Urachal Anomalies Research Articles

Strangulated Umbilical Herniation into Urachal Anomaly

Strangulated Umbilical Herniation into Urachal Anomaly

Urachal cyst abscess in an infant

Abstract Urachal anomalies are rare, in the literature it is reported that the three most common types of urachal anomalies are urachal cysts, urachal sinus, and urachal diverticulum. We present the case of an infant who has come to our observation with painful umbilical mass and purulent discharge, irritability and fever. The suspicion of abscess of urachal sinus was confirmed by ultrasound examination, the VCUG was performed to exclude urinary abnormalities. Surgical removal of urachal sinus was resolutive without complications in follow-up.

Conservative management of urachal anomalies

PurposeThe purpose of this study was to evaluate trends in management of urachal anomalies at our institution and the safety of nonoperative care. MethodsBased on our experience managing urachal remnants from 2000 to 2010 (reported in 2012), we adopted a more conservative approach, including preoperative antibiotic use, refraining from using voiding cystourethrograms (VCUG), postponing surgery until at least six months of age, and considering nonoperative management. A retrospective analysis of urachal anomaly cases was conducted (2011–2016) to assess trends in practice. Charts indicating anomalies of the urachus were pulled and trends in management (nonoperative versus surgical treatment), VCUG and antibiotic use, and outcomes were reviewed. ResultsData from 2000–2010 and 2013–2016 were compared. Our findings indicate care has shifted towards nonoperative management. A smaller proportion of patients from 2013–2016 was treated surgically compared to 2000–2010. Patients receiving nonoperative treatment exhibited lower rates of complication relative to surgically managed cases. VCUGs were eliminated as a diagnostic tool for evaluating urachal anomalies. Prophylactic preoperative antibiotic use was standardized. No patients with a known urachal remnant presented later with an abscess or sepsis. ConclusionsWe find that a shift towards nonoperative treatment of urachal anomalies did not adversely affect overall outcomes. We recommend observing minimally symptomatic patients, especially those under six months old. Study typePerformance improvement. Level of evidenceLevel IV.

Is excision necessary in the management of adult urachal remnants?: a 12-year experience at a single institution

Objectives: To determine the ideal management of uncomplicated adult urachal remnants and to confirm if conservative management with repeated imaging is acceptable.Patients and methods: This is a retrospective review of clinical notes and imaging of 45 patients with a mean age of 54.6 years who had been diagnosed with urachal anomalies at a single urology tertiary centre from January 2005 to December 2016. Patients who underwent surgical intervention and findings from patients managed non-operatively, with a mean follow up of 31 months, were evaluated.Results: Thirty (66.7%) patients had incidental findings, while 15 (33.3%) were symptomatic. Eight underwent excision, one underwent an incision and drainage of abscess, while 34 of the 36 remaining patients elected to undergo surveillance with repeated ultrasound imaging. Two were lost to follow-up. Malignancy was confirmed in three patients. There was interval stability of the urachal remnant in all the patients in the non-operative cohort. The small sample size, limited follow-up, and retrospective nature of the study are recognised limitations.Conclusions: It was found that simple and asymptomatic lesions can be monitored with ultrasound, but effort must be made on initial diagnosis to ensure that malignancy is excluded using CT imaging and flexible cystoscopy where possible. Long-term follow-up of this cohort is required to assess the natural history of observed urachal anomalies.

Urachal Remnants in Patients Presenting to the Emergency Department with Abdominal Pain

