Case Report: Tailgut cyst: diagnosis and treatment

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Despite the large spectrum of revelations, preoperative diagnosis is misleading, as there are no prodromic features. Case presentation We report a case of an incidental finding of a tailgut cyst in a 34-year-old man following closed abdominal trauma. The patient underwent laparoscopic surgery with complete resection. We should describe the difficulties encountered in preoperative diagnosis and in the choice of therapeutic means. Discussion Biological and radiological features are nonspecific in nature. Because preoperative sampling carries additional risks, surgical resection is mostly indicated as a diagnostic and therapeutic tool. The surgical approach causes a dilemma and should be tailored to the tumor location, awaited risk of hemorrhage or extended resection, and surgeon’s expertise. Postoperative follow-up is essential because of the high risk of recurrence. Conclusion Surgical resection remains the standard treatment approach. However, the optimal surgical route is still a matter of debate, as each technique has its own advantages. Therefore, the choice of approach should be guided by the patient’s medical history, as well as the location and specific characteristics of the tumor Surgical resection was the standard therapeutic course. The surgical route is controversial, as each approach has its advantages. For this reason, the decision should include the patient’s history, tumor location, and characteristics according to the surgeon’s expertise. To gain the most from awaited surgical results, precise assessment of the patient’s case is mandatory. 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Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Case Report Case Report: Tailgut cyst: diagnosis and treatment [version 1; peer review: awaiting peer review] Siala Rakia 1 , Mseddi Mohamed Ali https://orcid.org/0000-0002-5107-2122 1 , Mariem Hsairi https://orcid.org/0000-0002-8803-6926 1 , [...] Sallemi Karim 1 , Ghariani Brahim 1 , Karim Sassi 1 , Mohamed Ben Slima 1 Siala Rakia 1 , Mseddi Mohamed Ali https://orcid.org/0000-0002-5107-2122 1 , [...] Mariem Hsairi https://orcid.org/0000-0002-8803-6926 1 , Sallemi Karim 1 , Ghariani Brahim 1 , Karim Sassi 1 , Mohamed Ben Slima 1 PUBLISHED 30 Jul 2025 Author details Author details 1 general surgery "B", Rabta Hospital, Tunis, Tunis, Tunisia Siala Rakia Roles: Supervision, Writing – Review & Editing Mseddi Mohamed Ali Roles: Conceptualization, Methodology, Resources, Writing – Original Draft Preparation, Writing – Review & Editing Mariem Hsairi Roles: Funding Acquisition Sallemi Karim Roles: Funding Acquisition Ghariani Brahim Roles: Supervision Karim Sassi Roles: Supervision Mohamed Ben Slima Roles: Validation OPEN PEER REVIEW REVIEWER STATUS AWAITING PEER REVIEW Abstract Introduction Tailgut cysts are the most frequently reported type of retrorectal tumor. Despite the large spectrum of revelations, preoperative diagnosis is misleading, as there are no prodromic features. Case presentation We report a case of an incidental finding of a tailgut cyst in a 34-year-old man following closed abdominal trauma. The patient underwent laparoscopic surgery with complete resection. We should describe the difficulties encountered in preoperative diagnosis and in the choice of therapeutic means. Discussion Biological and radiological features are nonspecific in nature. Because preoperative sampling carries additional risks, surgical resection is mostly indicated as a diagnostic and therapeutic tool. The surgical approach causes a dilemma and should be tailored to the tumor location, awaited risk of hemorrhage or extended resection, and surgeon’s expertise. Postoperative follow-up is essential because of the high risk of recurrence. Conclusion Surgical resection remains the standard treatment approach. However, the optimal surgical route is still a matter of debate, as each technique has its own advantages. Therefore, the choice of approach should be guided by the patient’s medical history, as well as the location and specific characteristics of the tumor Surgical resection was the standard therapeutic course. The surgical route is controversial, as each approach has its advantages. For this reason, the decision should include the patient’s