Urologic Implications of Anorectal Malformations

Management of the urological tract in children with anorectal malformations - a contemporary review

Anorectal malformations (ARMs) consist of a broad spectrum of congenital anomalies that are associated with an equally wide variety of urological abnormalities, often with increasing incidence as the severity of the ARM increases. The importance of urologic involvement in the care of ARM patients has been noted for decades and is critical from birth to adulthood. Urology must be involved in the initial evaluation and operative care of the child as well as in monitoring and managing issues such as neurogenic bladder, renal disease, and eventually sexual function and fertility. Care of the ARM patient must be done through a multidisciplinary lens, with the urologist as a key player. This review will serve as an update on the management of the urologic tract in children with ARM.

Can sacral development as a marker for caudal regression help identify associated urologic anomalies in patients with anorectal malformation?

BACKGROUND AND AIM

The sacral ratio (SR) is a well-established tool to quantify sacral development in patients with anorectal malformations (ARM) and can be used as a predictor of fecal continence. We hypothesized that a lower SR correlated with the presence of urologic and renal malformations.

METHODS

We retrospectively reviewed the medical records of patients with ARM treated at our center from 2014 to 2016. We measured the lateral SR as a marker for sacral development and assessed the spine for the presence of tethered cord (TC). Urological and renal anomalies, including single kidney, hydronephrosis, hypospadias, vesicoureteral reflux (VUR), ectopic ureter, and penoscrotal transposition were assessed. Analysis of variance (ANOVA), t-tests, and multivariable linear regression were used to test for differences in SR with consideration of associated urologic malformations and tethered cord.

RESULTS

283 patients with ARM were included for analysis (156 females). The median age was 39months (10-90). Among these, 178 (55.6%) had 1 or more urologic malformations, and 81 (25.3%) had a TC. Hydronephrosis, high-grade VUR (3-5), solitary kidney, and tethered cord were significantly associated with lower SR (p<0.01). In multivariable regression models, the presence of urologic abnormalities remained significantly associated with lower a SR despite the presence or absence of TC (p<0.001).

CONCLUSION

SR is a potentially useful indicator of certain urologic anomalies including hydronephrosis, high grade VUR, and solitary kidney in patients with ARM. This association is independent of the presence of TC. A sacral ratio as a part of the VACTERL screening can help the surgeon identify which patients need closer urologic follow up.

LEVEL OF EVIDENCE

IV.

Vesicostomy and Colostomy in a Premature Neonate With Posterior Urethral Valves, Bilateral Dysplastic Kidneys, and High Imperforate Anus: The Challenge of Stoma Placement

Although anorectal malformations are often associated with urinary tract abnormalities, the association with posterior urethral valves is exceptionally rare. We report a unique case of a premature (35 gestational weeks) male neonate born with posterior urethral valves, bilateral dysplastic kidneys, and imperforate anus, successfully treated by Blocksom vesicostomy and left upper quadrant loop colostomy. The challenges involving placement of both stomas in a small abdominal wall of a 2200 g premature neonate are discussed.

Associations of anorectal malformations and related syndromes

Anorectal malformations (ARMs) represent a complex group of congenital anomalies resulting from abnormal development of the hindgut, allantois and Mullerian duct resulting in complete or partial urorectal septal malformations. There is a wide variety of phenotypic expression, ranging from mild anorectal to very complex severe ARM with >75 % having other associated malformations. 50 % of cases are syndromic although many may have other associated anomalies. This suggests a genetic link but the genetics of ARM are highly complex with a number of candidate genes being identified. Many can be classified as "field defects" as a result of a complex set of genetic interactions. Patients with associated malformations can be classified into those with multiple congenital anomalies (non-syndromic), those with chromosomal abnormalities and those with non-chromosomal syndromic associations, also, those with non-chromosomal syndromes and the influence of environmental factors (e.g. drugs in pregnancy). Although much is not known about the aetiology of ARM, the weight of evidence points to genetic factors as major causes for the condition. In this review, we look at the chromosomal and genetic associations and their underlying signalling pathways, to obtain a better understanding of the pathogenetic mechanisms involved in developing ARM. The spectrum of ARM phenotypic expression probably results from involvement and crosstalk between a number of critical signalling systems involved in development of this region. As a result, it may be expressed as a "field developmental defect" with many associated abnormalities. The role of environmental factors in the development of ARM is probably less.