BackgroundRare causes of abdominal pain include abnormalities of the urachus, including patent urachus and urachal cyst with or without infection. However, reviews discussing etiology of abdominal pain, even in children, may completely omit mention of urachal remnants. ObjectivesDetermine the incidence of symptomatic urachal remnants in patients presenting to the emergency department (ED), including common presenting findings and method of diagnosis. MethodsA retrospective chart review was performed of all patients presenting to the ED with abdominal pain who were diagnosed with urachal remnants, including patent urachus or urachal cyst or abscess over a period of 11 years and 7 months in one hospital. ResultsThere were a total of 833,317 ED visits over the time period of the chart review, with 76,954 patients or 9.2% presenting with a complaint of abdominal pain. Twenty-four patients were identified, or 0.03% of those presenting with abdominal pain. Ages ranged from 16 days to 59 years. Among those 18 years or older, there was a male-to-female ratio of 1:1 of 14 patients. Thirteen patients (54.2%) initially presented with drainage from the umbilicus. ConclusionsAlthough rare, symptomatic disorders of urachal remnants may present at any age. These disorders should be kept in mind by the emergency physician among the broad list of differential diagnoses accounting for abdominal pain. Urachal cyst and abscess may present with or without drainage from the umbilicus. Drainage from the umbilicus is highly suggestive, but not pathognomonic, of a urachal anomaly, and patients should be imaged to make a definite diagnosis and assist in the management plan.

Voiding Cystourethrography

The voiding cystourethrogram (VCUG) is a fluoroscopic examination commonly used in pediatrics to assess the presence of vesicoureteral reflux (VUR) disease and the structure and function of the bladder and urethra. Along with hydronephrosis and febrile urinary tract infections, the indications for VCUG are vast. Protocols set in place and modern techniques have helped reduce radiation exposure during VCUG to 1.7 to 5.2 mrad. Proper patient preparation and sterile technique during catheter placement are of the upmost importance. The bladder is filled with contrast to the patient’s capacity, followed by the patient voiding. A scout film (anteroposterior [AP]) along with views of early filling (AP), bladder capacity (AP and oblique), voiding (AP and oblique), and postvoid (AP) are obtained. VUR is diagnosed, and its grading system is determined by the VCUG study. Cyclic VCUG, PIC cystography, and radionucleotide VCUG are alternative techniques in diagnosing VUR. Neurogenic bladder, along with its associated pathologies, can be easily characterized by the VCUG examination, as can cloacal and urogenital sinuses via the contrasted study. Bladder ruptures, bladder masses, urachal anomalies, functional disorders of the bladder neck, and a host of urethral pathologies (most notably posterior urethral valves) can be diagnosed by VCUG. This review contains 62 highly rendered figures, 6 tables, and 9 references Key words: voiding cystourethrography, fluoroscopy, radiology, imaging, pediatric, urology, vesicoureteral reflux

Laparoscopic management of urachal cysts.

The urachus and the urachal remnants represent a failure in the obliteration of the allantois at birth that connects the bladder to the umbilicus. After birth it obliterates and presents as the midline umbilical ligament. Urachal cyst are the most common urachal anomaly in the pediatric population. The traditional surgical approach is a semicircular infraumbilical incision or a lower midline laparotomy. In a 10 years period at Pediatric Surgery Department of Vicenza 16 children were diagnosed with urachal anomalies presenting as abdominal or urinary symptoms. Eight underwent open excision; eight were treated by laparoscopic surgery. The average age was 5.5 years (range, 4 months-13 years) in open group and 10 years (range, 1 month-18 years) in laparoscopic group. Mean operative time was 63 minutes (range, 35-105 minutes) in open group, 50 minutes (range, 35-90 minutes) in laparoscopic group. There were no postoperative complications. The patients of laparoscopic group were all discharged after few days (range, 2-4 days). Pathological examination confirmed a benign urachal remnant in all cases. Reporting our experience since comparing the two surgical approaches we want to describe the technique step by step of laparoscopic urachal cyst excision as minimally invasive diagnostic and surgical techniques. Laparoscopy represents a useful alternative for the management of persistent or infected urachus, in particular when there's the suspect despite the lack of radiological evidence. The morbidity associated with this approach is very low as the risk or recurrence. Laparoscopy in the management of urachal cyst is safe effective and ensures good cosmesis with all the advantages of minimally invasive approach.

