Tailgut cysts are rare congenital (present at birth) lesions. It is estimated that one in 40,000 births will have a tailgut cyst. They are typically found behind the anus-rectum junction. Based on their location, they can be grouped with other lesions as retrorectal (located behind the rectum) or presacral (located in front of the sacrum) lesions. Tailgut cysts are also referred to as retrorectal cystic hamartomas.

Although they are known to be congenital lesions, patients often receive a diagnosis in adulthood. They are observed three times more frequently in females than in males. The reason for diagnosis in later ages is twofold: some tailgut cysts remain asymptomatic, while in some patients, symptoms are not attributed to a tailgut cyst, leading to a lack of further investigation.

What are the symptoms of a tailgut cyst?

In nearly half of the patients with a tailgut cyst, there are no symptoms. They are often detected incidentally during radiological examinations conducted for other reasons. In other patients, symptoms may arise due to the pressure of the cyst on surrounding organs or due to infection. While originating from behind the rectum, as the cyst enlarges, it can exert pressure not only on the rectum but also on organs such as the vagina and bladder. A tailgut cyst can cause symptoms such as frequent urination and burning sensation during urination due to pressure on the bladder, as well as a sensation of fullness in the rectum, painful or difficult bowel movements, narrowing of the stool, and constipation due to pressure on the rectum. Because of its space-occupying nature in the retrorectal area, individuals may feel discomfort in the buttocks and coccyx region while sitting, and they may have difficulty sitting comfortably. When infection occurs in these cysts, it can manifest as a pelvic/anal abscess, painful swelling in the anal area, and in some cases, as a fistula.

How is a tailgut cyst diagnosed?

In patients presenting with specific complaints, suspicion of a tailgut cyst may arise during a rectal examination when a mass effect is felt externally behind the rectum, or during a gynecological examination when a cystic lesion is seen on ultrasound. However, the radiological diagnosis of a tailgut cyst is usually made with pelvic MRI. Although a cystic structure may be seen on computed tomography in some patients, MRI is often the preferred radiological diagnostic method for the complete characterization of the lesion. Biopsy of lesions suspected to be tailgut cysts is not recommended.

Does a tailgut cyst turn into cancer?

In the medical literature, malignant transformation on the basis of a tailgut cyst has been reported in many cases, but it is not known exactly how many of these cysts carry the risk of developing cancer. Delay in diagnosis or failure to perform adequate surgery is thought to increase the risk of cancer development.

What is the treatment for a tailgut cyst?

There is no medication for treatment. Surgical removal of the cyst is necessary. Surgically removing the cyst allows for a definitive diagnosis of the suspected disease, resolution of any symptoms the patient may have, and elimination of the risk of cancer development. Extensive surgical intervention is required for tailgut cysts that have developed cancer, similar to any cancer, while for cysts that have not developed cancer, simply removing the cyst is sufficient.

How is surgery for a tailgut cyst performed?

The surgical approach is determined based on the level of the cyst. For cysts located well above the pelvic muscles, an abdominal approach, either open or laparoscopic, may be preferred. If the cyst is located below the pelvic muscles or in an easily accessible area, a posterior (back) approach may be used. In some patients, surgery may need to be performed from both sides.

During the abdominal approach, the surgeon carefully separates the cyst from the rectum, sacrum bone, and, in some cases, the vagina or pelvic muscles, and removes it outside the abdomen in a sterile bag. Maximum care should be taken during this separation process to avoid damage to the rectum, vagina, and surrounding blood vessels. In case of any injury, effective repair should be performed.

In the posterior approach (Kraske approach), with the patient in a prone position, an incision is made through the skin and fatty tissues from the side of the sacrum bone and coccyx (tailbone). After cutting the anococcygeal ligament, the cyst is accessed. In some patients, the coccyx bone may need to be removed at this stage due to reasons such as the need to expand the working area or adhesions of the cyst. Once the cyst is exposed, it is completely removed without causing damage to the levator muscles or rectum and leaving no tissue behind. Depending on the size of the field, the nature of the tissues, and the surgeon’s preference, a drain may be placed in the surgical area. Subsequently, the layers are sutured layer by layer to conclude the operation.

