Presacral cyst is a category of cystic lesions located in the pelvis between the rectum and the sacrum, exhibiting diverse pathological types with a predominance of benign cases. In recent years, with advancements in imaging technology and the widespread adoption of health screening, its detection rate has shown a significant upward trend. However, due to its deep anatomical location and proximity to critical nerves and blood vessels, surgical intervention carries high risks, and treatment strategies remain highly controversial. Accurate diagnosis of presacral cyst and the formulation of reasonable treatment plans are crucial factors affecting patient prognosis and quality of life. At present, although a domestic expert consensus on presacral cyst has been released in China, standardized diagnostic and therapeutic protocols remain contentious, constrained by the low clinical incidence rate and variations in surgeons' understanding. This article systematically reviews the clinical characteristics, imaging findings, pathological types, and mainstream surgical approaches for presacral cyst. It focuses particularly on the controversies in the surgical management of presacral cyst, aiming to draw clinical attention and enhance the standardization level of diagnosis and treatment of presacral cyst.