Presacral tumors: a retrospective analysis of 112 cases with emphasis on diagnostic challenges and surgical outcomes.

Background: Presacral tumors are rare entities with heterogeneous pathology including malignant potential. Due to nonspecific symptoms mimicking common anorectal diseases, misdiagnosis remains a major challenge that may delay treatment and worsen prognosis, particularly for malignant variants. This study analyzes diagnostic pitfalls and surgical outcomes in a large single-center cohort.

Methods: We retrospectively reviewed 112 presacral tumor cases treated at our tertiary colorectal center (2015-2025). Data included demographics, clinical presentation, misdiagnosis rates, imaging accuracy, surgical approaches, and complications. Statistical analysis utilized descriptive methods and Chi-square tests.

Results: Among 112 patients (male 62, female 50; median age 52 years, range 18-93), 57% presented with anal/rectal pain, while 20.5% were asymptomatic. 85.7% of patients were referred from non-specialized centers. Misdiagnosis occurred in 29.5% (predominantly as anal fistula/abscess or pilonidal sinus). Preoperative imaging (MRI/CT) correctly diagnosed 60% of tumors >3 cm vs. 21.2% of smaller tumors ( < 0.001). Surgical approaches: 93.8% underwent transsacral/transanal resection, 6.2% required laparoscopic/combined abdominoperineal resection. Major complications (Clavien-Dindo grade III) occurred in 4.5% of patients ( = 5/112), including hemorrhage, rectal injury, and sacral nerve injury. No mortality occurred. Pathology revealed 11.6% malignancy risk.

Conclusion: High misdiagnosis rates (29.5%) data support for heightened suspicion in patients with "refractory perianal sepsis", especially given the potential for malignancy. MRI showed significantly higher diagnostic accuracy for tumors >3 cm. Transsacral/transanal resection is safe and effective for most cases (93.8%), with low major morbidity. Centralized management in specialized centers optimizes outcomes.