Acquired posterior urethral diverticulum following surgery for anorectal malformations

PURPOSE

Despite significant advances in the surgical management of anorectal malformations (ARMs), many children still experience significant debilities from potentially avoidable complications. One complication, the posterior urethral diverticulum, may have untoward consequences if not recognized and treated.

METHODS

A retrospective cohort review was undertaken of male patients who presented to us with persistent problems after being operated on elsewhere for ARM. Twenty-nine patients presented with a urethral diverticulum. Their charts were reviewed for the type of malformation, prior repair, presentation, treatment, and postoperative follow-up.

RESULTS

Twenty-nine patients were identified that fit the criteria for this study. To date, 28 patients have been managed with reoperation. Urinary complaints were the most common presenting symptoms. All patients were repaired using a posterior sagittal approach. Pathology of the diverticulum in one patient revealed a well-differentiated mucinous adenocarcinoma.

CONCLUSION

The incidence of acquired posterior urethral diverticulum has decreased with the popularization of the posterior sagittal incision. There is a theoretical concern that the incidence may increase with the use of laparoscopy for the treatment of ARMs especially those where the fistula is below the peritoneal reflection. Once detected, the diverticulum should be excised.

Polyorchidism in a child with imperforate anus

Polyorchidism is a rare diagnosis. When recovered, it is frequently found in combination with other urologic pathologies. We report the case of a 14-month-old child with imperforate anus who was found to have polyorchia during repair of his inguinal hernia. Although cryptorchidism is not an uncommon finding in patients with imperforate anus, polyorchidism has never been reported. This is an unusual presentation of a rare entity.

Neurogenic bladder: etiology and assessment

A review of the various causes of neurologic impairment to the lower urinary tract in children was the aim of this presentation. The emphasis was on diagnosis, pathophysiology, and treatment that strive to maintain as normal a function as possible in order to achieve eventual urinary continence and health of the upper urinary tract. The latest principles based on the most up to date evidence are promulgated but with an eye towards historical prospective. The reader should gain an adequate understanding of various disorders that comprise this condition and feel comfortable with proposing options for management when faced with the responsibility of caring for an affected child.

Occult neurovesical dysfunction with anorectal malformations

OBJECTIVE

To evaluate for the occurrence of occult NVD in children with anorectal malformations (ARM) using urodynamic evaluation.

METHODS

This prospective study was carried out on children with ARM prior to and following definitive procedure. Urodynamic studies were performed on the Phoenix Griffon machine (Albyn Medical) using Phoenix plus software.

RESULT

Nineteen children in the age range of 3 months to 156 months (mean = 19.2) were included in this study. Among these 19 children 13 underwent re-evaluation after definitive surgery for ARM. There were 11(57.9%) males and 8(42.1%) females. Of the 19 children 14 (73.7%) were cases of high anorectal malformation (HARM) and 5 (26.3%) were cases of low anorectal malformation (LARM). Baseline evaluation done in 19 children revealed seven urodynamic patterns: Normal capacity, compliant without uninhibited contractions (UIC) (21.1%); Normal capacity, compliant with UIC (5.3%); Normal capacity, poorly compliant without UIC (5.3%); Normal capacity, poorly compliant with UIC (10.5%); small capacity, compliant with UIC (5.3%); Small capacity, poorly compliant with UIC (26.3%) and large capacity, complaint with UIC (26.3%). Thirteen patients were evaluated post operatively also and in only 23% (3 of 13) no change in urodynamic pattern were observed. In the remaining 76.9% (10 of 13) some changes in urodynamics pattern were observed. The deleterious changes observed were appearance of UIC in 30.8% (4 of 13), decrease in the bladder capacity in 23% (3 of 13) and decrease in bladder compliance in 15.4% (2 of 13).

CONCLUSION

Only 9 of of the 19 patients had normal urodynamics pre-operatively and post-operatively 3 more patients worsened. Incidence of occult NVD is high in patients with ARM even in the absence of clinical and radiological evidence of vertebral or lower urinary tract abnormalities. Though there seems to be a high incidence of changes in the neurovesical functions of these patients following definitive corrective surgery for ARM only time will show whether this has any deleterious effect on the upper tracts.

Anorectal malformations and their impact on survival

OBJECTIVE

To evaluate the incidence, types and the effect on outcome of associated anomalies in neonates with anorectal malformations (ARM).

