Management of urachal anomalies in pediatric patients: A comparison of treatment strategies between pediatric urology and general surgery.

INTRODUCTION: Persistence of embryonic urachal structures due to a failure of the urachus to involute into the median umbilical ligament is known as a urachal anomaly (UA). UAs may remain asymptomatic or lead to abdominal pain and recurrent infections. Management of UAs in pediatric patients has historically lacked a clear consensus between conservative and surgical management. While both urologists and general surgeons manage this pathology, a comparison of management style and outcomes between these specialties has not been published to our knowledge. OBJECTIVE: To (1) evaluate trends in management of UAs among pediatric urologists and general surgeons across three tertiary care children's hospitals and (2) identify factors that place patients at higher risk for requiring surgery. STUDY DESIGN: All patients diagnosed with a UA from 2016 to 2020 at our multi-site institution were identified by ICD-10 code Q64.4 "malformation of the urachus" and retrospectively reviewed. Patient demographics, treatment specialty, remnant subtype, and management strategy were recorded. Data was dichotomized between both urology and general surgery as well as between surgical and nonsurgical intervention to identify and compare management strategies. RESULTS: Overall, 143 patients diagnosed with UAs were identified. Of these patients, 74 were treated by urology and 69 were treated by general surgery. Patients who were treated by urology were significantly more likely to receive conservative treatment (66.2% treated conservatively vs. 33.8% treated surgically), while patients treated by general surgery were significantly more likely to undergo surgery (84.1% treated surgically vs. 15.9% treated conservatively, p < .0001). Though, urology was more likely to treat patients who presented incidentally (p < .01), and general surgery was more likely to treat patients who presented with an infected remnant (p < .01). Patients of male sex were more likely overall to receive surgery compared to female patients (p < .01). DISCUSSION: Management of UAs by urologists was more conservative than general surgeons. However, both specialties treat distinctly different patient presentations, with urology managing more incidental remnants and general surgery operating on more emergent, infected urachi. Limitations of the study included its retrospective nature and the insufficient reporting of urachal remnant subtypes and presence of infection among patients. CONCLUSIONS: Management strategies of UAs differ among urology and general surgery, but surgical and conservative treatments are necessary to appropriately treat their distinct patient populations. This study provides valuable insight into current practices of UA management and may help to inform future treatment.

Urachal Remnant Infection Caused by Actinomyces Turicensis.

BACKGROUND: Urachal remnants (URs) represent uncommon and underdiagnosed entities that are usually detected incidentally at imaging or present clinically different manifestations. METHODS: Here we presented a boy with UR infection. Ultrasonography and bacterial culture and identification were performed. He received antibiotic treatment and underwent surgical excision of the cyst. RESULTS: The patient presented with both a urachal cyst and umbilical-urachal sinus. UR infection was caused by Actinomyces turicensis. He recovered well from the operation without complications. CONCLUSIONS: The present case reminds clinicians to be familiar with imaging features of different types of URs and their potential complications and indicates the necessity of pathogenic microorganism analysis to tailor antibiotic treatment and post-operative follow-up to prevent complications.

Complicated urachal cyst in two pediatric patients: a case report.

BACKGROUND: A urachal cyst has a rare incidence that has been reported as 1/5,000 live birth. CASE PRESENTATION: We report two patients with a complicated urachal cyst, a 5-year-old female who presented to the emergency department with severe abdominal pain and a 3-year-old female presenting with abdominal pain and constipation. Upon laparoscopic exploration both patients had complicated urachal cysts which were adherent to the urinary bladder. CONCLUSION: Complicated urachal cysts can present with acute abdominal pain.

Prenatal Detection of Vesico-Allantoic Cyst: Ultrasound and Autopsy Findings.

Introduction: The vesico-allantoic cyst is a communication between the fetal bladder and the allantois through a patent urachus.Case Report: We describe a 17-week of gestational age (WGA) fetus with a 40 x 30 mm vesico-allantoic cyst. At 19 WGA, ultrasound (US) detected bilateral dilatation of renal pelvis (5-6 mm), hydroureters, and hypospadias. Amniotic fluid, umbilical cord flow, and fetal biometry were regular. Due to uncertain prognosis, the parents opted for legal termination of pregnancy. Autopsy confirmed the prenatal findings, also revealing intestinal malrotation and Meckel's diverticulum.Discussion/Conclusion: Probably an initial urinary tract obstruction occurred, not yet affecting the amniotic fluid volume, but evident as pyelectasis. This case highlights the possibility that genito-urinary and intestinal anomalies may be found in association with the vesico-allantoic cyst.

