Skip to main content

The Presacral Space

The presacral (retrorectal) space is the potential compartment between the posterior mesorectum and the anterior sacrum / coccyx. For the reconstructive pelvic surgeon it is the operative field of sacrocolpopexy, sacrohysteropexy, and rectopexy, the neural reservoir whose preservation governs post-operative bladder, bowel, and sexual function, and the vascular minefield of the presacral venous plexus, median sacral vessels, and left common iliac vein — where inadvertent injury can produce rapid, life-threatening hemorrhage. Understanding this space is also the anatomic foundation for total mesorectal excision (TME), presacral neurectomy, retrorectal tumor surgery, and posterior exenteration. This article focuses on the surgical anatomy, fascial planes, neurovascular geometry, and safe-zone landmarks that drive those operations.

See also Pelvic Neuroanatomy for the superior hypogastric plexus; Pelvic Vascular Anatomy for the iliac system; Bowel Anatomy for mesorectum and rectum; and The Uterus / The Vagina for apical prolapse context.

Boundaries​

The presacral space is a potential space — no structure truly occupies it in the resting pelvis, but it opens readily once the peritoneum is incised at the sacral promontory.[1][2][3]

BoundaryStructure
AnteriorMesorectum, covered by the proper rectal (mesorectal) fascia
PosteriorSacrum and coccyx, covered by the presacral fascia
SuperiorPeritoneal reflection at approximately the S2–S3 level
InferiorLevator ani, coccygeus, and anococcygeal ligament
LateralUreters, iliac vessels, pelvic sidewalls

Contents include the superior hypogastric plexus and hypogastric nerves, the median and lateral sacral vessels, the presacral venous plexus, lymph nodes, and connective tissue that embryologically hosts tailgut / neurogenic / notochordal remnants — the origin of most presacral tumors.

Fascial Anatomy — Three Layers, One Operative Plane​

Contemporary cadaveric work clarifies what was historically a confusing topic:[4][5][6]

LayerFunctionOperative relevance
Proper rectal (mesorectal) fasciaEnvelops the mesorectumThe anterior wall of the TME dissection plane
Presacral fasciaCovers the median sacral vessels and divides the retrorectal spaceThe posterior wall of the TME dissection plane
Parietal pelvic fasciaTwo lamellae ensheathing the pelvic autonomic nervesOuter lamella is the deep boundary of the presacral space; damage here injures the hypogastric / pelvic plexus

Key connective landmarks​

  • Waldeyer's fascia — historically described as the "floor" of the retrorectal space at the anorectal junction; formed by fusion of presacral and rectal fasciae.[6]
  • Rectosacral ligament (fascia) — originates from the presacral fascia at S2 (15%), S3 (38%), or S4 (46%) and inserts on the posterior rectum 3–5 cm above the anorectal junction.[5][6] Must be identified and transected for complete rectal mobilization during TME and low rectal reconstructions; failure to divide it leaves residual fixation and leads to incomplete mesorectal excision.
  • Anococcygeal ligaments — superficial (external sphincter myoseptum → coccyx) and deep (coccygeal periosteum → presacral fascia → external sphincter superior end). Contribute to anorectal positioning and continence.[7]
The TME plane is the presacral plane

Total mesorectal excision is performed in the areolar plane between the proper rectal (mesorectal) fascia and the parietal pelvic fascia. Staying in this "holy plane" preserves the pelvic autonomic nerves (within the parietal lamella) and the presacral venous plexus (behind the presacral fascia). Inadvertent posterior exit through the parietal fascia injures the hypogastric nerves; inadvertent exit through the presacral fascia opens the presacral venous plexus.[4][5]

Vascular Anatomy — The Minefield​

Median (middle) sacral artery​

Single midline vessel from the posterior aorta just above its bifurcation, running on the anterior sacrum.[8][9]

  • Mean distance from the midpoint of the sacral promontory: 4 mm (range 0–15 mm).[8]
  • May be to the right or left of midline.
  • Small caliber but constant; must be identified before placing sacrocolpopexy mesh sutures.

