It is very obvious that every day we feel the need and the pressure to evaluate the results of our operations in the most objective possible way. One of the biggest problems of medicine and surgery through history is the difficulty to measure, if possible with numbers, the quality of our results.

In an effort to be objective in the measurement of the bowel control, different surgeons created scores. Unfortunately, all of these scores that have been published until now are basically deficient, because they include very subjective issues. Some of them [1] try to give points to subjective and abstract concepts such as “extra underpants for liners needed,” “social problems,” “activity restrictions,” and “rashes.” Obviously, those concepts do not reflect the real result of an operation. Others [2] include concepts such as “influence in lifestyle,” “need to wear pad,” “taking constipation medicine,” and “lack of activity” to “defer defecation for 15 min.” Other scores [3] are extremely extensive, sophisticated, and complicated and therefore cannot be used on an everyday basis; in addition, they are full of subjective concepts not necessarily relevant to bowel control such as “in the last week has your child experienced constipation?” “In the last week, has your child experience pain in the abdomen?” Even when some of these scores have been “validated,” we considered them highly inadequate. Other scores [4] include a very controversial concept such as “frequency of defecation” that is not necessarily related to bowel control. We can say the same about “stool consistency,” “stool odor,” “constipation,” and “modifications of the diet.” Other highly controversial concepts included in these scores are, for instance [5]: “Does stool leak so that you have to change your underwear?” “Does bowel or stool leakage cause you to alter your lifestyle?” One of the first scores created to try to measure bowel control in an anorectal malformation was designed by Kelly [6] but, unfortunately, includes very subjective concepts, such as “strength of puborectalis muscle action on digital examination.”

Another very serious problem that we found in all of our literature review is that when discussing results, in terms of bowel control, unfortunately, most of the times, the surgeons continue using the old, archaic, misleading classification that divides the malformations into “high,” “intermediate,” and “low.” In addition, most of those papers do not include a description of the characteristics of the sacrum and/or the presence or absence of tethered cord. Those big deficiencies obviously disqualify many papers.

We propose that in the future, when we discuss results in terms of bowel control, we describe malformation per malformation, in other words, bladder neck fistula patients, prostatic fistula, bulbar fistula, etc., since each one of those has a different prognosis. In addition, we must subdivide them into those with normal sacrum and those with a very deficient one. A very deficient sacrum is one with a sacral ratio lower than 0.4. In addition, we must indicate if the patient has tethered cord or not. We will be comparing rectal prostatic fistula with rectal prostatic fistula, bulbar with bulbar, perineal with perineal, etc.

Frequency of bowel movements is not necessarily related to the potential for bowel control or the quality of the procedure that was used to repair a malformation. The frequency of bowel movements depends on the length of the colon and/or the possibility of the patient’s suffering from some sort of irritation or inflammation of the colon. Likewise, the presence or absence of constipation does not necessarily relate to the quality of the operation or the capacity of the patient to have bowel control. Constipation represents rather a hypomotility disorder that, as we discussed in this textbook, is aggravated by many other factors. In other words, there are patients with severe constipation but continent; and there are other patients that have no constipation and they are incontinent. We should discuss separately the results in terms of constipation and the results in terms of bowel control.

In summary, we do not use any scores in the evaluation of our patients. The optimal best result in the repair of an anorectal malformation is to have a patient that behaves like a normal individual, in other words, a person that has voluntary bowel movements and does not soil or smear the underwear. That is what we call totally continent patients. Another category of patients are those who have voluntary bowel movements. In other words, the patient tells the parents that he/she wants to use the toilet, voluntarily; he/she goes there and has a bowel movement; occasionally, the mother sees the underwear with smears or soiling. The third category includes patients that are totally incontinent; because they do not have voluntary bowel movements, they simply pass stool in the underwear. We realized that we are still far away from being able to quantify with numbers our results, but we believe that this is a better way to evaluate patients with anorectal malformations.

