approach, which is defined as the Kraske Procedure. This procedure enables a better view of the surgical field, but on the other hand is associated with increased pelvic pain, fecal/incontinence or sexual disfunction and surgical site infections. In a multicentric French study, which is the largest published study reporting experiences and findings regrading postoperative outcomes of retrorectal tumor surgery the surgery site infection rate as wound abscess with the Kraske Procedure was higher compared to the abdominal approach (14% vs 2%; \u003cem\u003ep\u0026thinsp;=\u0026thinsp;0.02\u003c/em\u003e), whereas the pelvic abscess rate was similar in both groups (7% vs 6%; \u003cem\u003ep\u0026thinsp;=\u0026thinsp;1\u003c/em\u003e).\u003c/p\u003e \u003cp\u003eIn our study we performed the modified Kraske Procedure to lower the surgical site infection rate such as wound infection, wound abscess and wound dehiscence. Although, there are various definitions of the Kraske Procedure, basically the Kraske procedure is defined as median or paramedian incision in or around the intergluteal cleft (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Therefore, we made an oblique incision from the right or left site of the of the gluteal area. The purpose of the oblique incision is to prevent or decrease the surgical site infection rate due to keeping a distance from the intergluteal cleft. The idea behind this technique is that this region\u0026rsquo;s vascularization is poorer, and this region is located in deeper in groove compared to other areas in the gluteal area, which impairs wound healing. With reposition the midline incision from the intergluteal cleft to a lateral oblique incision we have reduced any tension on the incision and achieved a promising and an excellent wound healing rate of 95.6% and surgical site infection was reported in only one (4.4%) patient.\u003c/p\u003e \u003cp\u003eThe most important limitation of the current study is that of retrospective studies such as selection and recall bias. Another limitation of this study is the small sample size of patients with retrorectal tumors and that this study is a single center case series without comparison of other surgical approaches and resection techniques.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe management of retrorectal tumors are difficult and challenging due to its rarity and heterogeneity. Especially, for retrorectal tumors located below S2/S3 the Kraske Procedure is the standard treatment option of choice, which allows a better visualization of the surgical field and facilitates an en bloc resection. The modified Kraske Procedure bears the same advantages as the standard Kraske Procedure with promising and enormous low surgical site infection rates with 4,4%.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHuman Ethics and Consent to Participate declarations: The study was conducted in accordance with the Declaration of Helsinki. Ethical approval was obtained from the Istanbul University, Istanbul Faculty of Medicine Clinical Research Ethics Committee. Due to the retrospective nature of the study and the use of anonymized patient data, informed consent to participate was waived.\u003c/p\u003e\u003cp\u003e \u003ch2\u003eGels and Blots\u003c/h2\u003e \u003cp\u003eThis study does not include any gels or blots. Therefore, no uncropped gel or blot images are applicable.\u003c/p\u003e \u003cp\u003eClinical trial number: not applicable\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis study did not receive any specific funding.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAdem Bayraktar, Cemil Burak Kulle, Metin Keskin and Mehmet T\u0026uuml;rker Bulut contributed to conception and design of the manuscript. Ozan Pastacıgil and Halil Alper Bozkurt collected the data. Cemil Burak Kulle, Adem Bayraktar and İlker \u0026Ouml;zg\u0026uuml;r analyzed and Neslihan Berker and Melek B\u0026uuml;y\u0026uuml;k interpreted the data. Cemil Burak Kulle, Adem Bayraktar, Halil Alper Bozkurt and Ozan Pastacıgil drafted and wrote the manuscript. Mehmet T\u0026uuml;rker Bulut, Metin Keskin, Adem Bayraktar and İlker \u0026Ouml;zg\u0026uuml;r critically revised the manuscript for important intellectual content. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003ethe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eJao SW, Beart RW, Spencer RJ, et al. Retrorectal tumors. Mayo Clinic experience, 1960\u0026ndash;1979. Dis Colon Rectum. 1985;28:644\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUhlig BE, Johnson RL. Presacral tumors and cysts in adults. Dis Colon Rectum. 1975;18:581\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHobson KG, Ghaemmaghami V, Roe JP, Goodnight JE, Khatri VP. Tumors of the retrorectal space. Dis Colon Rectum. 2005;48:1964\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHassan I, Wietfeldt ED. Presacral tumors: diagnosis and management. Clin Colon Rectal Surg. 2009;22:84\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaek SK, Hwang GS, Vinci A, Jafari MD, Jafari F, Moghadamyeghaneh Z, Pigazzi A. Retrorectal Tumors: A Comprehensive Literature Review. World J Surg. 2016;40(8):2001\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBurke JR, Shetty K, Thomas O, Kowal M, Quyn A, Sagar P. The management of retrorectal tumours: tertiary centre retrospective study. BJS Open 2022; 6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBilkhu AS, Wild J, Sagar PM. Management of retrorectal tumours. Br J Surg. 2024;111(1):znae012.