Lateral sacral arteries​

Paired branches of the internal iliac artery; supply the sacrum and piriformis. Not usually encountered in routine presacral dissection unless mobilization extends laterally.

Presacral venous plexus — the bleeder​

Thin-walled anastomosis of lateral and median sacral veins embedded within the presacral fascia.[10][11]

  • Not visible during routine rectal surgery until torn.
  • Communicates widely with the internal iliac venous system, dorsal vein complex of the penis/clitoris, and the vertebral venous plexus (Batson's).
  • Hemorrhage is rapid, difficult to control, and can be exsanguinating because the veins retract into sacral foramina and cannot be clamped.
  • Control options: direct pressure → tacking mesh / muscle fragment with thumbtacks to the sacral foramen → indigo carmine / bone wax / sterile thumbtacks → specific hemostatic agents.

Left common iliac vein and iliac tributaries​

  • Left common iliac vein is the closest major vessel to the sacral promontory — mean 27 mm cephalad and 22 mm lateral.[8]
  • External iliac vein tributaries are present in ~75% of cadavers in the presacral area (mean 4 mm diameter).[14]
  • These anomalies are the reason right-side approaches with sharp definition of the vascular borders are preferred during sacrocolpopexy and laparoscopic rectopexy.

Vertebral venous plexus (Batson's)​

Valveless network connecting pelvic, vertebral, and cranial venous systems.[12][13]

  • Allows retrograde flow from the pelvis to spine and brain.
  • Anatomic basis of prostate- and breast-cancer vertebral metastases and of rare CNS spread from pelvic infection.

The safe zone for sacrocolpopexy mesh placement​

Multiple cadaveric and 3D-CT studies converge on a small "safe rectangle" on the anterior sacrum bounded by the median sacral artery, the left common iliac vein, and the presacral venous plexus:[8][9][30]

  • Beginning ~10 mm below the sacral promontory, alongside the median sacral artery.
  • Recommended safe rectangle approximately 30 × 20 mm (length × width) for suture or tack placement.
  • Below this zone, the presacral venous plexus is at risk; above and to the left, the common iliac vein is at risk.

This geometry is why contemporary sacrocolpopexy targets the anterior longitudinal ligament just below the S1 promontory rather than the body of the sacrum itself.

Neural Anatomy — What Nerve-Sparing Actually Means​

The presacral space contains the superior hypogastric plexus and the proximal hypogastric nerves, the autonomic superhighway to the pelvis. Damage here is the mechanism behind post-sacrocolpopexy and post-TME bowel, bladder, and sexual dysfunction.[15][16][17][18][19][20]

Superior hypogastric plexus ("presacral nerve")​

  • Begins at the aortic bifurcation and descends across the sacral promontory within a connective-tissue sheet just below peritoneum.
  • Median position 21.3 mm below the aortic bifurcation in ~82% of specimens; left of midline in ~59%.[16]
  • Median dimensions: 39.5 mm long × 9 mm wide — a flat, band-like plexus, not a discrete cord.[16]
  • Predominantly sympathetic but carries postganglionic parasympathetic fibers as well (contrary to classical descriptions).[19]
  • Target of presacral neurectomy for refractory midline pelvic pain (dysmenorrhea, endometriosis-related central pain).[18]

Hypogastric nerves​

Paired branches emerging from the superior hypogastric plexus:[16]

  • Median position 23 mm below the sacral promontory.
  • Run within the parietal pelvic fascia along the pelvic sidewall toward the inferior hypogastric plexus.
  • Lie 0–0.5 mm from the uterosacral ligaments — a geometry critical to uterosacral suspension (USLS), radical hysterectomy, and rectopexy.

Inferior hypogastric (pelvic) plexus​

Formed by the hypogastric nerves (sympathetic) + pelvic splanchnic nerves (S2–S4, parasympathetic) ± sacral splanchnics (from sympathetic trunk):[16][20]

  • Lies 1–3 cm lateral to the rectum and the upper third of the vagina.
  • Receives parasympathetic contributions from S3 and S4 in all specimens, S2 in ~47%.
  • Gives bladder branches (deep to the ureter), uterine branches (superficial to the ureter, with the uterine artery), and rectal branches (S4 directly to lateral rectum in ~53%).