Dysuria, Rebound Tenderness, and a Palpable Mass-A Ticking Time Bomb.

A 37-year-old male presented to the emergency department with the complaint of periumbilical abdominal pain, radiating to just above pubic symphysis. The patient reported that the pain was worse with urination and associated with chills and nausea. This case reports discusses the Emergency Department (ED) course and subsequent treatment of a patient found to have an infected urachal cyst, a previously asymptomatic embryological anomaly in an otherwise healthy middle-aged adult male. This is a crucial diagnosis to make in order to avoid the potential for significant morbidity and/or mortality, given the unlikely symptomatic source.

Urachal remnants: from embryology to clinical practice.

The urachus is a tubular structure that is apparent on the third week and connects the ventral cloaca to the yolk sac, as a progression from the allantois. Following the normal regression procedure, the urachus remains as the median umbilical ligament. Urachal remnants are present in 1.03% of paediatric patients while in 92.5% of cases represent incidental findings. Urachal anomalies are classified in four types as patent urachus (50-52%), urachal sinus (15%), urachal cyst (30%) and urachal diverticulum (3-5%). Ultrasound scan is the most commonly performed diagnostic imaging study. In case of symptomatic urachal remnants, surgical excision is indicated. Asymptomatic urachal remnants that are diagnosed at the neonatal period or early infancy should be watched up to 6 months of age, as they are likely to resolve. In persistent or symptomatic urachal remnants there is a risk of inflammation or even malignancy development, therefore we believe that there is indication for preventive surgical excision that may be performed either open or laparoscopically or by robot-assisted laparoscopy.

[Urachal remnant and acute abdomen: when it's not what it seems].

Among the causes of acute surgical abdomen, infection of a urachal remnant may go unnoticed despite routine complementary studies. We present three cases in boys aged 11, 6, and 4 years who were brought to the emergency department for right iliac fossa pain, fever, and urinary symptoms. Examination and complementary tests results were compatible with acute complicated appendicitis and were sent to surgery. While in the operating room, appendicitis was excluded and inflammatory changes suggestive of infection of the urachal remnant were documented. Complications of urachal remnants should be considered in the differential diagnosis of acute surgical abdomen, since advanced infection of the urachus may be a cause of confusion. A more accurate presumptive diagnosis can change the therapeutic/surgical approach and follow-up.

Urachal Actinomycosis Presenting with Recurrent Urinary Tract Infections in a Middle-aged Woman: A Rare Case Report.

The urachal cyst, a remnant of allantois sac during embryogenesis, is a rare condition in adulthood. Urachus is an embryologic remnant degenerating after birth. Abberrant obliteration of the urachus causes urachal abnormalities. The urachal cysts are almost always symptomatic when infected. The symptoms include fever, abdominal pain, tenderness, lower abdominal mass, nausea, vomiting, and dysuria. Ultrasonography, computerised tomography, and magnetic resonance imaging techniques may be insufficient for diagnosis. In most cases, staphylococcus species are isolated from cultures of urachal cysts. Other microorganisms such as Escherichia coli, Enterococcus faecium, Klebsiella pneumonia, and rarely actinomyces may be isolated. Actinomyces, an anaerobic gram-positive filamentous bacterium, is a rare cause of granulomatous disease. In this case report, a 56-year woman with urachal cyst infection with actinomyces is discussed according to current knowledge. Key Words: Urachal cyst, Urachus, Chronic cystitis, Actinomyces.

[Three cases of urachal cyst in adults]. / Quistes de uraco en adultos. Presentación de 3 casos y revisión de la literatura.

