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Octavio A. Castillo, Gonzalo Vitagliano, Ruben Olivares, Rafael Sanchez-SalasComplete excision of urachal cyst by laparoscopic means: A new approach to an uncommon disorder

Archivos Espaoles de Urologa, vol. 60, nm. 5, junio, 2007, pp. 607-611,

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International Sectio

Arch. Esp. Urol., 60, 5 (607-611), 2007

COMPLETE EXCISION OF URACHAL CYST BY LAPAROSCOPIC MEANS:

A NEW APPROACH TO AN UNCOMMON DISORDER.

Octavio A. Castillo1,2, Gonzalo Vitagliano1, Ruben Olivares1and Rafael Sanchez-Salas1.

Santa Maria1and Department of Urology. School of Medicine, Universidad de Chile2. Santiago de Chile.

Correspondence

Octavio A. CastilloDepartment of UrologyClnica Santa MaraAvda Santa Mara 05007530234 ProvidenciaSantiago de Chileoctaviocastillo@vtr.net

Acepted for publication:

Summary.- OBJETIVE: Anomalies of the urachal rem-nant are rare. Urachal cysts are usually asymptomatic,however, when they become infected, they can mimic awide variety of intra-abdominal pathologies. We pre-sent two patients in which an urachal cyst was found.

METHODS: Two male patients 25 and 38 years oldrespectively underwent laparoscopic resection of an ura-chal remnant. In one of the cases the urachal remnantwas complicated by infection. Opportune clinical andradiologic diagnose was made in both cases and com-

plete excision of the urachal remnant was carried out bylaparoscopic means.

RESULTS: The procedures were performed without com-plications and follow up showed excellent results. Bothpatients presented very short convalescence with rapidrecovery.

Resumen.-Las anomalas del remanente de uraco soraras. Los quistes de uraco son generalmente asintomticos; sin embargo, cuando se infectan, pueden imitauna amplia variedad de patologas intraabdominalesPresentamos dos pacientes con quiste de uraco.

MTODOS: Dos pacientes varones de 25 y 38 aosrespectivamente, fueron sometidos a reseccin laparoscpica de remanentes de uraco. En uno de los casoel remanente de uraco se haba complicado con infeccin. En ambos casos se hizo el diagnstico clnico radiolgico adecuado y se llev a cabo escisin com

pleta del remanente de uraco por va laparoscpica.RESULTADOS: Las operaciones se realizaron sin complicaciones y el seguimiento mostr unos resultados excelentes. Ambos pacientes tuvieron una convalecenciamuy corta, con una rpida recuperacin.

CONCLUSIONES: El tratamiento de eleccin de la patologa de uraco es la escisin completa de la lesicomplicada. La ciruga laparoscpica asegura unoresultados quirrgicos comparables con la ciruga convencional, aadiendo las ventajas del abordaje mnmamente invasivo.

Keywords: Urachal cyst. Urachus. Cyst.Laparoscopy.

CONCLUSIONS: The treatment of choice for urachapathology is the complete excision of the complicatedlesion. For this matter laparoscopic surgery assures sugical results comparable to conventional surgery addingthe advantages of a minimally invasive approach.

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O. A. Castillo, G. Vitagliano, R. Olivares et al.608

MATERIAL AND METHODS

Two patients underwent laparoscopic surgeryfor urachal pathology at our institution.

Case N 1: A twenty-five year old male, with previous history of myelomeningocele, surgically treatedat 16 years of age, paraplegic, presented with feveand a lower abdominal mass. Patient had a diagnosis of neurogenic bladder in clean intermittent catheterism program. An abdominal ultrasound revealean infraumbilical cystic mass in continuity with thebladder. The CT-Scan confirmed the presence of acystic mass with heterogeneous content in continuitwith the bladder dome. A complicated urachal cyswas suspected. Laparoscopic abdominal exploratio

was performed.

Case N 2: A thirty-eight year old male with no pasmedical history was seen for an incidental cystic lesion of 1.9 cm found on a routine abdominal ultrasound. An abdominal CT-scan revealed a calcifie2 cm nodular image on the bladder dome (Figure 3)The patient requested surgery.

Surgical Technique

The patient is placed in a modified lithotomposition with the legs apart. The surgeon stands onthe left side of the patient. An assistant seated ibetween the patient legs simultaneously performs acystoscopy. Surgeon simultaneously views both thelaparoscopic and endoscopic fields. A three port technique is used. A 10 mm trocar is placed supra-umbilical for the 0 laparoscope and two paraumbilicatrocars, 10 mm on the right and a 5 mm on the lefare respectively placed (Figure 1). Using the combned cystoscopic and laparoscopic approach, partiacystectomy is performed. The bladder cuff is excisedin one piece with the urachus and umbilicus. Surgicamargins are controlled with cystoscopy. The bladdeis sutured transversally with a continuous intracorpo

real polyglactine 3-0 suture.

