High imperforate anus with rectourethral fistula: The role of preoperative distal loop colostography and cystourethrography – A case report and literature review

Objective To emphasize the role of preoperative distal loop colostography and cystourethrography in high anorectal malformations (ARMs) with rectourethral fistula and to describe a staged surgical approach in a preterm neonate. Case Presentation A 34-week preterm male neonate (2.1 kg) presented with failure to pass meconium, abdominal distension, respiratory distress, absent anal opening, and meconium-stained urine. Emergency sigmoid loop colostomy was performed on day 2 of life. Preoperative distal loop colostography and cystourethrography localized a rectourethral fistula at the prostatic urethra. At 6 months, posterior sagittal anorectoplasty (PSARP) was performed with fistula division and primary urethral closure. Postoperative cystourethrography confirmed complete fistula closure and restored urethral integrity. The postoperative course was uneventful; oral feeding resumed by day 3, discharge occurred on day 7, and early sphincter contraction suggested good continence potential. Colostomy closure was scheduled 6–8 weeks after PSARP. Conclusion Preoperative distal loop colostography and cystourethrography accurately define rectourethral fistula anatomy, guide PSARP, and help prevent urethral injury. Distinguishing isolated high imperforate anus from high ARMs with fistula is essential because fistula presence determines the surgical approach and helps avoid long-term urogenital complications.