history, tumor location, and characteristics according to the surgeon’s expertise. To gain the most from awaited surgical results, precise assessment of the patient’s case is mandatory. READ ALL READ LESS Keywords Tailgut cyst, retrorectal, case report, tumor, kraske, laparoscopy Corresponding Author(s) Mseddi Mohamed Ali ( [email protected] ) Close Corresponding author: Mseddi Mohamed Ali Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2025 Rakia S et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Rakia S, Mohamed Ali M, Hsairi M et al. Case Report: Tailgut cyst: diagnosis and treatment [version 1; peer review: awaiting peer review] . F1000Research 2025, 14 :747 ( https://doi.org/10.12688/f1000research.162400.1 ) First published: 30 Jul 2025, 14 :747 ( https://doi.org/10.12688/f1000research.162400.1 ) Latest published: 30 Jul 2025, 14 :747 ( https://doi.org/10.12688/f1000research.162400.1 ) Introduction Tailgut cysts are the most frequently reported retrorectal tumors. 1 Despite the large spectrum of revelations, preoperative diagnosis is misleading, as there are no prodromic features. 2 Transparietal biopsy should be avoided. Surgical resection is the standard therapeutic course. 3 The surgical approach remains controversial, as each technique offers distinct advantages. We believe this case report provides valuable insight into the diagnosis and management of tailgut cysts, while also providing well-founded arguments to help in the surgical choice. Presentation of case A 34-year-old man with no significant medical history was referred from an infirmary to our university hospital center for management of a post-traumatic hepatic laceration. The patient had no known allergies or hereditary diseases. Upon examination, his vital signs were found to be within the normal range. Physical examination revealed tenderness in the upper right quadrant. Biological examination revealed no abnormalities. On a full-body CT scan, a bilobed cystic mass measuring 5 cm presacral at the level of S4 displacing the rectum anteriorly and laterally measuring 67 mm was incidentally discovered. The patient reported no pain while sitting, rectal bleeding, constipation, urinary problems, or fever. Rectal examination revealed a painless, bulging posterior rectal wall with a palpable upper limit on the fingertip. Magnetic resonance imaging (MRI) revealed an 80 × 72 × 62 mm bilobed retrorectal cystic mass with a thin, regular wall, T1 hyposignal, and T2 heterogeneous signal, comprising a left paramedian portion with T2 hypersignal and a right paramedian portion with intermediate T2 signal, pushing back the rectum anteriorly and laterally without invading it ( Figure 1 ). The patient was administered analgesics, with good clinical and radiological outcomes. After convalescence, the patient underwent laparoscopic resection. He was placed supine in the French position. Trocart placement was as follows: T12 on the right iliac fossa, T5 on the left iliac fossa, and T5 on the right flank. Upon exploration, it was found to be a bilobed retrorectal mass measuring 4 and 7 cm well defined cleavable cystic masses. At the end of the dissection, the tumor ruptured, and jelly like mucoid material was aspirated. postoperative course was uneventful. The patient was discharged on 4 th postoperative day. Anatomopathological findings were as follows: cystic formation with a lumen filled with keratin strips and lined by regular squamous epithelium resting on a connective wall containing disorganized smooth muscle fibers ( Figures 2 and 3 ). Final histologic examination indicated a tailgut cyst. The patient was scheduled for a close follow-up. The patient was doing well and was fine three months postoperatively. Figure 1. A sagital MRI slice exhibiting an 8 cm bilobed retrorectal cystic mass. Figure 2. Haematoxylin-Eosin x 10: Fibromuscular cystic wall bordered by a squamous cell lining. Figure 3. Haematoxylin-Eosin x 40: Regular squamous coating topped by a layer of keratin. Discussion The retrorectal or presacral space is bounded anteriorly by the rectum, superiorly by the peritoneal reflection, inferiorly by the Waldeyer’s fascia, posteriorly by the presacral fascia, and laterally by the ureters and iliac vessels. It is a crossroads of different histological components, of which tumorigenesis can manifest as several histological types: neural, bony, inflammatory, fatty, lymph node, vascular, or congenital. Their invasive potential is variable but often benign (92%). 