Abstract / Summary
Tailgut cysts (TGCs) are congenital retrorectal lesions with heterogeneous clinical presentation. Uncertainties remain regarding diagnostic work-up, surgical management, recurrence, and the risk of malignant transformation. This systematic review aimed to provide a practice-oriented synthesis of the current evidence on TGCs. A systematic search of PubMed/MEDLINE, Embase, and the Cochrane Library was performed according to PRISMA 2020 guidelines. The protocol was prospectively registered in PROSPERO (CRD420261376260). Primary outcomes included clinical presentation, imaging work-up, operative approach, postoperative complications, recurrence, and malignancy risk. Sixteen studies including 362 patients were analyzed. Patients were predominantly female (81.9%), with median ages ranging from 35 to 52 years. Most patients were symptomatic (62.8%), with pain representing the most frequent presenting symptom (71.3%). Magnetic resonance imaging (MRI) was the most commonly used imaging modality (87.2%), whereas preoperative biopsy was performed in only 16.1% of patients. Surgical management was primarily anatomy-driven. The posterior approach was the most frequently adopted strategy (70.6%), followed by anterior (21.2%) and combined (8.2%) approaches. Minimally invasive surgery was increasingly reported. Malignant transformation was identified in 8.4% of lesions. Postoperative complications occurred in 25.6% of patients, including major morbidity in 5.2%, while recurrence was reported in 7.3%. TGCs should be considered both in symptomatic patients and in incidentally detected retrorectal lesions. MRI should be considered the imaging modality of choice, as it defines lesion extent and may help identify features suspicious for malignant transformation. Preoperative biopsy should be reserved for carefully selected cases because of the potential risks of infection and tumor spread. Surgical excision remains the most frequently reported management strategy, with operative approach primarily determined by lesion anatomy. The potential for malignant transformation remains one of the main factors supporting surgical excision in the published literature. However, this should be balanced against the risk of postoperative morbidity. These findings may support individualized decision-making, particularly in patients who are frail or highly comorbid. Given the risk of recurrence, long-term follow-up should be considered.