Efforts have been made in the past to evaluate bowel control, using radiology. Justin Kelly published some of the first studies on defecograms in anorectal malformations [7]. He emphasized the importance of the rectal angle, as a manifestation of the action of the “puborectalis muscle.” Yet, the studies were difficult to interpret, basically because in those years, anorectal malformations were still classified as “high,” “intermediate,” and “low.” The findings of those studies demonstrated that the presence of that angle, in general, correlates with good clinic results but not 100 %.

The concept was reintroduced by Yagi, doing what he calls “postoperative fecal flow metric analysis” in patients with anorectal malformations [8]. It is a very sophisticated study, but it does not tell us anything new and does not help us in the management of our patients. The same concept of the anorectal angle was again used to compare the results between posterior sagittal anorectoplasty and the laparoscopic approach, but unfortunately, the authors still refer to the malformations in terms of “high” and “intermediate” [9].

Early in our practice, we performed defecograms in all of our patients, and in general, a good angle was more frequently associated with patients with bowel control, but not necessarily in all cases. Very soon we learned that bowel control was something much more complex to evaluate.

Rectal manometry has been a very popular study. We exposed our methodological doubts about the validity of that study (see Chap.​ 25, Sect. 25.​3.​2). Again, the authors keep referring to the anorectal malformations as “high” and “low”; they even claim that they can manometrically evaluate the quality of the “internal sphincter” [10–16]. The quality of the sacrum as well as the presence or absence of tethered cord is not mentioned in those papers.

CT scan evaluation of anorectal malformations has frequently been used. Obviously, the images have better definition than the previous radiologic studies [17]. Unfortunately, CT scans show only transverse sections of the pelvis; therefore, when the rectum is completely anterior or posteriorly mislocated, the study is not good enough. On the other hand, when the rectum is placed into the ischiorectal fossa, the study is valid and may guide us to make a decision about repositioning of the rectum within the limits of the sphincter (see Chap.​ 22). Unfortunately, sagittal views are not seen in this kind of study, and we consider that an important deficiency. We were ecstatic and happily surprised to read in one of the papers that the authors no longer refer to the puborectalis and internal or external sphincter, but rather mention the “muscle complex” [18]. We were also very happy to see that some of the publications related with computed tomography in anorectal malformations were very honest papers, in which the authors mentioned that the clinical application of those imaging findings were not applicable in the everyday practice [19–21].

Electromyography has also been used to evaluate the sphincter mechanism in patients with anorectal malformations [22–24]. The information obtained with electromyography does not help us to make any decision preoperative or postoperative. We believe that there is no need to use an electromyographic study to see a sphincter that we already saw directly during an operation.

We have the feeling that sometimes the doctors who perform sophisticated studies do it with a specific goal in mind, to find the preconceived structures that they learned, such as “external sphincter,” “puborectalis,” and “internal sphincter.”

We are extremely enthusiastic about the MRI technology to evaluate the anatomy of the pelvis, particularly in anorectal malformations. We believe that the MRI studies provide the best images that reflect the real anatomy of the patient. In fact, we feel that the MRI studies confirm our operative findings and our concepts, related with the anatomy of the sphincter mechanism in a normal individual and in patients with anorectal malformations (see Chap.​ 2). We use MRI studies when we deal with complex malformations and particularly in patients that already had a previous operation and suffer from fecal incontinence. The MRI study allows us to determine exactly the position of the rectum as related with the sphincter mechanism. This study provides beautiful sagittal images as well as transverse sections. We perform the study introducing a large rubber tube into the rectum to be able to see exactly what is rectum and what is sphincter mechanism [25]. We have been very impressed by the fact that in spite of the beautiful, realistic images, provided by the MRI study, some authors insist in being able to see a distinct “puborectalis muscle,” as well as an “internal sphincter” with this study; and yet, when we look at the images that they provide, we only see a continuum of muscle and no separation between those structures [26–29]. Some authors claim not only to be able to see the “internal sphincter” in the MRI study, but they evaluate the sphincter, creating what they call an “internal sphincter score” [30]. The MRI study has been used by others to “compare differences between patients with constipation and fecal incontinence” [31]. We do not believe that this excellent imaging study is necessary to differentiate those two conditions.