RESULTS

On the first case, surgery lasted 90 minutes with no bleeding. The mass was extracted in aplastic bag through an umbilical incision (Figure 2)Histologic analysis revealed a 12x6 cm mass whicincluded bladder wall and an infected urachal cystThe patient was discharged on post operative day 5and the urethral catheter was withdrawn on day 7During the 72 months of follow up no recurrence waevident.FIGURE 1. Three trocar approach.

Palabras clave:Quiste de uraco. Uraco. Quiste.Laparoscopia.

INTRODUCTION

The urachus is the embryological remnant ofthe allantois, which originally communicates with thevertex vesicae (the apex of the bladder) to the um-bilicus. During embryonic development the urachusstarts to obliterate in the 10 mm embryo, coming to acomplete fusion in the 16 mm embryo; in this phase,it separates from the umbilicus and then completelyobliterates, shortly after birth, giving rise to the me-

dian umbilical ligament (1).

Urachal defects are rare with urachal cystsbeing the most common anomaly occurring inapproximately 1/5,000 births. Usually urachal cystsare asymptomatic and manifest themselves only wheninfected.

The traditional approach for removing ura-chal remnant and for the treatment of complicated ura-chal cysts has been open surgery. This interventionis recommended over drainage of the abscess cavityand antibiotic therapy due to the risk of recurrenceand the potential for malignant change of the urachalremnant (2,3). However, open surgery is associatedwith increased morbidity and longer convalescence.Herein, we report our experience in the laparoscopicmanagement of urachal anomalies.

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COMPLETE EXCISION OF URACHAL CYST BY LAPAROSCOPIC MEANS: A NEW APPROACH TO AN UNCOMMON DISORDER.

On the second case, OR time was 75 minu-tes and the patient was discharged from hospital onpost operative day 5 without an indwelling urinarycatheter. Final pathological evaluation confirmed thepresence of a non-complicated partially calcified ura-chal cyst (Figure 4). There was no recurrence duringan 8 month follow-up.

DISCUSSION

The urachus is the embryologic remnant ofthe allantois and is found among the medial umbilicalligaments which in turn are remnants of the fetal um-bilical arteries.

The allantois appears for the first time in thfetus around day 16; as the bladder grows and descends to the pelvis, the distal allantois obliterates. During the fourth and fifth months of gestation the fetustretches and grows the distance between the vertevesicaeand the navel. The urachus or medial ligament turns into a fibrous cord originating in the vescal apex and extending to the navel, oscillating from3 to 10 cm in length and from 8 to 10 mm in diamete(1).

The incapacity for obliteration of the urachuis infrequent, but when it appears it is usually in infancy, clinically important anomalies have an incidenceof 2 in 300,000 births (4).

Urachal anomalies can be divided into congenital and acquired (5). Congenital anomalies manifest themselves as loss of urine through the naveand cause a persistence of the permeability of theurachus or the bladders impossibility to descend tothe pelvis. The acquired anomalies appear when thurachus closes after birth and reopens later due topathological factors.

Urachal cysts arise out of desquamation anddegeneration of the urachal epithelium. The smaconnection existing between the urachus and thbladder can clear the way for a bacterial infectiowhich becomes manifest with fever, abdominal paiand may even resemble an acute abdomen, a palpable abdominal mass or a urinary infection (6). Thcomplications of infected urachal cysts include rupture in the peritoneal cavity leading to an inflammatorinvolvement of the adjacent intestine and necrotizing

60

FIGURE 2. Mass extracted in a plastic bag through theumbilical incision.

FIGURE 3. An abdominal CT-scan reveals a calcified 2cm nodular image on the bladder dome. CUC- calci-

fied urachal cyst. B- bladder.

FIGURE 4. Partially calcified urachal cyst. The complete surgical specimen includes umbilicus (U), calcified

urachal cyst (CUC) and bladder cuff (BC).

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O. A. Castillo, G. Vitagliano, R. Olivares et al.610

Author

NeufangT.

1992

SiegelJF

1994

JorionJL.

1994

StoneN.

1995

CadedduJ.

2000

YamadaT.

2001

YohannesP.

2003

CastilloO.

2005

Sex F F F M 3

F1M F F M M

Age 28 18 57 21 4

3.3(mean)

48 16 25 38

Presentingsymptom

Trainingsinus

attheumbilicus

Infection

Infection

Infection

Acutesuprapubic

painandfever

Abdominaltumor

Umbilicaldischarge

Abdominalpainandfever

Incidental

Surgery

Laparoscopicexcision

ofurachalremnant

Laparoscopicexcision

ofurachalremnant

Laparoscopicexcision

ofurachalremnant

Laparoscopicexcisionofsinusandcyst,

bladderclosurewithstapler

Laparoscopicradicalexcisionof

urachalremnantinallcases

Laparoscopicremovalanterior

abdominalwallmass

Laparoscopicradicalexcision

ofurachalsinus

Laparoscopicexcisionofurachal

remnantinbothcases

Pathology

Urachalcyst

Urachalcyst

Urachalcyst

Urachalcyst

Urachalcyst

Urachalcyst

Urachalsinus

Infectedurachalcyst

Urachalcyst

Complicat

ion

None

None

None

None

None

None

None

None

TABLEI.TO

DA

TEREPORTSON

LAPAROSCOPICEXC

ISIONOFCOMPLICATEDURACHALR

EMNANTSIN

ADULTS.