First sacral nerve — the somatic neighbor​

The S1 nerve lies outside the presacral space behind the parietal fascia over the piriformis:[21]

  • Median vertical distance from the sacral promontory to the S1 foramen: 26 mm (range 22–37).
  • Median horizontal distance from midline: 19 mm (range 13–23).
  • Clinically: suture or tack placed more than ~2.5 cm below and ~2 cm lateral to the sacral promontory can injure S1 → lower-limb radiculopathy after sacrocolpopexy.
Nerve-sparing sacrocolpopexy — the working rule

Open the posterior peritoneum in a longitudinal incision along the right common iliac artery and carry it onto the sacral promontory without crossing to the left side (where the superior hypogastric plexus sits, left of midline in ~60%). Dissect the anterior longitudinal ligament medial to the hypogastric nerves. Place mesh sutures in the 30 × 20 mm safe zone starting ~10 mm below the promontory, avoiding the median sacral artery laterally, the presacral plexus below, the left common iliac vein to the left, and S1 foramen ~2.5 cm below.[16][20][21][30]

Lymphatic and Bony Anatomy​

Lymphatics​

Presacral lymph nodes accompany the median sacral vessels and communicate upward with the para-aortic basin — a route of potential metastasis for cervical and rectal cancers. In cervical cancer, presacral nodes contain approximately 4–6% of sentinel nodes.[17]

Sacrum and coccyx​

  • Sacral promontory — anterior projection of S1; key operative landmark.
  • Anterior sacral foramina — transmit ventral rami of sacral nerves; exit points for the presacral venous plexus when torn.
  • Anterior longitudinal ligament — covers the anterior sacrum; median thickness at the promontory 1.9 mm (range 1.2–2.5 mm) — adequate for sacrocolpopexy suture purchase.[21]
  • Coccyx — 3–5 fused rudimentary vertebrae; anococcygeal-ligament and levator-ani attachment site.

Presacral Tumors — The Retrorectal Mass Differential​

The presacral space hosts a wide range of tumors reflecting its mixed embryologic contributions (notochord, hindgut, neural-crest, mesenchymal, osseous). Contemporary series estimate an incidence of ~1 in 40,000 hospital admissions; ~60–70% are benign.[1][22][23][24]

Clinical framework​

CategoryBenignMalignant
Congenital (most common — 60%)Epidermoid / dermoid cyst, mature teratoma, tailgut cyst, anterior meningoceleChordoma (most common 1° sacral malignancy), immature teratoma
NeurogenicSchwannoma, neurofibroma, ganglioneuromaMalignant peripheral nerve sheath tumor, neuroblastoma, ependymoma
OsseousOsteoma, aneurysmal bone cyst, giant cell tumorOsteosarcoma, chondrosarcoma, Ewing sarcoma
InflammatoryAbscess, granuloma—
MiscellaneousLipoma, hemangioma, leiomyomaLiposarcoma, leiomyosarcoma, metastatic carcinoma

Clinical presentation and workup​

  • ~25% are asymptomatic, discovered incidentally.[22][24]
  • Palpable on DRE in 75–93% of symptomatic patients — a key exam finding.
  • Typical symptoms: sacrococcygeal / perianal pain (~57%), palpable perineal mass (~36%), lower-limb symptoms (suggestive of malignancy), constipation or obstructive voiding from local compression.
  • Delayed diagnosis is the norm — mean delay ~2.6 years in published series.[25]
  • Imaging: MRI is the modality of choice for anatomic detail and surgical planning; CT for bone involvement; biopsy is selective and generally percutaneous / transperineal rather than transrectal to avoid seeding the rectal wall.