Robotic-Assisted Excision of a Urachal Diverticulum

Study ObjectiveTo demonstrate a combined robotic-assisted laparoscopic technique with concomitant cystoscopy use for excision of a urachal diverticulum to ensure complete resection of diverticulum and bladder cuff. DesignStep-by-step demonstration and explanation of the procedure using video illustration. Institutional Review Board/Ethics Committee ruled that approval was not required for this case report; however, patient consent was obtained (Canadian Task Force Classification III). SettingVesicourachal diverticula account for approximately 3% to 5% of congenital urachal anomalies. Although usually asymptomatic, the diverticulum may be associated with an increased risk of urinary tract infections, intraurachal stone formation, and an increased prevalence of carcinoma after puberty. When diverticula become symptomatic or infected, surgical management is warranted. PatientA 68-year-old gravida 0 woman was evaluated with cystoscopy for recurrent culture-proven urinary tract infections. A suspected vesicourachal diverticulum was identified on cystoscopy, and the diagnosis was confirmed on computed tomography. She was counseled on management options and elected to undergo robotic-assisted excision of the urachal remnant with concomitant cystoscopy. InterventionAfter identifying the diverticulum both laparoscopically and on cystoscopy, the anterior peritoneum was incised to dissect the diverticulum off the anterior abdominal wall. The dissection was carried down to the level of the bladder dome, necessitating entry into the retropubic space of Retzius. A partial cystectomy was performed to ensure complete resection of the diverticulum. The bladder was repaired in 2 layers. Concurrent laparoscopy and cystoscopy allowed for assurance of watertight closure by retrograde filling of the bladder and observing laparoscopically. Although entered, the space of Retzius is an avascular potential space between the pubic symphysis and the bladder and does not necessitate closure. Surgery was performed successfully without intraoperative or postoperative complications. On final pathology, a benign urachal diverticulum was completely excised. The patient’s presenting symptoms resolved postoperatively. ConclusionRobotic-assisted excision of a vesicourachal diverticulum with concomitant use of cystoscopy is a safe, effective, and efficient technique for successful, minimally invasive, management of symptomatic urachal diverticula.

To excise or not to excise infected urachal cysts: A case report and review of the literature

Abstract Urachal anomalies, and urachal cysts in particular, are common congenital anomalies that can remain asymptomatic throughout a lifetime or rarely cause life threatening illness if infected. We present a case of a complicated infected urachal cyst and review the literature on its work up and management, including the controversial issue of whether surgical management is always necessary for definitive treatment of this entity.

The role of laparoscopy in the management of urachal anomalies in children

Objectives Management for urachal anomalies (UAs) is controversial. Although traditional treatment of UAs has been surgical excision, recent literature report also a conservative approach. We reviewed our experience to define the role of laparoscopy in the management of UAs in children. Patients and methods From July 2005 to July 2015, 23 children underwent 24 interventions for the treatment of UAs. In four patients, the technique was a laparoscopicassisted removal of the anomaly, in two patients a laparoscopic-assisted drainage of an urachal abscess, and a pure laparoscopic technique was started in 17 patients. Results Laparoscopic-assisted removal of the UAs was achieved in five cases. In two cases a laparoscopic-assisted drainage of an urachal abscess was performed. The remaining patients were treated by pure laparoscopic technique. Operative or postoperative complications did not occur. Follow-up ranged from 6 months to 10 years and 6 months. Conclusion The pure laparoscopic approach to UAs appears safe and effective in most urachal remnants. Laparoscopic-assisted excision is an alternative approach that is easier to perform in infants. The decision to remove the UAs must be taken after an accurate informed consent of the parents, especially in cases of asymptomatic anomalies.

Imaging of the Urachus: Anomalies, Complications, and Mimics.

