Quote from "Pediatric Surgery (Springer Surgery Atlas)" by Prem Puri, Michael E. Höllwarth -

"If the surgeon does not have a clear and reliable image that shows the rectum located below the coccyx, he or she should never approach a patient posterior sagittally without a colostomy and without a distal colostogram. The distal colostogram, which is by far the most valuable study in defining the anorectal anatomy, can be done in patients with anorectal malformations only when the patient already has a colostomy. We have seen catastrophic complications during the performance of posterior sagittal operations in male patients who did not have a distal colostogram."

quote from "Pediatric Surgery (Springer Surgery Atlas)" by Prem Puri, Michael E. Höllwarth -

"When the surgeon is dealing with a rectourethral bulbar fistula, he or she can expect to see a bulging rectum as soon as the levator muscle is split. In cases of rectoprostatic fistula, the rectum is much smaller and it may not bulge through the incision; the surgeon expects to find it immediately below the coccyx. The surgeon should not look for the rectum in the lower part of the incision in patients with rectoprostatic fistula. Looking for a rectum without preoperative evidence that the rectum is there is the main source of complications in this approach. The surgeon will instead find the urethra, vas deferens, prostate, or seminal vesicles and can damage the nerves important for urinary control and sexual potency."

quote from "Pediatric Surgery (Springer Surgery Atlas)" by Prem Puri, Michael E. Höllwarth -

"The posterior rectal wall is easily identified by its characteristic whitish appearance. The surgeon must keep in mind that there is a fascia covering the rectum posterior and laterally, which must be removed. The dissection of the rectum must be performed as close as possible to the rectal wall without injuring the rectal wall itself."

The Blood Supply to the Rectum is INTRAMURALE this why we advice not to injury it

PSARP is not a Blind Exploration Operation?

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 -

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.