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Delayed Laparoscopic Assisted Treatment of Complicated Urachal Cysts in Children: Report of two Cases

Mirko Bertozzi, Niccolo Nardi, Marco Prestipino and Antonino Appignani
Clinica Chirurgica Pediatrica – Universita degli Studi di Perugia
Ospedale S. Maria della Misericordia
Perugia, ITALY

 

Correspondence

Mirko Bertozzi MD
Clinica Chirurgica Pediatrica - Universita degli Studi di Perugia
Ospedale S. Maria della Misericordia
S. Andrea delle Fratte, 06100 Perugia – ITALY
Tel : +39-075-5783376; Mob: +39-339-3196807; Fax : +39-075-5782492
E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

 

Abstract

Urachal remnants are rare congenital anomalies generally treated by open surgery. In the last decade laparoscopic treatment of these anomalies became more frequent. The authors present an alternative operative technique never reported before for treatment of complicated remnants in two children with complicated urachal cysts. A laparoscopic assisted radical excision was performed easily via an umbilical incision. Operative time was 90 minutes in the first case and 40 minutes in the second one. Intra- or post-operative complications and recurrences did not occur and the cosmetic results were very good. Laparoscopic assisted surgery for complicated urachal cysts is reliable, diagnostic and therapeutic at the same time and allows a radical excision with all of this procedure advantages.

Key words: cysts, infected, laparoscopic-assisted surgery, urachal remnants, urachus

 

 

Introduction

Urachal remnants (URs) are manifestations of an incomplete regression that may occur at various levels of the urachus, therefore we may have different types of remnants like cyst, sinus tract, diverticulum or patent urachus.

Clinical presentation of symptomatic urachal remnants includes abdominal pain, periumbilical inflammation and umbilical spillage. Traditionally these anomalies are treated by open surgical excision but in the past 10 years laparoscopy had a major role. We report two cases of complicated urachal cyst (UC) treated by laparoscopic assisted surgery.

Case 1

 A 7 year old boy with a history of bilateral inguinal hernia and distal hypospadias repair was referred to our Department for fever, abdominal pain and stranguria. Clinical examination showed hypogastric pain. Blood tests demonstrated leukocytosis and urine analysis was negative. The ultrasonography (US) revealed a complicated cystic mass of 4 cm of diameter just upon the bladder roof probably due to a complicated UR. Subsequent computed tomography was not useful to clarify the diagnosis. Oncological markers taken were negative. Intravenous antibiotic therapy was promptly administered and 3 days later symptoms disappeared. Two more days later the child underwent the operation. A previous cystoscopy was performed that demonstrated that the roof of the bladder was imprinted by external mass with mild signs of inflammation of the mucosa ( fig. 1). Laparoscopy was performed: a 10 mm laparoscope was introduced through the umbilicus by “open” technique: an infected supravesical UC was found ( fig. 2).

urachal cysts 1 urachal cysts 2
Fig. 1 Case 1: cystoscopic image of the imprinted bladder’s roof Fig. 2 Case 1: laparoscopic image of urachal cyst

Two 5 mm working trocars in left and right upper abdominal wall were placed to isolate the cyst. An accurate and complete laparoscopic excision of the cyst from the bladder was impossible due to infection; so it was exteriorized via the umbilical incision ( fig. 3) and excised. Muscular layer of bladder was closed with a 3/0 running absorbable suture. A new pneumoperitoneum was created to check the filled bladder and the haemostasis. The operative time was 90 minutes. Vesical catheter was removed in the third postoperative day and the child was discharged the same day. Histopathological assessment confirmed the diagnosis of infected UC. At 3 years and 2 months follow up no postoperative complications or recurrences occurred. 

urachal cysts 3

Fig. 3 Case 1: urachal cyst exteriorized through the umbilical incision 

Case 2

A 10 month old infant was referred at our Department for omphalitis and umbilical spillage. Intravenous antibiotic therapy was administrated and a US was performed that showed a suspected infected urachal cyst close to the umbilicus. Cystography was not helpful to clarify the continuity between the bladder and the suspected remnant.

Once omphalitis and umbilical leakage were resolved (3 days) we decided to submit the patient to a diagnostic laparoscopy. A 5 mm laparoscope was inserted in the right low abdominal wall and it showed an infected urachal cyst close to the umbilicus ( fig. 4). Radical excision of the cyst was done through a 10 mm umbilical incision. The operative time was 40 minutes. Vesical catheter was removed the day after the intervention and the infant was discharged in the second postoperative day. No postoperative complications or recurrences was seen at 2 years and 8 months follow-up

urachal cysts 4

Fig. 4 Case 2: laparoscopy shows the presence  of urachal cyst close to the umbilicus 

 

Discussion

The urachus is an allantoic remnant located between the umbilicus and the roof of the bladder. Usually, the lumen obliterates itself during fetal life and produces the median umbilical ligament. The URs are rare (1:5000 live birth) [1] and develop from an abnormal persistence of the lumen. URs may be associated with other anomalies like hypospadias, meatal stenosis, vesico-ureteral reflux, ureteropelvic obstruction, crossed renal ectopia, umbilical and inguinal hernias, cryptorchidism, anal atresia and omphalocele [2-4]. Clinical manifestations of persistent URs are rare and may be represented by local signs and symptoms of infection with or without laboratory evidence but usually these anomalies are diagnosed incidentally [4,5]. The most frequent manifestations of infected URs are periumbilical inflammation, umbilical spillage, abdominal pain and recurrent urinary tract infections. Diagnosis is accomplished with clinical examination, US and computed tomography. Additional diagnostic studies, including voiding cystourethrogram, generally are not necessary [6], although Yiee et al. reported the relevance of this radiological examination for the diagnosis of patent urachus [7].

URs are treated surgically because of their potential infection and even for malignant degeneration. [8]. Even if in case of infected URs some authors suggest a staged approach [3, 9], in our two cases we prefer to treat the cysts administrating an aggressive intravenous antibiotic therapy [6] for few days till the end of symptoms and performing a delayed laparoscopic assisted excision. In this way no recurrence or wound infection was seen.

Traditionally the excision of the URs is performed via open but in the last 10 years laparoscopic excision has become more frequent. Laparoscopic approach to URs may be different: camera port may be inserted in different abdominal sites [1, 9, 10].

In the first case we decided to insert the camera port through an umbilical incision, because the suspected infected UC was close to the bladder roof and the others two operative ports were inserted in left and right upper abdominal quadrants respectively. In the second case we preferred to insert the camera port in the right inferior abdomen since the infected cyst was very close to the umbilicus. We decided for different camera port sites to obtain an optimal view of the UCs in both cases without any section of vesical ligament as described by Turial et al. [19]. In the first case a laparoscopic isolation of the cyst was done but the excision from the bladder was very difficult because of the strong adherences between the cyst and the bladder due to the previous infection; therefore we exteriorised the cyst via the umbilical incision and the complete open excision was easily accomplished. The dissection of the cutaneous portion of UR was done through the umbilical incision.

In the second case we used laparoscopy to confirm the US diagnosis. Once the laparoscopic diagnosis was established, excision of the cyst via a small subumbilical incision was accomplished.

Conclusions

Laparoscopic assisted surgery for infected UCs is safe, diagnostic and therapeutic at the same time and may be an alternative approach to the laparoscopic one. In our small experience aggressive antibiotic therapy and delayed laparoscopic assisted excision of infected urachal cysts is effectiveness with all the advantages of laparoscopic surgery.

 

 

 

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