2 Malignancy appears to be related to male sex (p < 0.05) and young age (43 vs 54.4 years, p < 0.05). 4 Tailgut cysts tops the list of these tumors, accounting for 41% of all tumors and 75% of benign tumors. 2 However, it remains a rare tumor with only 53 cases in the largest series. 5 These tumors manifest themselves through vague symptoms such as pain when sitting, 6 defecatory pain, or rectorrhagia. 1 Proctological examination revealed a well-defined soft and mobile retrorectal mass. 6 The initial workup must include a CT and magnetic study. Transparietal biopsy for histological evidence is not recommended because of the hypothetical risks of hemorrhage, infection, and tumor dissemination. 7 Moreover, their interpretation may be inconclusive because they often contain only fibrous tissues, without epithelial tissues or malignant foci. 8 In addition, surgical excision can be performed without difficulty in the majority of cases and therefore does not require neoadjuvant treatment for tumor downsizing. This therapeutic modality can be proposed in cases of Ewing’s sarcoma, osteosarcoma, and lymphoma 3 ; thus, the interpretation of iconographic images is essential to guide the diagnosis. The first diagnostic step is to rule out meningocele, as any inadvertent procedure can worsen the prognosis by causing iatrogenic meningitis. Recurrent headaches associated with bowel movements should raise suspicion of this diagnosis. 7 “The scimitar sign” and signal intensity of its content parallel to the cerebrospinal fluid signal on all sequences are present in meningicele. 13 The second diagnostic step is to consider malignant features such as the presence of enhancing or necrotic soft tissue, mural nodularity, post-contrast enhancement, 9 intracystic vegetation, or infiltration of perilesional fat. 1 On non-injected sequences, one should also look for irregular walls or loss of nodule sphericity. 1 This stage is crucial for guiding the surgical procedure, anticipating tissue sacrifice, and adapting to the surgical approach. In fact, in sacrectomies, at least one side of S2 must be preserved to avoid urinary and bowel disturbance. 10 No iconographic data characterize the tailguit cyst, but rather retrorectal, presacral, median topography above the plane of the levator ani is suggestive of the diagnosis. These lesions usually present as several loculi with a honeycomb appearance. The signal is variable, depending on the protein concentration; T2 hypersignals most often. 1 Diffusion sequences reveal isosignal lesions associated with mucinous content. 1 But many cases escape preoperative diagnosis: in a cohort of 28 patients, the diagnosis was mistaken in 35,7% of cases. 11 A broad range of complications may arise during the course of the tumor, including hemorrhage, infection, fistulization, destruction or compression of the surrounding structures, and degeneration. There are many types of malignant transition in tailgut cysts, including NETs, adenocarcinoma, and squamous carcinoma. 11 Resection is essential to avoid these complications, confirm the histological diagnosis, and establish milestones for subsequent follow-up. This preventive attitude is reinforced by the absence of a correlation between the presence of complaints and tumor histology, 4 and complete resection does not prevent systemic tumor recurrence in cases of degenerescence. 12 A wait-and-see approach should be avoided as asymptomatic lesions are at greater risk of malignancy (46,2 vs. 72,2%; p = 0.08). 13 Surgery must resect the entire tumor without spilling the contents, especially if malignancy is suspected, bearing in mind that postoperative pain is not influenced by the associated bone resection (p = 0,3). 14 The choice of the procedure should consider tissue sacrifice 10 and tumor location. The posterior approach should be avoided for high-lying tumors (above S3), as a lack of access to the pelvic vessels in cases of intraoperative bleeding represents a real threat. 15 When using a perineal approach, coccygectomy is often performed to improve surgical exposure and reduce the risk of recurrence by removing totipotent cells that may reside in the coccyx When operating via a perineal approach, coccygectomy is associated with improved surgical exposure and eliminates the possibility of recurrence from totipotent cells in the coccyx. 