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COMPLETE EXCISION OF URACHAL CYST BY LAPAROSCOPIC MEANS: A NEW APPROACH TO AN UNCOMMON DISORDER.

fasciitis which is a rare complication usually seen inchildren (7-9).

The presence of an urachal cyst must bealways suspected when localized supra-pubic painis associated with micturition disorders, even withsterile urine. Cases have been reported of patientswith infected cysts which were mistakenly diagnosedas acute appendicitis, ovarian torsion or complicatedMeckels diverticulum (10).

The location of the urachus on the inferior ab-dominal wall makes diagnosis of the cyst easier bymeans of ultrasound and tomography (11). Compu-ted tomography can ease diagnosis of urachal ade-nocarcinoma and also show specific characteristics

associated with pyourachus (12).

Complicated urachal cysts usually warrantsurgical treatment, but initially conservative manage-ment can be attempted (5). A 30% of recurrence isseen when complicated urachal cysts are managedconservatively by means of drainage and antibiotictherapy (13). Therefore the treatment of choice is acomplete excision of the lesion with a partial cystec-tomy of the bladder apex.

There have been few reports on laparoscopicexcision of urachal abnormalities (2,14-18). (Table I).

The scarce number of cases published andthe absence of perioperative and convalescence datafor incisional urachal surgery limit the comparisonbetween the open and laparoscopic approaches.We believe that the outcomes described in this reportmay help favor the laparoscopic approach over theconventional incisional approach in the managementof urachal pathology.

CONCLUSIONS

Clinical diagnosis and treatment of urachal

pathology is often delayed due to non specific signs.The use of ultrasound and computed tomography isfundamental so as to obtain a prompt and precisediagnosis. The treatment of choice is the completeexcision of the complicated lesion. For this matterlaparoscopic surgery assures surgical results compa-rable to conventional surgery adding the advantagesof a minimally invasive approach.

MOORE, K.L.: The developing Human, 2nd Edition

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CADEDDU, J.; BOYLE, K.; FABRIZIO, M. et al: La

paroscopic management of urachal cysts in adulthood

J. Urol., 164: 1536, 2000.

NAVARRETE, S.; SANCHEZ-ISMAYEL, A.; SAN

CHEZ-SALAS, R.E. et al: Treatment of urachal ano

malies: a minimally invasive surgery technique. JSLS

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STERLING, J.A.: Lesions of the urachus which ap

pear in the adult. Ann. Surg., 137: 120, 1953.

BERMAN, S.M.; TOLIA, B.M. et al: Urachal rem

nants in adults. Urology, 31: 17, 1988.

MACNEILY, A.E.; KOLEILAT, N.; KIRIULUTAH.G. et al: Urachal abscesses: protean manifestations

their recognition and management. Urology, 40: 530

1992.

IUCHTMAN, M.; RAHAV, S.; ZER, M. et al: Mana

gement of urachal anomalies in children and adults

Urology 42: 426, 1993.

HORGAN, P.G.; JOHNSON,S.; COURTNEY, D.: In

traperitoneal rupture of infected urachus. BJU Int, 73

216, 1994.

OCONNOR, J.; BIYANI, C.; AUSTIN, O. et al: Ne

crotizing fasciitis: a rare complication of an infecte

urachal remnant in adults. J. Urol., 170: 920, 2003.

BLICHERT-TOFT, M.; NIELSEN, O.: Congenital pa

tent urachus and acquired variants. Act. Chir. Scand

137: 807, 1971.ROBERT, Y.; HENNQUIN, C.; CHAILLET D.: Ura

chal remnants: sonographic assessment. J. Clin. Ultra

sound, 24: 339, 1996.

HERMAN, T.E.; SCHACKELFORD, G.D.: Pyoura

chus CT manifestations. J. Comput. Assist. Tomogr

19: 440, 1995.

MARMOL, S.; GUADALAJARA, J.; CANCELO, P

Quiste piouracal. Arch. Esp. Urol., 45: 1034, 1992.

NEUFANG, T.; LUDTKE, F.E.: Laparoscopic exci

sion of an urachal fistula new therapy for a rare disor

der. Min Invasive Ther. 1:245, 1992.

JORION, J.L.: Laparoscopic removal of urachal cyst

J. Urol., 151: 1006, 1994.

SIEGEL, J.F.; WINFIELD, H.N.; VALDERRAMA

E.: Laparoscopic escisin of urachal cyst. J. Urol., 1511631, 1994.

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(*of special interest, **of outstanding interest)

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