Urachal anomalies are more common than previously thought, with more cases discovered incidentally, because of the increased use of cross-sectional imaging. Although an abnormal persistence of an embryologic communication between the bladder and the umbilicus is often recognized and managed in childhood, it may persist into adulthood, with a greater risk of morbidity. Congenital urachal anomalies that are detected early can benefit from an optimized management including surgical approach with a complete resection of the urachal remnant in cases when spontaneous resolution or medical management has failed. At imaging, the different types of urachal anomalies have a distinct appearance. A patent urachus is recognized as an elongated patent connection between the bladder and the umbilicus. An umbilical-urachal sinus is depicted as a blind focal dilatation at the umbilical end, whereas a vesicourachal diverticulum is a focal outpouching at the vesical end. Urachal cysts are visualized as midline fluid-filled sacs most frequently located near the bladder dome. Complications of urachal anomalies have nonspecific clinical findings and can mimic other abdominal and pelvic processes. Potential complications, such as infection and tumors, should be recognized early to ensure optimal management. Understanding of the embryonic development of the urachus is necessary for the radiologist to diagnose the wide variety of urachal disease. ©RSNA, 2016.

Incidental Diagnosis of Giant Cell Tumor After Urachal Remnant Removal in a Thalassemic Child

Urachal anomalies are relatively uncommon; they usually present in childhood as urachal cysts, urachal sinuses, diverticula, and patent urachus. The malignant involvement of the urachus, although rare in children, is commonly found in adulthood when adenocarcinoma accounts for the majority of the cases, representing up to 20-30% of all adenocarcinomas of the bladder. Urachal tumors of variable histology have been reported in children and adolescents as single case report. We present the first case of a 4-year-old thalassemic boy, with an incidental finding of giant cell tumor arising in an urachal remnant.

Massive pyuria as an unusual presentation of giant infected urachal remnant in a child

Urachal remnants (URs) are manifestations of an incomplete regression of the urachus; therefore, there may be different types of remnants such as cyst, sinus tract, diverticulum or patent urachus. The clinical presentation of a urachal anomaly includes umbilical discharge, lower abdominal pain and urinary tract infection, although a UR may also be asymptomatic. We present the case of a 2.5-year-old girl who presented with abdominal pain, stranguria and massive pyuria in which a giant infected UR was found. The diagnosis was made using abdominal MRI. The child was subjected to laparoscopic-assisted drainage and had an uneventful postoperative course. Keywords : differential diagnosis, infected urachal remnant, laparoscopy, pyuria

Diagnosis and Management of Urachal Anomalies in Children

Congenital urachal anomalies are present in less than 2 % of the general pediatric population. While traditionally thought of as pre-malignant, their clinical significance particularly in the asymptomatic patient has been questioned. The presence of a urachal anomaly in childhood does not appear to confer an increased risk of urachal cancer in adulthood. These remnants are classified based upon their anatomic location and communication with either the umbilicus or bladder and may present with a variety of symptoms. When clinical signs and symptoms suggest the presence of an urachal anomaly, ultrasonography is the most appropriate initial diagnostic imaging test. Observation with or without follow-up imaging is an acceptable initial step in management as these often regress without surgical intervention particularly in asymptomatic patients. When infectious symptoms are present, a course of antibiotics may be recommended prior to surgery to reduce the chance of postoperative wound infection.

Prise en charge des résidus de l’ouraque au cours de l’enfance : l’exérèse chirurgicale est-elle obligatoire ?

The classical management of urachal remants consists in surgical resection, in order to prevent infections and long term malignancies. However, some reports have recently spread a wait and see management. The aim of our study was to report the results of the surgical management in our center. We conducted a retrospective, monocentric review of all patients managed for urachal remnants from January 2005 to December 2014. Thirty-five patients have been operated during the study period (18 girls and 17 boys). Mean age at surgery was 4,9±4,4 years old. Twenty-seven patients were referred due to symptoms whereas 8 were discovered incidentally (4 by ultrasound scan and 4 during laparoscopy). Among them, 10 were urachal cysts, 15 were urachus sinusa and 10 were patent urachus. Thirty were operated using an open approach and 5 using a laparoscopic approach. Mean length of stay was 3,8±1,7days (1-10) with a mean duration of bladder drainage of 2,5±1 days. No major complications occurred. No abnormal tissue was discovered at the histological analysis. Presentation of urachal remnants is variable but surgical outcomes remain excellent in our experience. When symptoms occur, the surgical decision is easy, but when the diagnosis is incidental, the decision is much more complicated. Official guidelines could ease the decision process and the management of urachal anomalies.