15 When the boundary between the presacral tumor and the rectum is unclear, rectal palpation with the left hand can help delineate the interface, aiding in rectal preservation during dissection When no clear boundary was noted between the presacral tumor and rectum, rectal palpation with the left hand could be used to indicate the boundary between the presacral tumor and rectum to better protect the rectum. 16 In cases of capsule rupture or when cyst decompression is required during surgery, the use of iodine tincture may help prevent seeding of cyst contents. When the capsule ruptures or cyst decompression is necessary during surgery, supplementary iodine tincture treatment could help prevent cyst content seeding. 17 Moreover, in a French cohort of 270 patients who underwent surgery for retrorectal tumors, laparoscopic resection was associated with a lower incidence of intraoperative complications. Moreover, in the French cohort of 270 patients who underwent surgery for retrorectal tumors, laparoscopic resection avoided intraoperative accidents, and there was no statistical difference between the laparoscopic and Kraske approaches in terms of lesion perforation (47 vs. 47%, p = 1), rectal perforation (6 vs. 5%, p = 0,6), presacral hemorrhage (6 vs. 2%, p = 0,4) and bladder rupture (2 vs. 0%, p = 0,2). 2 And as a corollary, no statistical difference in postoperative recurrence (12 vs. 3,5%, p = 0,06). 2 In addition, there was no statistically significant difference in overall morbidity between the laparoscopic and Kraske approaches (28 vs. 30%, p = 0,7) neither in unplanned readmissions (9 vs. 11%, p = 0,8) nor, postoperative pain (10 vs. 20%, p = 0,3) nor, sexual dysfunction (3 vs. 1%, p = 0,5) nor urinary incontinence (3 vs. 1%, p = 0,5). 2 Rectal fistula was only observed in patients who underwent laparoscopic surgery (6 vs. 0%, p = 0,01) but it should be however, the latter was preferred in cases of rectal invasion, which explains this marked difference. An important point to emphasize in this study is the importance of postoperative urinary disorders in patients undergoing laparoscopic surgery (13 vs. 0%, p = 0,006) and postoperative defecation (10 vs. 0%, p = 0,02) whereas these tumors presented more uro-defecatory disorders in patients operated on by the Kraske approach (9 vs. 11%, 6 vs. 13%). 2 Severe postoperative complications (Clavien-Dindo ≥ 3) are non-negligible, reaching 7,6% in a cohort of 144 patients who underwent surgery for retrorectal tumors. 18 Despite the absence of consensus guidelines on surveillance schedule, patients should be followed up closely, as the risk of recurrence is approximately 5% according to the follow-up of 73 patients in a median of 24 months, despite an R0 resection rate of 94%. 19 In addition, in a cohort study of the Mayo Clinic, 8% of resected specimens harbored malignancy. 19 Although no conclusions can be drawn from our case report, it can be added to the current reported cases to further widen the literature, especially by featuring its incidental presentation and surgical difficulties. Conclusion Tailgut cysts are mostly benign tumors with low malignant potential. Definitive diagnosis was based on the histological examination of the resected mass. Preoperative sampling is considered hazardous. Both surgical routes are proven procedures, with adequate short- and long-term results. The choice should be tailored to the tumoral extent and planned tissular damage. Ethics Ethical approval was not required. Reporting guidelines The CARE checklist was uploaded to the Zenodo plateform. Its DOI is: 10.5281/zenodo.15872750 Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0). Consent Written informed consent for the participation and publication of clinical details and images was obtained from the patients. Data availability No data are associated with this article. References 1. Faradji A, Derinck A, Coget J, et al. : Hamartome kystique rétrorectal ou tailgut cyst: à propos d’un cas. Imagerie de la Femme. juin 2020; 30 : 98–100. 2. Aubert M: Prise en charge chirurgicale des tumeurs rétrorectales. Expérience Multicentrique Française. 2 oct 2020; 21 . 