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case from Dr Usman Akram What will be the best plan according to you in this case ?

quote from "Pediatric Colorectal Conundrums: Case Studies: From Fundamental to Advanced (Pediatric Colorectal Surgery)" by Marc Levitt, Thomas Xu, Hussein Wissanji - A technically correct high-pressure distal colostogram should provide data on the following six key components: 1. The mucous fistula site. 2. The amount of bowel length available for the pull-through (AP view). 3. The rectal end and communication with the urinary tract (if present) (lateral view). 4. The tip of the sacrum. 5. The urethra and bladder (if possible). 6. An anal marker.

quote from "Pediatric Colorectal Conundrums: Case Studies: From Fundamental to Advanced (Pediatric Colorectal Surgery)" by Marc Levitt, Thomas Xu, Hussein Wissanji - 1. For all anal stenosis (and rectal atresia) cases you must check for a presacral mass. 2. For any such presacral mass, always make sure there is no dural component (pelvic plus spinal MRI) and, if present, involve neurosurgery. 3. If Currarino syndrome, genetic testing is warranted for the patient and first-degree relatives. 4. For management, removal of the mass is key which will likely solve much of the constipation. 5. If the anus is narrow that must be treated; an anal canal sparing technique can accomplish this. Occasionally, dilation alone can work. 6. With mass removal the colon should improve, although in such a case antegrade flush access with a Malone may be beneficial to promote daily colonic emptying. 7. Whether the colon will recover is a key question, but it can be decided later whether a colon resection is required.

Regarding PSARP for recto-bulbar fistula quote from "Pediatric Colorectal Conundrums: Case Studies: From Fundamental to Advanced (Pediatric Colorectal Surgery)" by Marc Levitt, Thomas Xu, Hussein Wissanji - "The key maneuver required is to open the posterior rectal wall and carefully inspect the anterior wall for any connections and, if a fistula is found, then carefully mobilize the anterior rectum off the urethra."

quote from "Pediatric Colorectal Conundrums: Case Studies: From Fundamental to Advanced (Pediatric Colorectal Surgery)" by Marc Levitt, Thomas Xu, Hussein Wissanji - "while the AP view might misleadingly suggest an underdeveloped sacrum, the lateral view typically provides a more accurate representation. The pelvic tilt can distort the appearance of the sacrum and coccyx in the AP view, leading to a falsely low sacral ratio. The lateral view, however, allows for a more reliable calculation by minimizing distortions caused by patient positioning"

quote from "Pediatric Colorectal Conundrums: Case Studies: From Fundamental to Advanced (Pediatric Colorectal Surgery)" by Marc Levitt, Thomas Xu, Hussein Wissanji - "It is crucial not to chase the anteriorly directed fistula toward the scrotum, as it runs parallel to the urethra. Attempting to trace this fistula surgically could lead to significant complications, including spongiosum bleeding and urethral injury. Instead, the focus should be on mobilizing the distal rectum and avoiding dissection of the anterior rectal wall to avoid a urethral injury."

quote from "Pediatric Colorectal Conundrums: Case Studies: From Fundamental to Advanced (Pediatric Colorectal Surgery)" by Marc Levitt, Thomas Xu, Hussein Wissanji - "A recent study from the ARM-Net registry highlights the need for sufficient screening and vigilant management of high-grade VUR in ARM patients. This study underscores the fact that despite normal kidneys on US, a significant proportion of patients may still have high-grade VUR, necessitating prophylaxis. All patients with ARM should have a newborn screen renal US and, in most, a follow-up VCUG should be done to assess for VUR."