A 25-year-old male presented with an anterior sacral meningocele (ASM) manifesting as repeated urinary tract infections. Surgical correction was completed by simple ligation of the thecal sac next to the ostium via sacral laminectomy, and the thickened filum terminale was sectioned. A 22-year-old female presented with an ASM manifesting as transient difficulty in micturition. Subsequent to sacral laminectomy, the thickened filum terminale was sectioned. However, an aberrant nerve root over the ostium made simple ligation hazardous, so that transdural suture around the ostium was carried out. Complete obliteration was confirmed 5 months after the surgery. Magnetic resonance (MR) imaging could clearly demonstrate the involvement of neurologically important structures. Surgical strategy for ASM based on neurosurgical considerations is proposed, because of the frequent association of caudal spinal cord anomaly as well as presacral mass lesion. Intraoperative assistance systems such as endoscopy for cyst content examination and neurophysiological monitorings are recommended. Several months follow up with MR imaging is required to confirm successful surgical correction.