3. Reiter MJ, Schwope RB, Bui-Mansfield LT, et al. : Surgical Management of Retrorectal Lesions: What the Radiologist Needs to Know. Am. J. Roentgenol. févr 2015; 204 (2): 386–395. PubMed Abstract | Publisher Full Text 4. Dziki Ł, Włodarczyk M, Sobolewska-Włodarczyk A, et al. : Presacral tumors: diagnosis and treatment – a challenge for a surgeon. Arch. Med. Sci. mai 2019; 15 (3): 722–729. PubMed Abstract | Publisher Full Text | Free Full Text 5. Hjermstad BM, Helwig EB: Tailgut cysts. Report of 53 cases. Am. J. Clin. Pathol. févr 1988; 89 (2): 139–147. PubMed Abstract | Publisher Full Text 6. Mora-Guzmán I, Casado APA, Rodríguez Sánchez A, et al. : Tailgut cysts: Presentation of four cases. Gastroenterol. Hepatol. 1 févr 2018; 41 (2): 103–105. PubMed Abstract | Publisher Full Text 7. Aranda-Narváez JM, González-Sánchez AJ, Montiel-Casado C, et al. : Posterior approach (Kraske procedure) for surgical treatment of presacral tumors. World. J. Gastrointest. Surg. 27 mai 2012; 4 (5): 126–130. PubMed Abstract | Publisher Full Text | Free Full Text 8. Lillemoe KD, Kaushal S, Cameron JL, et al. : Distal Pancreatectomy: Indications and Outcomes in 235 Patients. Ann. Surg. mai 1999; 229 (5): 693. PubMed Abstract | Publisher Full Text | Free Full Text 9. Patel N, Maturen KE, Kaza RK, et al. : Imaging of presacral masses—a multidisciplinary approach. Br. J. Radiol. mai 2016; 89 (1061): 20150698. PubMed Abstract | Publisher Full Text | Free Full Text 10. Ghosh J, Eglinton T, Frizelle FA, et al. : Presacral tumours in adults. Surgeon. 1 févr 2007; 5 (1): 31–38. Publisher Full Text 11. Mathis KL, Dozois EJ, Grewal MS, et al. : Malignant risk and surgical outcomes of presacral tailgut cysts. Br. J. Surg. 4 mars 2010; 97 (4): 575–579. PubMed Abstract | Publisher Full Text 12. Wichmann MW, Lau-Werner U, Müller C, et al. : Carcinoembryonic antigen for the detection of recurrent disease following curative resection of colorectal cancer. Anticancer Res. déc 2000; 20 (6D): 4953–4955. PubMed Abstract 13. Jain BK, Arora H, Srivastava UK, et al. : Insight into the management of non-traumatic perforation of the small intestine. J. Infect. Dev. Ctries. 15 oct 2010; 4 (10): 650–654. PubMed Abstract 14. Jérémie L, Nathalie C, Guillaume M, et al. : Prise en charge chirurgicale des tumeurs rétrorectales: résultats à court et long terme sur une série de 47 patients. Color. Dis. 2013; 15 : e476–e482. 15. Haydar M, Griepentrog K: Tailgut cyst: A case report and literature review. Int. J. Surg. Case Rep. 25 mars 2015; 10 : 166–168. PubMed Abstract | Publisher Full Text | Free Full Text 16. Zhao X, Zhou S, Liu N, et al. : Is There Another Posterior Approach for Presacral Tumors Besides the Kraske Procedure? — A Study on the Feasibility and Safety of Surgical Resection of Primary Presacral Tumors via Transsacrococcygeal Transverse Incision. Front. Oncol. 26 mai 2022; 12 : 892027. PubMed Abstract | Publisher Full Text | Free Full Text 17. Li Z, Lu M: Presacral Tumor: Insights From a Decade’s Experience of This Rare and Diverse Disease. Front. Oncol. 16 mars 2021; 11 : 639028. PubMed Abstract | Publisher Full Text | Free Full Text 18. Burke JR, Shetty K, Thomas O, et al. : The management of retrorectal tumours: tertiary centre retrospective study. BJS Open. 1 avr 2022; 6 (2): zrac044. PubMed Abstract | Publisher Full Text | Free Full Text 19. Broccard SP, Colibaseanu DT, Behm KT, et al. : Risk of malignancy and outcomes of surgically resected presacral tailgut cysts: A current review of the Mayo Clinic experience. Color. Dis. avr 2022; 24 (4): 422–427. PubMed Abstract | Publisher Full Text Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 30 Jul 2025 ADD YOUR COMMENT Comment Author details Author details 1 general surgery "B", Rabta Hospital, Tunis, Tunis, Tunisia Siala Rakia Roles: Supervision, Writing – Review & Editing Mseddi Mohamed Ali Roles: Conceptualization, Methodology, Resources, Writing – Original Draft Preparation, Writing – Review & Editing Mariem Hsairi Roles: Funding Acquisition Sallemi Karim Roles: Funding Acquisition Ghariani Brahim Roles: Supervision Karim Sassi Roles: Supervision Mohamed Ben Slima Roles: Validation Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (1) version 1 Published: 30 Jul 2025, 14:747 https://doi.org/10.12688/f1000research.162400.1 Copyright © 2025 Rakia S et al . 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