In a combined approach, part of the surgery can be performed abdominally while the rest is done from the back, or vice versa, using the same principles and techniques.

Is surgery for a tailgut cyst risky?

Surgery for a non-malignant tailgut cyst, when performed by experienced hands, is not considered to carry significant risks. However, in cases where malignancy has developed, in patients who have previously had infections, or when surgery is performed by individuals lacking sufficient experience, complications such as rectal injury, vaginal injury, urinary tract injury, vascular injury, residual disease, or damage to the anal sphincter or pelvic muscles may occur. If these problems are not effectively addressed, long-term complications such as recurrence, fistula, or fecal incontinence may develop.

What is the cost of surgery for a tailgut cyst?

The cost of surgery is calculated based on factors such as the duration of the surgery, whether the patient has had previous interventions in the same area, whether the surgery is performed abdominally or posteriorly, and whether malignancy is present.

Recovery after surgery for a tailgut cyst

If the surgery is performed safely without any damage to the rectum or other surrounding organs, one night of hospitalization is usually sufficient. If repair of possible damage to surrounding organs is performed, the patient may need to be hospitalized for observation during the recovery period, which can extend up to 4-5 days. After complete recovery, patients can resume their normal activities without any issues.

Follow-up after surgery for a tailgut cyst

If there are no findings suggestive of malignancy in the cyst removed during surgery and sent for pathological examination, patients do not require any additional treatment. Since recurrence is not expected if the cyst is completely removed, no radiological or clinical examination/control is necessary. However, if the cyst is not completely removed, the surgeon may recommend periodic follow-ups based on the patient’s characteristics. There is no universally accepted follow-up algorithm for this purpose.

A rectovaginal fistula is the formation of a tunnel or canal between the rectum, the final portion of the large intestine, and the vagina. Through this tunnel, gas and feces may pass from the vagina. It can be considered a significant health problem due to its negative impact on quality of life and the low success rates of treatment.

What Causes It?

The most common cause is trauma during childbirth, accounting for nearly 85% of cases. Additionally, previous surgeries can also lead to rectovaginal fistulas. These may occur after procedures such as rectal surgery, pelvic floor surgery, hemorrhoid surgery, or local tumor excision. Rough sexual intercourse or intercourse with foreign objects can also lead to fistula formation.

It’s also possible for rectovaginal fistulas to develop secondary to rectal or gynecological tumors, as well as due to radiotherapy. Inflammatory conditions such as Crohn’s disease or inflammatory conditions like Bartholin’s abscess can also play a role in fistula formation.

How Is a Rectovaginal Fistula Identified, and What Are Its Symptoms?

The most common symptom is the passage of gas and/or fecal matter from the vagina, either during normal activities or during defecation. In some patients, recurrent urinary tract infections or vaginal infections may indicate an underlying rectovaginal fistula.

How Is It Examined?

In patients presenting with complaints of gas or fecal matter coming from the vagina, a detailed medical history is taken before proceeding to examination. Examination can be performed in the lithotomy position, lying on the left side, or in the knee-chest (prayer) position. During the examination, the fistula tract can be attempted to be felt with a finger through the anus, and the fistula opening can also be felt from the vagina.

In cases suspected of having a fistula, examination and the dye-soaked gauze method can be used as a diagnostic tool. After gently inserting moist gauze into the vagina, the patient is laid on their side. Betadine or methylene blue is applied to the anus, and whether the dye has spread to the gauze in the vagina is checked. To avoid confusion during this examination, the colored fluid should not leak from the anus to the vaginal side. After 1-2 minutes, the gauze in the vagina is removed, and if the color of the substance given from the anus is seen on the gauze, a diagnosis of rectovaginal fistula can be made. However, it should be noted that even if a fistula is present in the patient, there may be no contamination with the colored fluid.

How Is It Diagnosed?

Although diagnosis can be made using the methods mentioned above, the best diagnostic method for rectovaginal fistula is pelvic MRI. Pelvic MRI evaluates findings such as the level, course, presence of accompanying abscess, and whether it affects the sphincters.