Suburothelial and extrinsic lesions of the urinary bladder: radiologic and pathologic features with emphasis on MR imaging.

The purpose of this article is to present a contemporary review of the imaging appearance of diseases which affect the deeper layers of the urinary bladder, including both suburothelial and extrinsic pathologies, using radiologic-pathologic correlation. Compared to the more common urothelial lesions, at cystoscopy, suburothelial and extrinsic diseases of the urinary bladder wall oftenhave a non-specific appearance or may be occult. Cross-sectional imaging, in particular MRI, plays an integral role in diagnosis. Mesenchymal tumors have distinct imaging features on MRI. Leiomyomas are characteristically low signal intensity on T2-weighted (T2W) imaging and progressively enhance. Lipomas and lipomatous hypertrophy are diagnosed by the presence of macroscopic fat. Neurofibromas, hemangiomas, and paragangliomas are hyperintense on T2W sequencesand hypervascular. Reactive lesions occur in the setting of chronic inflammation and include: nephrogenic adenoma, cystitis cystica, and cystitis glandularis. Imaging findings are commonly non-specific; however, a mass with internal cystic spaces in association with pelvic lipomatosis is suggestive ofcystitis glandularis. Urachal anomalies may be complicated by infection or malignancy. Urachal mucinous adenocarcinoma has a poor prognosis and may present as aT2-hyperintense suburothelial/extrinsic mass centered in the bladder dome. Other diseases may extrinsically involve the urinary bladder by hematogenous and peritoneal spread, including infection, endometriosis, and malignancy. A familiarity with suburothelial and extrinsic pathologies of the urinary bladder is critical for the radiologist, who may be the first to suggest these diagnoses.

Trends in surgical management of urachal anomalies

PurposeWe have noted an increasing frequency of diagnosed urachal anomalies. The purpose of this study is to evaluate this increase, as well as the outcomes of management at our institution over 10years. MethodsA retrospective analysis of urachal anomalies at our institution was performed. Inclusion criteria were Anomalies of Urachus (ICD 753.7) or Urinary Anomaly NOS (ICD 753.9) between January 2000 and December 2010. Exclusion criteria were having an asymptomatic urachal remnant incidentally excised. ResultsEighty-five patients (49 male, 36 female) presented between 0 and 17years of age (mean 1.5years). Diagnoses increased from 0 in 2000 to 21 in 2010. Zero was surgically managed in 2000 while 21 were managed in 2010 (p=0.0145). Fifteen patients (17.6%) were observed with 13 (13/15, or 15.3%) resolving without complication while 2 were operated on. Average time to resolution (clinical or radiologic) was 4.9months (Range: 0.4–12.6). A total of seventy-two patients (84.7%) underwent excision. Thirty-nine (54%) surgical cases were outpatient while 33 (46%) were admitted. Thirteen (18%) had post-operative complications. Ten (77%) of the complications were wound infections. Patients under 6months of age accounted for 60% (6 of 10) of all wound infections and 52% (17 of 33) of hospitalizations. ConclusionsOur experience and review of the literature suggest a high complication rate with surgical management in young patients, mostly from infections and support non-operative management of all non-infected urachal remnants in children.

The Youngest Korean Case of Urachal Carcinoma.

Urachal anomalies are relatively uncommon and result from incomplete obliteration of the urachus perinatally. In children, most urachal diseases including urachal cysts and sinuses are benign, and these can sometimes become secondarily infected. Malignant involvement of the urachus is rarely reported, one in 5 million people, accounting for 0.35% to 0.7% of all bladder cancers. There are only five cases of urachal cancer diagnosed at the age of twenties in English written literature. Age at the diagnosis of urachal carcinoma is important to understand pathogenetic transition from benign to malignancy. A 26-year-old man visited our clinic with gross hematuria starting a few months before. CT scan showed a 4.0 × 6.8 cm sized lobulated cystic mass over the bladder dome. Cystoscopy showed a ball-shaped extrinsic mass from the bladder dome with intact bladder mucosa. With an impression of urachal cancer, laparoscopic partial cystectomy with wide excision of urachus was performed. Final diagnosis was well differentiated mucinous urachal adenocarcinoma invading bladder muscle, staged as pT3a based on Sheldon's staging system. To our best knowledge, this case is the youngest Korean case of urachal carcinoma (the fourth youngest ever in English written literature).