Key diagnoses the reconstructive surgeon should recognize​

  • Chordoma — midline malignancy of notochordal remnants; the commonest primary malignant sacral tumor; en-bloc sacrectomy is the definitive treatment and requires reconstructive reinforcement.[26][27]
  • Tailgut cyst — the most frequent congenital presacral mass in adults; complete excision mandatory due to ~6% malignant-transformation risk.
  • Sacrococcygeal teratoma — dominant neonatal presacral mass; Altman I–IV classification by external/internal components.
  • Currarino syndrome — autosomal-dominant triad of presacral mass + partial sacral agenesis + anorectal malformation; HLXB9 / MNX1 mutations. Screen siblings; teratomatous components carry malignant-transformation risk.[28]

Surgical approaches​

  • Posterior (Kraske / transsacral) — for small, low, benign lesions below S3.
  • Anterior (laparotomy or laparoscopy) — for high, large, or vascular lesions above S3.
  • Combined abdominoperineal — for large, infiltrative, or recurrent tumors requiring sacrectomy or pelvic exenteration.
  • Selection depends on tumor level relative to S3, vascularity, involvement of sacrum, and relationship to autonomic nerves.

Clinical Correlations for the Reconstructive Surgeon​

  • Sacrocolpopexy / sacrohysteropexy. Target the anterior longitudinal ligament in the ~30 × 20 mm safe zone ~10 mm below the promontory; stay right of midline to spare the superior hypogastric plexus; avoid the left common iliac vein cephalolaterally and S1 foramen ~2.5 cm caudolateral.
  • Nerve-sparing approach. Longitudinal peritoneal incision along the right common iliac artery, extending onto the promontory; dissection medial to the hypogastric nerves; preserves bladder, bowel, and sexual function.[20]
  • Rectopexy. Similar vascular and neural hazards as sacrocolpopexy. Ventral (Orr–Loygue, d'Hoore) rectopexy uses the presacral plane and places mesh between rectum and vagina; posterior (Wells) rectopexy places mesh between rectum and sacrum. Nerve injury produces postoperative constipation / obstructed defecation and voiding dysfunction.
  • TME and the "holy plane." The TME dissection is carried in the areolar plane between mesorectal fascia and parietal pelvic fascia — the single operative maneuver that most improved rectal-cancer oncologic and functional outcomes in the last 40 years.
  • Presacral hemorrhage control. Torn presacral venous plexus is a surgical emergency. Sequence: pack and press → thumbtack or muscle tamponade at the bleeding sacral foramen → hemostatic agents (e.g., Floseal, Surgicel, Arista) → bone wax. If uncontrolled, packing and damage-control laparotomy with delayed definitive repair.
  • Sacral colpopexy complications. Mesh erosion / exposure, discitis / osteomyelitis (sacral or L5-S1), fistulization to rectum / vagina / small bowel, and delayed hemorrhage from mesh tack near vessels.[29]
  • Presacral neurectomy. Transect the superior hypogastric plexus for refractory midline chronic pelvic pain (most evidence in endometriosis / dysmenorrhea). Does not help lateral or vulvar pain; does not address small-bowel visceral pain.
  • Retrorectal / presacral tumors. MRI characterization and multidisciplinary planning (colorectal, urology, orthopedic oncology for high sacrectomy). Preoperative ureteric stenting helps identify ureter during extensive dissection. Reconstructive urology may be called for urinary diversion or bladder reconstruction after pelvic exenteration.
  • Posterior pelvic exenteration. Removes uterus, cervix, vagina, rectum, and part of the sacrum; urinary diversion done when bladder or urethra also involved; perineal reconstruction with gracilis or VRAM flap.
  • Sacral fracture and presacral hematoma. Pelvic-ring trauma can produce massive presacral bleeding requiring pelvic packing ± angiographic embolization of the median and lateral sacral arteries.
  • Coccygectomy. For chronic coccydynia refractory to conservative measures; the deep anococcygeal ligament and presacral fascia attachments must be divided.