Does Rectovaginal Fistula Heal on Its Own?

In some cases, the fistula may heal spontaneously. The rates of spontaneous healing vary depending on the reason for the fistula. Analyses from clinics that see a high number of rectovaginal fistula patients have indicated that non-surgical treatment can be applied to about 20% of patients. Improvement was observed in about 50% of patients who were expected to undergo non-surgical treatment. Therefore, it can be said from these data that spontaneous healing will occur in only about 10% of all rectovaginal fistula cases.

How Is It Treated?

The main treatment for rectovaginal fistula is surgery. The problem can be resolved with appropriate surgery performed by a colorectal surgeon.

What Happens If It’s Not Treated?

If left untreated, a fistula can lead to recurrent urinary tract infections, vaginitis, painful sexual intercourse, or perineal rash. In very rare cases, cancer may develop at the site of the fistula many years later.

Rectovaginal Fistula Surgery

Several techniques have been identified for the treatment of rectovaginal fistula. One of these is the application of a special staple resembling an OTSC (Over-The-Scope Clip) colonoscopically to close the fistula. This staple is expelled through the anus within weeks. Success rates of up to 40% have been reported.

Fistula plugs, which have also been tried for anal fistulas, can be used for rectovaginal fistulas as well. This involves inserting a specially manufactured plug into the fistula to fill it, extending from the vagina to the bowel. Success rates of around 20-30% have been reported.

Although attempts have been made to heal rectovaginal fistulas using special tissue adhesives called fibrin glue, success has only been achieved in about 30% of cases. Stem cell therapy has been tried, particularly for rectovaginal fistulas associated with Crohn’s disease, and improvement has been observed in about 27% of cases.

In addition to these local treatments, many surgical methods have been described. Depending on the approach area during surgery, these methods can be categorized into four different approaches: transperineal (entered between the vagina and anus), transvaginal (from the vagina side), transanal (from the anus side), and abdominal (entered through the abdomen). While the goal in all approaches is to eliminate the fistula, the techniques vary.

The Martius flap technique has been described as a method used to repair fistulas between the urinary tract and vagina, where a flap of bulbocavernous muscle is used as a filler. Subsequently, a modified Martius flap technique has been described for rectovaginal fistulas. In the modified Martius flap technique, a cut is made in the perineal skin between the vagina and anus, and tissues between the rectum and vagina are separated. After identifying the fistula tract, it is sutured from both sides and cut in the middle to divide the fistula. Subsequently, usually a straight incision is made from the left labium majus (outer lips) to free the subcutaneous fat tissue without disrupting the vascular structure. This fat flap is then spread between the rectum and vagina to separate the fistula. Finally, the incisions made in this area are closed with absorbable sutures. Cuts are present both in the perineum and on the outer lips. Success rates of between 65-100% have been reported.

In the method where the gracilis muscle is used as a flap, similar to the Martius flap, after preparing the tissues, the gracilis muscle is used as the flap. The gracilis muscle is a thin, long muscle that extends to the knee. The lower parts of this muscle are freed and cut with incisions made in the thigh. Then, it is passed under the skin and spread into the space between the rectum and vagina, and secured. The incision sites are sutured to conclude the surgery.

The endorectal advancement flap is a method applied through the anal route. The patient is preferably placed in the prone jack-knife position (lying face down with knees bent). After identifying the fistula tract, similar to the application in anal fistulas, the fistula tract extending from the rectum to the vagina is completely removed as much as possible without damaging the muscle tissue. The rectum wall is lifted upwards for about 4-5 cm. There should be mucosa and submucosa in the lifted wall. Depending on the surgeon’s preference, there may be some amount of muscle tissue. It is even possible to lift the entire rectum wall. The lifted flap can be in the form of a broad-based V or U shape. The prepared flap should be tension-free to be sutured smoothly under the dentate line. At this stage, the area from which the fistula is removed is tightly closed with absorbable stitches. Then, the prepared flap is sewn onto the anal mucosa with absorbable stitches in a regular manner. There is no visible incision on the patient in this method. The healing rate of the fistula is reported within a wide range of 42-78%. Success rates are influenced by factors such as the tension of the flap, ischemia of the tissue, the cause of the fistula, and whether the patient has additional diseases.