A Comprehensive Review of Pediatric Urachal Anomalies and Predictive Analysis for Adult Urachal Adenocarcinoma

We examined the presentation, diagnosis and management of radiologically detected pediatric urachal anomalies and assessed the risk of malignant degeneration. Our radiology database (2000 to 2012) was queried for all children younger than 18 years who were diagnosed with a urachal anomaly radiographically, and the operative database was used to determine those who underwent excision. Data collected included demographics, presenting symptoms, imaging modality and indication for excision. These data were compared to the Ontario Cancer Registry to determine the risk of malignancy. A total of 721 patients were radiographically diagnosed with a urachal anomaly (667 incidentally), yielding a prevalence of 1.03% of the general pediatric population. Diagnoses were urachal remnants (89% of cases), urachal cysts (9%) and patent urachus (1.5%). Ultrasonography was the most common imaging modality (92% of cases), followed by fluoroscopy/voiding cystourethrography (5%) and computerized tomography/magnetic resonance imaging (3%). A total of 61 patients (8.3%) underwent surgical excision. Indications for imaging and treatment were umbilical drainage (43% of patients), abdominal pain (28%), palpable mass (25%) and urinary tract infection (7%). Mean age at excision was 5.6 years and 64% of the patients were male. Based on provincial data, the number needed to be excised to prevent a single case of urachal adenocarcinoma was 5,721. Urachal anomalies are more common than previously reported. Children with asymptomatic lesions do not appear to benefit from prophylactic excision, as the risk of malignancy later in life is remote and a large number of urachal anomalies would need to be removed to prevent a single case of urachal adenocarcinoma.

V3-13 ENTIRELY MINIMALLY-INVASIVE MANAGEMENT OF AN INFECTED URACHAL CYST IN THE PEDIATRIC PATIENT

You have accessJournal of UrologyPediatrics1 Apr 2014V3-13 ENTIRELY MINIMALLY-INVASIVE MANAGEMENT OF AN INFECTED URACHAL CYST IN THE PEDIATRIC PATIENT Christopher Jaeger and Candace Granberg Christopher JaegerChristopher Jaeger More articles by this author and Candace GranbergCandace Granberg More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1314AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Urachal cysts are the most common urachal anomaly in the pediatric patient population. Minimally-invasive approaches have become increasingly prevalent in management. We present an approach to entirely minimally-invasive management of a case of an infected urachal cyst utilizing percutaneous drainage and subsequent robot-assisted laparoscopic cyst excision. METHODS After initial ultrasound-guided percutaneous drain placement and culture-specific antibiotics, an adolescent male underwent delayed robot-assisted urachal cyst excision and partial cystectomy for an infected urachal cyst. The steps of this approach are demonstrated in this video, including (1) ultrasound-guided percutaneous drain placement; (2) placement of robotic ports; (3) identification of anatomic landmarks; (4) dissection of the urachal cyst and bladder from the anterior abdominal wall; (5) dissection of the cyst from the bladder; (6) removal of cyst with small cystotomy; (7) bladder closure in two layers; and (8) interrogation of closure with bladder distension. No perivesical drain was left. RESULTS The patient was discharged on postoperative day 1. A Foley catheter was left indwelling for three days and removed without need for cystogram. There were no complications and incisions were hidden within the umbilicus and at the level of the Pfannenstiel line, rendering the incisions non-visible when the patient wears a bathing suit. CONCLUSIONS Entirely minimally-invasive management of the pediatric infected urachal cyst including percutaneous drain placement and subsequent delayed robot-assisted laparoscopic urachal cyst excision with bladder cuff removal is simple, safe, and offers excellent cosmesis. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e425 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Christopher Jaeger More articles by this author Candace Granberg More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...