METHODS

This retrospective study was carried out on all neonates with ARM admitted to the neonatal surgical intensive care unit (NSICU) from 1998 through 2003.

RESULTS

Of the 754 neonates admitted to the NSICU during the study period of 6 years, there were 124 (16.4%) neonates with anorectal malformations. Of these 110 were included in the study. 73 % were male and 27% female. 86% of these were high ARM (HARM) while only 14% were low ARM (LARM). Associated anomalies were seen in 68% of patients. The incidence was 72% for HARM and 50% for LARM. The major associated anomalies consisted of esophageal (13%), gastrointestinal (GIT) (11%), genitourinary (GUT) (32%), skeletal (26%), cardiac (33%) and miscellaneous 26%. The overall survival rate was 84% (82% for HARM and 94% for LARM). The survival among those with associated esophageal anomalies was 43%, GIT 67%, GUT 80%, cardiac 61%, skeletal 76% and miscellaneous 79% respectively. This difference in survival was significant only for those with esophageal (p=0.004) and cardiac anomalies (p=0.0026). The survival rates among those with one, two or more than two organ systems involved with associated anomalies were 88%, 82% and 58% respectively. This difference was significant only for more than two organ systems involvement (p=0.003).

CONCLUSION

Associated anomalies are common in neonates with ARM, the incidence being similar for HARM and LARM. The survival depends upon the number and severity of associated anomalies both in patients with LARM and HARM. Neonates with more number of organ systems involved have a poorer survival specially when associated with esophageal and cardiac anomalies. All neonates with ARM merit a meticulous search for associated anomalies so that the management can be tailored for each baby.

Recurrent epididymo-orchitis caused by posterior urethral valve associated with imperforate anus

Epididymo-orchitis is an uncommon complication of imperforate anus. A 14-year-old boy who received surgical repair for imperforate anus was diagnosed with right epididymo-orchitis. Intravenous pyelography showed a right solitary kidney. Posterior urethral valve, reflux of contrast medium to the ejaculatory duct and incomplete duplicate urethra were suspected from voiding cystourethrography. Valve ablation was performed to prevent the recurrence of epididymo-orchitis. Improvement of urinary force was achieved and the patient has been free of recurrence during a 2-year follow up. For the patient with imperforate anus, we should evaluate not only anorectal function, but also the genitourinary tract in order to preserve renal function and fertility.

How to Investigate Neurovesical Dysfunction in Children With Anorectal Malformations

PURPOSE

Neurovesical dysfunction (NVD) is common in children with anorectal malformation (ARM). NVD is mainly related to tethered cord or iatrogenic injury but how to investigate it is still debated. We evaluate the usefulness of routine magnetic resonance imaging (MRI) and urodynamics (UDS) for ARM.

MATERIALS AND METHODS

A total of 89 children were screened for sacral, spinal or urological anomalies using sacrum x-ray, MRI, renal and spinal ultrasound, uroflowmetry and/or 4-hour voiding observation. UDS was performed in 60 patients with suspected NVD. Mean +/- SD followup was 9.8 +/- 5.2 years.

RESULTS

Of the 89 patients 29 presented with urinary tract anomalies. The prevalence of sacral (53 cases) and spinal cord (54) anomalies was no different between patients with low, intermediate and high ARM. Spinal cord tethering was present in 13 patients with a normal sacrum x-ray. NVD was found in 31 of the 89 patients (hyperreflexia 21 and hypo-areflexia 10), and was associated with sacral and spinal anomalies in 23, occult spinal dysraphism without bone lesion in 3 and sacral anomalies in 5. The incidence of NVD was 40% of cases with low and 51% with high ARM.

CONCLUSIONS

Because tethered cord occurs in children without sacral anomalies as well as in those with low ARM, we recommend evaluation of all patients using MRI. When MRI is positive UDS should be performed. We agree with a previous suggestion to evaluate all males with rectourethral fistula and females with cloaca malformations. Finally we recommend a noninvasive evaluation for all other children and UDS when neurogenic dysfunction is suspected.

Epididymitis in infants with anorectal malformation

OBJECTIVE

To document the characteristics of epididymitis in boys with anorectal malformations.

METHODS

Sixty-six boys with anorectal malformation were treated between January 1990 and January 2000, in our center. Four of these boys experienced epididymitis attacks. The first three patients had rectourinary fistula and the fourth had a low type anorectal malforation without a rectourinary fistula.

