Tumours of the presacral or retrorectal space are uncommon, pathologically heterogeneous and can be difficult to diagnose. There is much controversy over their surgical management. The retrorectal space contains multiple embryological remnants and diverse tissue types with pluripotent capability.Tthe majority are tailgut cysts, neural, tumours and chordomas. The true incidence of this tumour type in unknown since we have no idea how many asymptomatic tumours there are in the community. The increasing use of routine imaging for a variety of “unrelated” conditions has led to an increase in the number of tumours diagnosed. Thus, presentation and diagnosis of retrorectal tumours is often incidental with 26–50 per cent of patients being asymptomatic. Those that do present, do so with poorly localising symptoms secondary to pelvic organ invasion or nerve compression, the most common being non-specific chronic discomfort. Tumour diversity, anatomical complexity, and rarity of disease gives rise to a challenging surgical problem, managed by very few tertiary centres internationally and with reported substantial morbidity and risk of inappropriate management. CT and MRI can be used for preoperative planning and is effective at differentiating between benign and malignant pathologies. Indeed the key to preoperative diagnosis is good quality radiology; biopsy is often unnecessary. Following diagnosis, patients undergo surgery to alleviate symptoms and prevent malignant transformation; however, this may not be necessary in all cases with some evidence suggesting cystic lesions without suspicious radiological features can be followed by serial imaging without resection. This presentation will provide strategies for the management of retrorectal tumours and offer surgical tips.