Background: High anorectal malformations (ARMs) with recto-urinary fistulas constitute some of the most complex congenital anomalies in pediatric surgery. The recto-prostatic variant is particularly rare and poses significant diagnostic and reconstructive challenges, especially in resource-limited settings. Early and accurate identification of the fistula level and preservation of the sphincteric complex are crucial for optimal functional outcomes. Case presentation: We report a 1-year-old male with a high ARM associated with a recto-prostatic urethral fistula. The patient initially underwent an emergency diverting colostomy shortly after birth for an absent anal opening. Definitive repair was delayed due to limited diagnostic capacity. Distal colostogram and cystourethrogram later revealed a high rectal pouch communicating with the prostatic urethra. A posterior sagittal anorectoplasty (PSARP) was performed, confirming the recto-prostatic fistula intraoperatively. The fistula was ligated under direct vision, and the rectum was reconstructed precisely within the sphincter complex under nerve stimulation. The postoperative course was uneventful, and colostomy closure was successful. At 6-month follow-up, the child had good fecal continence, preserved urinary function, and a well-formed perineum. Discussion: This case demonstrates that despite diagnostic and technical constraints, favorable results can be achieved when fundamental surgical principles are upheld. Meticulous preoperative imaging, accurate anatomical delineation, and careful dissection under direct vision remain key determinants of success. The case further highlights the value of multidisciplinary collaboration, structured postoperative follow-up, and caregiver education in ensuring long-term continence and quality of life. Conclusion: Recto-prostatic urethral fistulas, though rare and challenging, can be effectively managed through staged repair and precise PSARP even in resource-constrained environments.
Shadrack et al. (Thu,) studied this question.