References​

1. Hain KS, Pickhardt PJ, Lubner MG, Menias CO, Bhalla S. "Presacral Masses: Multimodality Imaging of a Multidisciplinary Space." Radiographics. 2013;33(4):1145–1167. doi:10.1148/rg.334115171

2. A E, Prakash A, Ashta A, et al. "Pediatric Presacral Tumors With Intraspinal Extension: A Rare Entity With Diagnostic Challenges." Acta Radiol. 2023;64(12):3056–3073. doi:10.1177/02841851231202688

3. Fritsch H. "Topography and Subdivision of the Pelvic Connective Tissue in Human Fetuses and in the Adult." Surg Radiol Anat. 1994;16(3):259–265. doi:10.1007/BF01627680

4. Zhang C, Ding ZH, Li GX, et al. "Perirectal Fascia and Spaces: Annular Distribution Pattern Around the Mesorectum." Dis Colon Rectum. 2010;53(9):1315–1322. doi:10.1007/DCR.0b013e3181e74525

5. Stelzner S, Heinze T, Nikolouzakis TK, et al. "Perirectal Fascial Anatomy: New Insights Into an Old Problem." Dis Colon Rectum. 2021;64(1):91–102. doi:10.1097/DCR.0000000000001778

6. García-Armengol J, García-Botello S, Martinez-Soriano F, Roig JV, Lledó S. "Review of the Anatomic Concepts in Relation to the Retrorectal Space and Endopelvic Fascia: Waldeyer's Fascia and the Rectosacral Fascia." Colorectal Dis. 2008;10(3):298–302. doi:10.1111/j.1463-1318.2007.01472.x

7. Jin ZW, Hata F, Jin Y, et al. "The Anococcygeal Ligaments: Cadaveric Study With Application to Our Understanding of Incontinence in the Elderly." Clin Anat. 2015;28(8):1039–1047. doi:10.1002/ca.22629

8. Wieslander CK, Rahn DD, McIntire DD, et al. "Vascular Anatomy of the Presacral Space in Unembalmed Female Cadavers." Am J Obstet Gynecol. 2006;195(6):1736–1741. doi:10.1016/j.ajog.2006.07.045

9. Shen P, Peng C, Zhang W, et al. "Exploration of the Safe Suture Area of the Presacral Space in Sacrocolpopexy by 3-Dimensional (3D) Models Reconstructed From CT." Int Urogynecol J. 2021;32(4):865–870. doi:10.1007/s00192-020-04645-2

10. Ishii M, Shimizu A, Lefor AK, Noda Y. "Surgical Anatomy of the Pelvis for Total Pelvic Exenteration With Distal Sacrectomy: A Cadaveric Study." Surg Today. 2021;51(4):627–633. doi:10.1007/s00595-020-02144-x

11. Baqué P, Karimdjee B, Iannelli A, et al. "Anatomy of the Presacral Venous Plexus: Implications for Rectal Surgery." Surg Radiol Anat. 2004;26(5):355–358. doi:10.1007/s00276-004-0258-7

12. Zurcher KS, Staack SO, Spencer EB, et al. "Venous Anatomy and Collateral Pathways of the Pelvis: An Angiographic Review." Radiographics. 2022;42(5):1532–1545. doi:10.1148/rg.220012

13. Nathoo N, Caris EC, Wiener JA, Mendel E. "History of the Vertebral Venous Plexus and the Significant Contributions of Breschet and Batson." Neurosurgery. 2011;69(5):1007–1014. doi:10.1227/NEU.0b013e3182274865

14. Kanjanasilp P, Ng JL, Kajohnwongsatit K, et al. "Anatomical Variations of Iliac Vein Tributaries and Their Clinical Implications During Complex Pelvic Surgeries." Dis Colon Rectum. 2019;62(7):809–814. doi:10.1097/DCR.0000000000001335

15. Huber SA, Northington GM, Karp DR. "Bowel and Bladder Dysfunction Following Surgery Within the Presacral Space: An Overview of Neuroanatomy, Function, and Dysfunction." Int Urogynecol J. 2015;26(7):941–946. doi:10.1007/s00192-014-2572-x