RESULTS

Patients were followed up for seven to nine years and epididymitis did not recur after the definitive operation in the first three patients. The fourth patient had four other episodes of epididymitis postoperatively and no reason for these episodes could be found during the further urological evaluation. Two patients had urinary tract infection and one patient had urinary tract contamination during their episodes of epididymitis.

CONCLUSION

The cause of the epididymitis can be anorectal malformation with rectourethral fistula itself or another urogenital anomaly that is associated with anorectal malformation. There is a relationship between urinary tract infection and epididymitis in these patients.

Tethered cord syndrome in children with anorectal malformations

OBJECT

Anorectal malformations are known to be associated with neurological deficits, which may contribute to the disability suffered by patients with these malformations. This study was undertaken to determine the incidence and pattern of sacral abnormalities in children with anorectal malformations, the incidence and nature of the neurological deficits, and the incidence and nature of operable intraspinal abnormalities in patients with this condition.

METHODS

Neurological evaluation was performed in 81 children with anorectal malformations. Plain x-ray films were obtained to identify the presence of sacral abnormalities. The patients with neurological deficits were evaluated for the presence of operable intraspinal anomalies, and when such anomalies were identified, correction of the same was undertaken. In 21% of these children radiographic evidence of sacral abnormalities was shown. Fifteen percent of patients harbored neurological deficits, and 10% harbored operable intraspinal anomalies. In addition, one patient had split notochord syndrome. Patients with operable intraspinal anomalies underwent surgical correction, with resultant neurological improvement.

CONCLUSIONS

Bone abnormalities of the sacrum, neurological deficits, and operable intraspinal lesions are not uncommon in children with anorectal malformations. Because the neurological deficits can contribute to the disability suffered by these individuals, we recommend routine screening of patients with anorectal malformations and neurological deficits and/or sacral abnormalities for the early identification and treatment of potentially correctable intraspinal lesions.

Acute scrotum due to edidymo-orchitis associated with vasal anomalies in children with anorectal malformations

Epididymo-orchitis, an uncommon cause of acute scrotum in prepubertal boys, is infection or inflammation of epididymis and testis. Epididymo-orchitis may be associated with urinary tract infections or reflux of urine predisposed by an underlying vasal anomaly. Two infants with anorectal malformations who presented with acute scrotum are reported. The surgical exploration of the testes showed findings consistent with epididymo-orchitis. Further radiological investigations of urinary tract showed vasal anomalies in both patients. If a patient with anorectal malformation presents with acute scrotum, epididymo-orchitis should be suspected initially. Evaluations should be directed toward defining predisposing vasal anomaly, and appropriate therapeutic measures should be undertaken to prevent recurrences.

Comparison of urodynamic investigations before and after posterior sagittal anorectoplasty for anorectal malformations

METHODS

The authors evaluated 21 patients (10 boys, 11 girls) who had anorectal malformations (ARM). Ten of them had infralevator (low-group I) and 11 of them had supralevator (high-group II) type ARM. All of the patients underwent urodynamic investigation before and after posterior sagittal anorectoplasty (PSARP) operation.

RESULTS

Sacral and spinal anomalies were found in 54% (6 of 11) patients who had supralevator type ARM. None of the patients with infralevator type ARM had additional sacral or spinal anomalies. Before PSARP operation urodynamic investigations of all infralevator type ARM patients were within normal limits, whereas 82% (9 of 11) of patients with supralevator type ARM showed neurovesical dysfunction (NVD). There was no significant difference between the preoperative and postoperative urodynamic findings. The possibility of additional sacral or spinal anomalies and NVD in supralevator type ARM was high. After PSARP operation no additional lower urinary tract dysfunction was detected in the urodynamic evaluation of ARM patients.