In classical fistula surgery, as done in traditional methods, the cutting of all muscles until reaching the fistula can also be considered. After cutting the muscles and exposing the fistula, the fistula tissue is removed. The sphincter muscles can be repaired by suturing them back together with absorbable or non-absorbable stitches, depending on the surgeon’s preference. After repairing the mucosa on both the rectum and vagina sides, the skin is sutured to conclude the surgery. Healing rates have been reported as 78-100%. However, it should be noted that in patients with birth injuries undergoing sphincter repairs, there is a possibility of developing sphincter dysfunction over time, as the effectiveness of the repair may diminish.

For high-positioned fistulas, an abdominal approach is generally preferred. Open, laparoscopic, or robotic techniques can be applied. The basic principle is the removal of the tissue causing the fistula and closure of the vaginal side. The removal of the tissue causing the fistula usually involves a procedure requiring anastomosis in the small intestine, colon, or rectum. Therefore, there is a possibility of leakage and recurrence of the fistula. In an attempt to prevent this, abdominal fat tissue called omentum is spread between the vagina and tissues. Success rates have been reported around 50%.

The surgeon will choose the most familiar and successful method personally, considering factors such as the characteristics of the tissues, whether the fistula is close to the anus or positioned higher, the presence of active infection, and the cause of the fistula development.

Is a Stoma Created in the Treatment?

The opening of a stoma is a approach that can be considered at every stage in the treatment of rectovaginal fistula. It has been observed that spontaneous healing can occur if there is a stoma opened in the first surgery for fistulas developing after rectal surgery. In cases where a stoma was not opened in the first stage after rectal surgery and a rectovaginal fistula develops, opening a stoma as an ileostomy or preferably colostomy can promote spontaneous healing.

Additionally, a surgeon applying the aforementioned methods may decide to open a stoma in addition. The aim here is to keep the surgical area dry and clean, thus increasing the healing rates. When making this decision, the benefits of opening a stoma should be compared with the psychological impact it may have on the patient, and a decision should be made on a case-by-case basis.

How Long Does Rectovaginal Fistula Surgery Take?

The duration of the surgery can vary between 20 minutes to 180 minutes, depending on factors such as the technique applied, the surgeon’s experience and dexterity in this field, the presence of obesity in the patient, and the presence of fibrosis due to previous surgeries.

If the radiological examinations show that the cancer has adhered to surrounding organs, the treatment decision depends on the organ of origin and the tissue/organ involved. In some tumors, treatment may begin with chemotherapy and/or radiotherapy, followed by surgery after a certain period, while in others, the tumors are directly removed through surgery.

Before surgery, the surgeon must make a thorough radiological assessment to determine which organs will be removed along with the organ of origin. Additionally, during radiological examinations, the possibility of detecting adhesions during surgery should be considered, and both the patient and their relatives should be prepared for the possibility of additional organ removal.

At this point, one might wonder, “Isn’t it sufficient to remove the organ of origin of the cancer?”

As expected, the adhesion of cancer to surrounding organs may indicate that cancer cells have started to penetrate the adjacent organ. Leaving the organ adhered to by cancer in place while only removing the organ of origin may lead to the spread of cancer cells into the abdominal cavity and the progression of the disease.

Another question that may arise is, “Does the adhesion of cancerous tissue to surrounding organs necessarily occur due to the progression of cancer?”

We can approach this question in two ways. If it is clearly visible on tomography or MRI that cancer has entered the surrounding organ, there is no doubt in such cases. In this group, in patients who have the chance of being operated on, cancer cells in the removed surrounding organ can be seen in pathological examination.

On the other hand, in patients where there is suspicion of adhesion radiologically, or where it is clearly visible during surgery that cancer has not penetrated, the situation may be different. It is known that cancer cells can adhere to surrounding organs through an inflammatory reaction called desmoplastic reaction. This situation is particularly observed at a higher rate if an infection has developed within the tumor or in the remaining part of the organ connected to the tumor. If desmoplastic reaction is present in the patient, removing the surrounding organ may be unnecessary and may increase the risk of surgery. On the other hand, if there is adhesion due to the tumor but it is evaluated as desmoplastic reaction and the adhered organ is left in place, the tumor will remain in the abdominal cavity. It is often not possible to make this distinction.