16. Ripperda CM, Jackson LA, Phelan JN, Carrick KS, Corton MM. "Anatomic Relationships of the Pelvic Autonomic Nervous System in Female Cadavers: Clinical Applications to Pelvic Surgery." Am J Obstet Gynecol. 2017;216(4):388.e1–388.e7. doi:10.1016/j.ajog.2016.12.002

17. Rob L, Halaska M, Robova H. "Nerve-Sparing and Individually Tailored Surgery for Cervical Cancer." Lancet Oncol. 2010;11(3):292–301. doi:10.1016/S1470-2045(09)70191-3

18. Eid S, Iwanaga J, Chapman JR, et al. "Superior Hypogastric Plexus and Its Surgical Implications During Spine Surgery: A Review." World Neurosurg. 2018;120:163–167. doi:10.1016/j.wneu.2018.08.170

19. Kraima AC, van Schaik J, Susan S, et al. "New Insights in the Neuroanatomy of the Human Adult Superior Hypogastric Plexus and Hypogastric Nerves." Auton Neurosci. 2015;189:60–67. doi:10.1016/j.autneu.2015.02.001

20. Shiozawa T, Huebner M, Hirt B, Wallwiener D, Reisenauer C. "Nerve-Preserving Sacrocolpopexy: Anatomical Study and Surgical Approach." Eur J Obstet Gynecol Reprod Biol. 2010;152(1):103–107. doi:10.1016/j.ejogrb.2010.05.009

21. Florian-Rodriguez ME, Hamner JJ, Corton MM. "First Sacral Nerve and Anterior Longitudinal Ligament Anatomy: Clinical Applications During Sacrocolpopexy." Am J Obstet Gynecol. 2017;217(5):607.e1–607.e4. doi:10.1016/j.ajog.2017.07.008

22. Li Z, Lu M. "Presacral Tumor: Insights From a Decade's Experience of This Rare and Diverse Disease." Front Oncol. 2021;11:639028. doi:10.3389/fonc.2021.639028

23. Bullard Dunn K. "Retrorectal Tumors." Surg Clin North Am. 2010;90(1):163–171. doi:10.1016/j.suc.2009.09.009

24. Lev-Chelouche D, Gutman M, Goldman G, et al. "Presacral Tumors: A Practical Classification and Treatment of a Unique and Heterogeneous Group of Diseases." Surgery. 2003;133(5):473–478. doi:10.1067/msy.2003.118

25. Feldenzer JA, McGauley JL, McGillicuddy JE. "Sacral and Presacral Tumors: Problems in Diagnosis and Management." Neurosurgery. 1989;25(6):884–891.

26. Adin ME, Woolf G, Hegde R, et al. "Sacral Tumors: A Comprehensive Review of Imaging, Diagnostic Challenges, and Tumor Mimics." Skeletal Radiol. 2025;54(8):1581–1606. doi:10.1007/s00256-024-04862-6

27. Stacchiotti S, Sommer J, Chordoma Global Consensus Group. "Building a Global Consensus Approach to Chordoma: A Position Paper From the Medical and Patient Community." Lancet Oncol. 2015;16(2):e71–e83. doi:10.1016/S1470-2045(14)71190-8

28. Urioste M, Garcia-Andrade Mdel C, Valle L, et al. "Malignant Degeneration of Presacral Teratoma in the Currarino Anomaly." Am J Med Genet A. 2004;128A(3):299–304. doi:10.1002/ajmg.a.30028

29. Haouari MA, Boulay-Coletta I, Khatri G, et al. "Complications of Mesh Sacrocolpopexy and Rectopexy: Imaging Review." Radiographics. 2023;43(2):e220137. doi:10.1148/rg.220137

30. Giraudet G, Protat A, Cosson M. "The Anatomy of the Sacral Promontory: How to Avoid Complications of the Sacrocolpopexy Procedure." Am J Obstet Gynecol. 2018;218(4):457.e1–457.e3. doi:10.1016/j.ajog.2017.12.236