The tethered spinal cord in patients with anorectal malformations

The aims of this study were to find the prevalence of tethered cord in patients with anorectal malformations; to determine if the presence of tethered cord relates to the severity of the anorectal defect, and to certain symptoms, signs, radiologic findings, and associated anomalies; and finally to determine whether tethered cord impacted on a patient's functional prognosis and whether surgical untethering improved the patient. The authors studied 934 patients with anorectal malformations, 111 of whom had magnetic resonance imaging (MRI) of the spine. We compared patients with and without tethered cord by using parametric and nonparametric statistical tests. Tethered cord occurred in 24% of the patients. The prevalence varied according to the type of anorectal defect from 43% in the complex group to 11% in patients with rectovestibular fistula. Patients with tethered cord had a lateral sacral ratio lower than that of patients without tethered cord (0.410 versus 0.702). Tethered cord was present in 90% of patients with myelodysplasia, 60% of patients with a presacral mass, 57% of patients with sacral hemivertebrae, and 56% of patients with a single kidney. The greater number of associated anomalies a patient had, the greater the risk of having tethered cord (P < .05 for all differences). The authors noted differences between patients with and without tethered cord in the presence of voluntary bowel movements (46% versus 70%), fecal soiling (91% versus 63%), constipation (21% versus 43%), and urinary incontinence (86% versus 42%). The data indicate that patients with tethered cord have a worse functional prognosis than patients without tethered cord. However, the incontinence in our patients was also predictable based on the type of anorectal defect and the character of the sacrum irrespective of the presence of tethered cord. Eighteen patients underwent surgical untethering of the cord, and none had any significant change in bowel or urinary function postoperatively. No patient with tethered cord experienced incontinence that could be attributed to the cord defect alone. This study suggests that tethered cord occurs more frequently in patients with severe anorectal defects, sacral hypodevelopment, myelodysplasia, presacral mass, sacral hemivertebrae, or a single kidney, or in those with an anorectal defect with poor functional prognosis. At present no solid evidence supports the concept that tethered cord by itself affects the functional prognosis of patients with anorectal malformations. Also, there is no good evidence demonstrating that surgical untethering improves the prognosis.

Posterior urethral diverticula: a complication of surgery for high anorectal malformations

We describe five boys, all of whom presented with urinary tract infection or acquired urinary incontinence some years after surgery for a high anorectal malformation (ARM). All were found to have a posterior urethral diverticulum thought to represent the remains of the original rectourethral fistula accompanying the high rectal atresia. Excision of the diverticula resulted in complete relief of symptoms. The clinical features and radiological appearances of the diverticula are described. A urethral diverticulum is one treatable cause of urinary symptoms in children with high anorectal malformations, and should be considered when symptoms recur late after definitive surgical correction of the malformation.

Male infertility after surgery for imperforate anus

Congenital abnormalities of the genitourinary tract often coexist, and cryptorchidism is common in patients who have had imperforate anus. Twenty men who had pull-through procedures for imperforate anus in infancy have been evaluated for infertility. Seven had coexisting renal abnormalities, 4 had had recurrent epididymitis, 3 had had bilateral orchidopexies (at age 7 to 12), 2 had spina bifida, and 1 had a pituitary adenoma. Seven had no ejaculate (aspermia), 11 were azoospermic, 1 was severely oligozoospermic, and 1 had a normal sperm concentration in a small volume of ejaculate. Both vasa were blocked in 5 men, and this appeared to be a result of the original operative procedure. One vas was blocked in another 7 patients who had abnormalities on the contralateral side; three had epididymal blocks after epididymitis, and four had congenital malformations associated with an absent or ectopic kidney. After reconstruction (4), insertion of sperm reservoirs (4), microscopic epididymal sperm aspiration (2), or artificial insemination (1), sperm were retrieved from 9 men (ejaculated by 4) 2 pregnancies occurred. Male infertility after treatment of imperforate anus in infancy can be related to a wide variety of cause, some of which are amenable to treatment.

The effect of posterior sagittal anorectoplasty and its variants on lower urinary tract function in children with anorectal malformations

The effect of posterior sagittal anorectoplasty (PSARP) and its variants on lower urinary tract function was investigated urodynamically in 32 patients with anorectal malformations. In 27 patients urodynamic evaluation was performed before and after surgery and in 4 it was done postoperatively only. One child was clinically assessed with no postoperative urodynamic study. Minor postoperative changes in the specific preoperative urodynamic pattern were observed in 4 cases but the changes did not seem to be related to surgery. In 3 boys with rectourethral fistulas detrusor failure consistent with autonomic denervation was noted postoperatively. Standard posterior sagittal anorectoplasty was performed in 1 of the 3 boys and posterior sagittal anorectoplasty combined with additional transabdominal procedures was done in the other 2. In general our findings suggest that posterior sagittal anorectoplasty and its variants do not affect lower urinary tract function unless these surgical techniques are combined with major transabdominal procedures and extensive retrovesical dissection.

