Single-stage versus staged reconstruction for high and intermediate anorectal malformations in neonates: a systematic review and meta-analysis.

The surgical approach to high and intermediate anorectal malformations remains controversial. This systematic review compared continence and infection outcomes between the two approaches. MEDLINE, Embase, and Cochrane CENTRAL were searched per a registered protocol (PROSPERO CRD420261291319). Comparative studies of single-stage versus staged repair in neonates with high or intermediate anorectal malformations were included. Risk of bias was assessed using ROBINS-I. Random-effects meta-analysis with prediction intervals was performed. Four comparative studies (746 patients: 399 single-stage, 347 staged) were included. Pooled analysis showed no significant difference in incontinence outcomes (RR 0.93, 95% CI: 0.52-1.66, p = 0.80; 95% prediction interval: 0.28-3.08) with substantial heterogeneity (I²=83%). Infection data could not be pooled due to methodological concerns in outcome reporting. All included studies demonstrated moderate to serious risk of bias. GRADE certainty was LOW for incontinence and VERY LOW for infection. Current evidence does not demonstrate superiority of either approach for bowel continence (LOW certainty). Infection evidence was insufficient for synthesis (VERY LOW). Wide prediction intervals indicate substantial uncertainty; available data cannot confirm or refute inferior outcomes after single-stage repair. Prospective studies with standardized outcomes are needed. Protocol registration: PROSPERO CRD420261291319.