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# Discussion  Anterior sacral meningocele develops as a result of a defect characterized by focal erosion or hypogenesis of segments of the sacrum with herniation of the meningeal sac through the defect into the pelvis. They account for about 5% of retrorectal masses, it is masses and are  usually diagnosed in the second or third decades and are being  more prevalent in women.\cite{6828997} Presentation in elderly patients are is  less common, however it can occur as in the case described. The presentation of anterior sacral meningoceles can be subtle. Therefore, the patient’s medical history and physical examination findings are critical diagnostic tools. The patients may remain asymptomatic or present with nonspecific symptoms such as long-term constipation, urinary dysfunction, lower back pain, or perineal hypoalgesia.\cite{21977087}\cite{6470791} These symptoms may be due to direct compression of the herniated meningeal sac, spinal cord tethering, or sacral nerve root compression, diminished rectal and detrusor  tone, or numbness and paresthesia in the lower sacral  dermatomes.\cite{11956924} compression.\cite{11956924}  Also fluid shifts between the sac and the spinal subarachnoid space can cause intermittent low or high-pressure headache, nausea and vomiting related to changes in body position.\cite{6828997} As a result of this nonspecific symptoms, the diagnosis can be difficult and ASM  occasionally can be confused with other entities.   The diagnostic tests include several imaging studies like plain radiograph which could show the curved appearance of the residual sacrum, sacrum  scalloped beneath the defect, this defect. This  finding is considered as almost pathognomonic, and it  is present in 50% of cases.\cite{3335662} CT-scans are useful to display bony anomalies and lumbar erosions. Intrathecal contrast enhanced CT scanning is the diagnostic procedure of choice. Nevertheless, this method usually is discarded as it  is invasive and has the disadvantage of ionizing radiation. MRI is preferred as it  is a safe, rapid, and noninvasive.\cite{3418399} Abdominal ultrasound could reveal the presence of the intra-abdominal cystic abnormality, careful abnormality. Careful  examination should be made to avoid misdiagnosis with cysts in other locations, a typical example of this is the confusion Confusion  with ovarian cysts, cysts is not rare,  as happened with our patient, shown in the case we present,  and has been described in other reports.\cite{16673368}\cite{23486628} In our patient an invasive technique was executed with the consequent increased risk of producing a CSF leak into the abdominal cavity, although however  sometimes the fistula can occur by itself.\cite{21882098}\cite{18447698}\cite{20871432} spontaneously.\cite{21882098}\cite{18447698}\cite{20871432}  Surgical options consist primarily of either an anterior transabdominal or a posterior transsacral approaches. The main goal of surgery should be to safely disconnect the cyst from subarachnoid space to prevent further enlargement, thereby reducing the compression of nearby structures.   The anterior transabdominal approach could may  be performed via laparoscopic or open trans-abdominal/laparotomy, usually it  is not considered as the first surgical  option unless decompression and rapid removal of the cyst wall is required. Extreme caution must be taken when extensive resection of the cyst wall is performed since adherence to surrounding visceral structures can lead to complications such as fecal or vesical fistulas.\cite{16793455} Several reports have stressed the advantages of the posterior transsacral technique, since there is usually no need to decompress or remove the cyst. Instead, treatment via a posterior approach to interrupt the fistula is sufficient, and the cyst will gradually and spontaneously resolve(citas).