What is the best method for drainage of presacral fluid collections?

From the Guidelines

The best method for drainage of presacral fluid collections is CT-guided percutaneous drainage, which offers a minimally invasive approach with high success rates. This technique involves inserting a drainage catheter under CT guidance through the transgluteal, transvaginal, transrectal, or anterior abdominal approaches, depending on the collection's location and patient anatomy 1. The procedure typically uses local anesthesia with sedation and requires leaving the catheter in place until drainage output decreases to less than 10-20 mL per day, usually for 5-14 days.

Key Considerations

• Antibiotic coverage should be initiated before the procedure, with empiric broad-spectrum antibiotics like piperacillin-tazobactam 4.5g IV every 8 hours or a combination of metronidazole 500mg IV every 8 hours plus ceftriaxone 2g IV daily, later adjusted based on culture results.
• CT-guided drainage is preferred because it allows precise targeting of the collection while avoiding critical structures, reduces the risk of complications compared to open surgical drainage, and provides effective resolution in 80-90% of cases 1.
• For complex, multiloculated, or recurrent collections, endoscopic ultrasound-guided drainage or surgical intervention may be necessary.

Post-Procedure Care

• Post-procedure monitoring should include daily assessment of drainage output, vital signs, and inflammatory markers to ensure resolution of the collection.
• The choice of technique is primarily operator preference, though the trocar technique has been advocated for endocavitary drain placement to avoid the risk of loss of access during the process of serial dilation, a complication associated with the Seldinger technique 1.

Additional Techniques

• Techniques such as hydrodissection and alternative approaches like transhepatic drainage of abdominal collections have been described to improve technical success rates 1.
• The efficacy and safety of these routes have been established by a number of retrospective reports, with transrectal and transvaginal approaches used much more commonly in academic centers 1.

From the Research

Methods for Drainage of Presacral Fluid Collections

• CT-guided percutaneous drainage is a recommended approach for presacral abscess drainage, as it is minimally invasive and has lower morbidity and mortality rates compared to surgical drainage 2, 3
• The trans-sacral-foramen approach is a novel method that has been shown to be effective in draining presacral abscesses under CT guidance, with the advantage of being the shortest path to reach the presacral abscess 2
• Other approaches that have been used for presacral abscess drainage include:
  • Transgluteal approach: although proven to be valuable, it can have complications such as local pain 4
  • Paracoccygeal-infragluteal approach: a CT-guided approach that minimizes patient discomfort and minimizes the risk of potential injury to the sciatic plexus or blood vessels 4
  • Precoccygeal approach: a CT-guided approach that provides an easy, straight vector to all points in the presacral space 5
  • Transsacral approach: a minimally invasive approach that can be used in combination with other interventional techniques, such as CT-guided bone biopsy and abscess drainage 6

Considerations for Choosing a Drainage Method

• The choice of drainage method depends on the location and accessibility of the presacral abscess, as well as the patient's overall condition and medical history 2, 6
• CT-guidance is preferred when the interposition of viscera, vascular and skeletal structures, counteracts the ultrasound guidance 3
• The use of sensitive antibiotics is also an important consideration in the treatment of presacral abscesses 2