Reconstructive techniques for complex anorectal malformations (ARMs) require intestinal pull-through on vascular pedicles. Traditionally, the visual inspection of the intestinal perfusion is the sole modality adopted to assess tissue viability. In this article, we report the case of a child with a rectourethral prostatic fistula, who had a Peña's descending colostomy with distal mucous fistula in the neonatal period and a posterior sagittal anorectoplasty at 6 months of life. The ARM repair was guided by indocyanine green (ICG), which was intravenously administered to evaluate the blood flow of the intestinal pull-through using the EleVision IR system (Medtronic Ltd, U.K.). ICG-based fluorescence-guided surgery helped to define the proximal resection margin, impacting intraoperative decision making, and no postoperative complications occurred. We envisage that this technology will become part of the armory of pediatric surgeons soon, by reducing the risk of intra- and postoperative complications.