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMathis KL, Dozois EJ, Grewal MS, Metzger P, Larson DW, Devine RM. Malignant risk and surgical outcomes of presacral tailgut cysts. Br J Surg. 2010;97:575\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCh\u0026eacute;reau N, Lefevre JH, Meurette G, Mourra N, Shields C, Parc Y, et al. Surgical resection of retrorectal tumours in adults: long-term results in 47 patients. Colorectal Dis. 2013;15:e476\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAubert M, Mege D, Parc Y, Rullier E, Cotte E, Meurette G, et al. Surgical Management of Retrorectal Tumors: A French Multicentric Experience of 270 Consecutives Cases. Ann Surg. 2021;274:766\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDindo D, Demartines N, Clavien P-A, et al. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSagar AJ, Koshy A, Hyland R, Rotimi O, Sagar PM. Preoperative assessment of retrorectal tumours. Br J Surg. 2014;101:573\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNicoll K, Bartrop C, Walsh S, Foster R, Duncan G, Payne C, et al. Malignant transformation of tailgut cysts is significantly higher than previously reported: systematic review of cases in the literature. Colorectal Dis. 2019;21:869\u0026ndash;78.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAubert M, Mege D. Kraske approach to retrorectal tumors: Surgical technique. J Visc Surg. 2022;159(3):229\u0026ndash;33. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jviscsurg.2022.01.009\u003c/span\u003e\u003cspan address=\"10.1016/j.jviscsurg.2022.01.009\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2022 Feb 5. PMID: 35135747.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKraske P. Zur extirpation hochsitzender mastdarm-krebse. Verhandl Deutch Gellesch Chir. 1885;14:464\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Retrorectal tumors, Modified Kraske approach, Surgical outcomes","lastPublishedDoi":"10.21203/rs.3.rs-9117525/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9117525/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eThe aim of this study is to evaluate the early postoperative morbidity rates with a particular focus on surgical site infection rates, in patients undergoing resection for retrorectal tumors with the modified Kraske Procedure.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis retrospective single-center study included patients who underwent resection for retrorectal tumors performing the modified Kraske Procedure between August 2006 and August 2025. Patients with recurrent disease or a history of pelvic radiotherapy or chemotherapy were excluded. The primary outcome was early postoperative morbidity, especially in terms of surgical site infections, which was defined as complications occurring within the first 30 days after surgery.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAmong 35 patients operated for retrorectal tumors, 23 (65.7%) underwent a resection performing the modified Kraske Procedure and were included in the analysis. The majority of patients were female (82.6%), with a mean age of 40.3\u0026thinsp;\u0026plusmn;\u0026thinsp;15.8 years. The mean tumor size was 42.5\u0026thinsp;\u0026plusmn;\u0026thinsp;10.0 mm, and most lesions were benign (87%). Postoperative complications occurred in three patients (13%), with surgical site infection observed in only one patient (4.4%). The mean length of hospital stay was 3.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9 days.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe modified Kraske Procedure appears to be a safe and effective surgical option for retrorectal tumors, offering the advantages of the standard Kraske procedure with a low surgical site infection rate.\u003c/p\u003e","manuscriptTitle":"Modified Kraske Procedure for Retrorectal Tumors Decreases Surgical Site Infection Rate: A Single Center Experience","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-03 11:17:36","doi":"10.21203/rs.3.rs-9117525/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"119405227920508532736692430256077072677","date":"2026-05-14T09:13:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"243397503801538301963164715555409671817","date":"2026-05-07T09:31:48+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-05T21:29:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"20158016956081634907638490990331206810","date":"2026-05-05T20:50:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"261697796165975898794960842572485647010","date":"2026-03-31T02:07:09+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-29T11:23:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"61399489800094625419036972010249739940","date":"2026-03-28T13:17:31+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-28T12:07:33+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-19T10:34:09+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-17T04:29:44+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-17T04:29:37+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2026-03-13T18:43:28+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d3147fd0-4110-4d48-a93d-9aa87e1d52ad","owner":[],"postedDate":"April 3rd, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"119405227920508532736692430256077072677","date":"2026-05-14T09:13:50+00:00","index":55,"fulltext":""},{"type":"reviewerAgreed","content":"243397503801538301963164715555409671817","date":"2026-05-07T09:31:48+00:00","index":54,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-05T21:29:23+00:00","index":53,"fulltext":""},{"type":"reviewerAgreed","content":"20158016956081634907638490990331206810","date":"2026-05-05T20:50:39+00:00","index":52,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-03T11:17:36+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-03 11:17:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9117525","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9117525","identity":"rs-9117525","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}