ure distal colostography is performed. Hydrosoluble contrast material is injected into the distal stoma to demonstrate the precise location of the distal rectum and its likely urinary communication. Hydrostatic pressure under fluoroscopic control is required. A foley catheter is placed in the mucous fistula and the 3 cc balloon is inflated and pulled back to occlude the stoma during contrast injection. The hydrostatic pressure must be high enough (manual syringe injection) to overcome the muscle tone of the striated muscle mechanism that surrounds the rectum and keeps it collapsed. This is the best way to demonstrate a recto-urinary communication, and to determine the real height of the rectum. The contrast material usually fills the proximal urethra and bladder through the fistula. The injection is continued until the child voids, and pictures are taken during micturition in order to show, in a single picture, the sacrum, height of the rectum, perineum, fistula location, bladder, vesicoureteral reflux if present, and urethra.
This study is vital in determining the anatomy so the definitive repair can be planned. In 10% of patients, the fistula is at the level of the bladder neck. In this case, during the main repair, the surgeon knows that the rectum will be found only through the abdomen, and a combined posterior sagittal and abdominal or laparoscopic approach is employed. The anorectal defect of imperforate anus without fistula may also be demonstrated with this radiologic evaluation. This defect occurs in approximately 5% of patients, has a good functional prognosis, and is common in patients with Down's syndrome. Except for cloacas, in most cases of female malformations, distal colostography is not necessary because the fistula is evident clinically. If the spine was not evaluated in the newborn period with ultrasound, magnetic resonance imaging is necessary after age 3 months to rule out the presence of tethered cord and other spinal anomalies.
A. Early decision-making
The early management of a newborn infant born with an anorectal anomaly is crucial and two important questions must be answered during the first 24 to 48 hours of life. First; are there associated anomalies that threaten the baby's life and should be dealt with right away? And second, should the infant undergo a primary procedure and no protective colostomy or a protective colostomy and a definitive repair at a later date? For babies born with persistent cloaca, the surgeon must also determine whether a dilated vagina is present and if it should be drained, as well as determining whether urinary diversion will be required. These maneuvers are intended to prevent sepsis or metabolic acidosis .
The decision to perform an anoplasty in the newborn period or to delay the repair and to perform a colostomy is based on the infant's physical examination, the appearance of the perineum, and any changes that occur over the first 24 hours of life [15–17].
After the baby is born, an intravenous line is placed for fluids and antibiotics, and a nasogastric tube is inserted to keep the stomach decompressed to avoid the risk of vomiting and aspiration. Meconium is usually not seen at the perineum in a baby with a recto-perineal fistula until at least 16–24 hours. Abdominal distension does not develop during the first few hours of life and is required to force meconium through a recto-perineal fistula as well as through a urinary fistula. This is because the most distal part of the rectum in these children is surrounded by a funnel-like voluntary muscle structure that keeps that part of the rectum collapsed and empty. The intraabdominal pressure must be high enough to overcome the tone of the muscles that surround the rectum if one expects to see meconium at the perineum or in the urine. Therefore, the decision of whether to perform a colostomy or an anoplasty must wait for these 16–24 hours while the surgeon observes for clinical evidence of the baby's anorectal anomaly.
Clinical inspection of the buttocks is important. A flat "bottom" or flat perineum, as evidenced 