In scientific studies on colorectal cancer, where it is assumed that every adhesion is due to cancer, and additional organs are removed and it is checked pathologically whether there is a tumor, it has been observed that adhesion due to the tumor occurs in up to 30% of cases. In other words, in cases where there is no obvious invasion, the removal of the adhered organ is unnecessary in 70% of cases. At this point, instead of focusing on the idea that removing the adhered organ will be unnecessary in 70% of cases, it is recommended to focus on the idea that if the organ is not removed, cancer cannot be completely removed in 30% of cases. That is, it is recommended to remove the adhered organ if there is doubt during surgery.

The organ to which the cancerous tissue is adhered must be removed as a whole (en bloc). For example, in a colon tumor adhered to the uterus, the colon and uterus must be removed together without separation to prevent tumor spread. Even if the surgeon first separates the colon and then completely removes the uterus and ovaries, the risk of recurrence will be very high because cancer cells will have spread.

It has been mentioned earlier that in tumors adhered to surrounding organs, oncological treatments or direct surgery can be initiated. At this stage, treatment approaches for cancers grown according to organs can be found below with examples.

In cases of gastric cancer, if the tumor has invaded the gastric wall and adhered to surrounding tissues, chemotherapy is initiated first regardless of which tissue it adhered to. After a certain period of chemotherapy, radiological evaluations are performed to check if the tumor has shrunk. If the desired degree of shrinkage has occurred and the adhered organ can be removed along with the tumor, the patient undergoes surgery.
If necessary, the spleen, tail or body of the pancreas can be removed in gastric cancer cases. In some patients, removal of the colon, diaphragm muscle, abdominal wall, liver tissue may also be required.

Similarly to gastric cancer, chemotherapy is initiated in cases of pancreatic cancer with cancer presence towards surrounding tissues. However, due to anatomical features, some patients with pancreatic cancer may be considered initially inoperable. In cases considered operable on the border, if sufficient shrinkage is seen after chemotherapy ± radiotherapy, surgery can be performed. In pancreatic cancer, cases may arise where the stomach, colon, or portal vein need to be removed.

In cases of colon cancer with adhesion to surrounding organs, surgery is often the first treatment option. Since the colon is in contact with a large area in the abdomen, it can invade many organs. Therefore, during interventions to eliminate colon cancer, organs such as the stomach, duodenum, small intestines, pancreas, gallbladder, liver, uterus, ovaries, bladder, and spleen may need to be removed. Although preoperative chemotherapy application for advanced colon cancers has been considered lately, it has not been widely accepted. As ongoing studies progress, the practice of starting with chemotherapy similar to stomach or pancreatic cancer may be highlighted. On the other hand, there are also studies recommending the evaluation of these patients with genetic analyses and starting immunotherapy if appropriate.

In cases of rectal cancer, when adhesion to surrounding organs is observed, it is a accepted approach to reduce the tumor by giving radiotherapy and, in some cases, chemotherapy. After treatments extended up to 6 months depending on the condition, the surgical approach is decided after radiological evaluation. Depending on the progression of rectal cancer in surrounding tissues, it is recommended to remove either the wall or the entirety of the organ to which it adhered. In rectal cancer, structures such as the prostate, seminal vesicles, bladder, coccyx or sacrum bone, vagina, uterus, and ovaries may need to be removed.

Depending on factors such as the patient’s body structure, the size of the tumor, and the surgeon’s experience, multi-organ removal surgeries can be performed openly, laparoscopically, or robotically.

In surgeries where multiple organs are removed, the duration of the operation is longer, there is more blood loss, and the need for intensive care is higher. The probability of complications during and after surgery may also be higher. Accordingly, the hospitalization period may be prolonged.

Despite all these negative situations, for effective oncological surgery, all tissues and organs in contact with cancer must be removed with clean surgical margins in patients where it is deemed necessary.