Cloacal and urogenital abnormalities induced by etretinate in mice

Etretinate, a synthetic retinoid, is a potent teratogen. It has previously been shown that acute exposure of gestational day 8 (equivalent to human week 4 post-fertilization) C57BL/6J mouse embryos to this retinoid results in a spectrum of abnormalities that are recognized as constituting caudal regression (dysgenesis). These defects, which include spina bifida, imperforate anus, genitourinary anomalies, omphalocele and limb anomalies, result from a major insult to the primitive streak, that is the gastrulation process. Developmental stages present early on gestational day 9 in mice represent the final stages during which the primitive streak contributes to the trunk of the embryo and, therefore, the last opportunity for abnormalities within the realm of caudal regression to be induced. In fact, acute etretinate exposure on gestational day 9 resulted in anal and urethral atresia, bladder and ureteral dilatation, and tail deficiencies as observed in 251 near-term fetuses in this study. To examine in further detail the gestational day 9 etretinate induced urogenital and anal abnormalities and their pathogenetic basis, analyses were conducted using scanning electron microscopy, light microscopy, antegrade cystourethrograms and a vital staining technique as early as 6 hours following maternal drug administration. It appears that diminution of the caudal cell populations, including those of and those surrounding the cloaca, at this critical stage of embryogenesis accounts for the observed phenotype. We propose that anal and urethral atresia temporally represents the end of the caudal regression (dysgenesis) syndrome.

Vaginal reconstruction: critical technical principles

Childhood vaginal anomalies are frequently encountered, often in association with significant anorectal or urinary tract abnormalities. As a result, reconstruction poses a number of technical challenges. We maintain that the best results are achieved by single stage perineal reconstruction. The primary goal of achieving a functional and cosmetically adequate vagina must not be at the expense of the optimal repair of associated urinary and anorectal abnormalities. In addition, since these repairs are performed early in childhood, vaginal growth is an issue that further limits the choice of reconstructive technique. We present a series of successful vaginal reconstructions in complex cases and an outline of the principles of surgical care.

Urodynamic evaluation of the patient with an imperforate anus: a prospective study

Prospective urodynamic evaluation of 14 patients with an imperforate anus revealed detrusor-sphincter dyssynergia in 4. Subsequent contrast voiding cystourethrograms demonstrated radiographic changes in all 4 cases, consisting of bladder trabeculation, new onset of vesicoureteral reflux or hydroureteronephrosis. Of the 4 patients 3 had a high (supralevator) imperforate anus, while 1 had a low (infralevator) lesion. Two patients had bony vertebral abnormalities and 2 had normal plain radiographs and magnetic resonance imaging of the spine. Therefore, early urodynamic study is recommended for all patients with an imperforate anus and it should complement neonatal uroradiographic evaluation. The finding of detrusor-sphincter dyssynergia should alert the urologist to the need for adjunctive management.

Anorectal malformations: evaluation of associated spinal dysraphic syndromes

The early recognition and treatment of correctable lesions of the terminal spinal cord in patients with anorectal malformations may preserve important neurologic function. Tethered cord and intraspinal masses are detectable with the use of high-resolution ultrasonography in the neonate. Fourteen infants and children with anorectal malformations and associated spinal dysraphism have been identified in our institution over the past 7 years. Six patients had cloacal exstrophy, and eight had imperforate anus (four high and four low lesions). The spinal lesions caused symptoms in only seven children; progressive neurologic deficit in five, and urinary incontinence or retention in two others. Five asymptomatic patients with cutaneous abnormalities on the back were studied and two were discovered during scoliosis evaluation. Imaging techniques included high-resolution ultrasonography, computed tomography with and without metrizamide myelography, and magnetic resonance imaging. Spinal sonography was highly accurate in the neonatal period. The application of ultrasonography can be of great advantage in early screening of patients with anorectal malformations and, in some cases, may eliminate the need for invasive imaging techniques.

The genitourinary system in patients with imperforate anus

The incidence and significance of associated genitourinary abnormalities was reviewed in a series of 484 infants with imperforate anus encountered over a 17-year period. Fourteen percent of the entire series had significant bilateral upper tract urinary abnormalities (either asymmetric or symmetric). Of 67 such patients only 14 had combinations of renal agenesis and hypoplasia-dysplasia representing uncorrectable renal pathology. A high incidence of vesicoureteral reflex and neurovesical dysfunction represent additional important sources of preventable renal deterioration.