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# Discussion  Anterior sacral meningocele ASM  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 accounts  forabout  5% of retrorectal masses masses,  and are usually diagnosed in the second or third decades being decades. They are  more prevalent in women.\cite{6828997} Presentation in elderly patients is less common, however it can occur as in the case described. The presentation of anterior sacral meningoceles ASM  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.\cite{11956924} Also Furtermore,  fluid shifts between the sac and the spinal subarachnoid space can cause intermittent low or high-pressure low-pressure  headache, nausea and vomiting related to changes in body position.\cite{6828997} As a result of this the  nonspecific symptoms, the diagnosis can be difficult and ASM occasionally can be confused with other entities.   The diagnostic tests includeseveral imaging studies like  plain radiograph which could show the curved appearance of the residual sacrum scalloped beneath the defect. This finding is consideredas almost  pathognomonic, and it is present presents  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 the gold standard  as it isa  safe, rapid, and noninvasive.\cite{3418399} Abdominal ultrasound could reveal the presence of the an  intra-abdominal cystic abnormality. lesion.  Careful examination should be made to avoid misdiagnosis with cysts in other locations, locations.  Confusion with ovarian cysts is not rare, asshown  in the case we present, and has also  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, however sometimes the fistula can occur spontaneously.\cite{21882098}\cite{18447698}\cite{20871432}  In our patient, as a consecuence of the misdiagnosis, a presumed ovaryan cyst puncture was performed with the consequent CSF leak into the abdominal cavity. However, spontaneous fistula can occur sometimes. \cite{21882098}\cite{18447698}\cite{20871432}  Surgical options consist primarily of either an anterior transabdominal or a posterior transsacral approaches. approach.  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 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}