'High' anorectal malformation in boys: need for clarity of definition and management.

Posterior sagittal anorectoplasty is purported to be the approach of choice for the treatment of both intermediate and high variety of anorectal malformations. The authors describe their devastating experiences with 2 cases of high variety of anorectal malformations in which defects were repaired thorough the posterior sagittal approach. In the first case, because of the high level of the rectal pouch, complete urethrovesical disconnection was done along with inadvertent mobilization and pull-through of urinary bladder. The patient subsequently required major reconstructive procedures. In another case, the bladder was partially mobilized before the mistake was realized; the high-lying rectum was later identified, and a pull-through was performed without any ill consequences. The authors infer that only the patients with rectal pouches ending caudal to the third sacral vertebra should have their definitive surgery performed through posterior sagittal approach. They suggest that PS3 line should be the watershed in management of anorectal malformation in boys.