The urachus is a thick fibrous cord that appears in the fifth month of pregnancy as a result of the allantois obliteration. Urachal cysts occur as a result of a defect in the obliteration of the duct, anomaly detected mainly in children and very rarely in adults. We present three cases of urachal cysts in adults, one of them detected during the study of abdominal pain and the other two, found incidentally during the study of other pathologies. In any case the possibility of urachal cysts was clinically suspected. Histologically, these lesions are lined by epithelium of urothelial type with expression of CK7, CK20, CK5/6, P63 and GATA3. The diagnosis of urachal cysts certainty lies in the histopathological study where the morphology, immunohistochemistry and a proper clinical-pathological correlation, allow to differentiate it from other more frequent abdominal cystic lesions in adults.

Posterior urethral valves and urachal cyst: an unusual combination.

Combination of posterior urethral valves and urachus remnants has been described as rare occurrence. We report a case of a baby boy with normal antenatal scans, in whom the presence of large urachal cyst and posterior urethral valves causing high pressure bladder and chronic kidney disease was found. The patient underwent ablation of posterior urethral valves at 23 days of life and urachal cyst removal at age of 4 and a half months.

A rare urachal abscess in a young bull with conservative management.

Background: The urachus is an embryonic remnant occurring as a result of the involution of the allantoic duct and the ventral cloaca. This canal becomes progressively obliterated after birth. It uncommonly persists to different degrees after birth. Case Description: A young bull was presented with distended abdomen and clinical signs of chocking, with low-grade fever, loss of appetite, frothy mouth arched back. On the first inspection, the animal was suspected to have simple indigestion. The treatment was attempted in this stage by introducing a stomach tube but only little relief was achieved. Therefore, 5 days later, an exploratory laparotomy was done and a big balloon-like cyst structure extended ventro-latrally in the abdominal cavity was noticed. That structure was located on the floor of the abdominal cavity extending from the pelvic rim caudally to the umbilical region cranially. The structure was then incised and evacuated and a rubber tube was fixed for constant drainage for up to one month later. The bull was followed-up and made a good recovery after a month post-surgery. Conclusion: We found that urachal abscess could be treated simply via surgical evacuation of the abscess and proper drainage for some time with a very promising outcome. Additionally, this affection can be diagnosed based on history, clinical signs, and exploratory surgery, when relatively modern diagnostic techniques are not available.

Case of Infected Urachal Cyst in an Adult Presenting as an Incarcerated Umbilical Hernia.

The urachus is a remnant of the allantois. Failure to obliterate can result in one of four anomalies, urachal cyst being most common. Urachal cysts are relatively rare, especially in adults. This paper presents a patient with an umbilical hernia and a ruptured urachal cyst. A 39-year-old male presented with concern for umbilical hernia, but he also noted drainage. Computed tomography scan showed a urachal cyst and umbilical hernia. The urachal cyst was excised and umbilical hernia closed primarily. The incidence of an urachal cyst is unknown, but persists in roughly 2% of adults. Diagnosis is with ultrasound or CT scan. Management is excision due to risk of urachal carcinoma, which is present in over 50% of specimens. Review of literature did not reveal any other cases of a patient with both an urachal cyst and an umbilical hernia, thus making this case a unique presentation for this condition.

[Infected urachal cyst in an adult manifests as urosepsis]. / Infizierte Urachuszyste beim Erwachsenen, Manifestation als Urosepsis.

The following is a case of an 81-year-old male adult who presented to our emergency department with signs of urosepsis. The patient came with an indwelling urinary catheter due to benign prostatic hyperplasia. Extended diagnostic investigation demonstrated an infected urachal cyst as the cause of infection, which was surgically treated.

Evaluation and management of urachal remnants in children.

BACKGROUND: This study aimed to evaluate the diagnosis and treatment of pediatric patients with urachal remnants. METHODS: Medical records of patients diagnosed with urachal remnants between 2015-2019 were evaluated retrospectively. Age, gender, admission complaints, diagnosis, size of cysts, the complications that developed, and treatment modalities were recorded. RESULTS: The study population consisted of 15 cases including seven girls. Most of the cases were asymptomatic. The urachal remnants were detected by ultrasonography. The most common symptom in symptomatic patients was abdominal pain and umbilical discharge. Three patients required surgery and most of them were conservatively followed up. Complication, infection, and bladder rupture were observed in one case. CONCLUSIONS: Follow-up of patients with urachal remnants can be performed conservatively. The type of complaint and the presence of clinical and radiological regression (if any) are important for deciding the treatment during the follow-up. However, conservative follow-up is more prominent today, as shown in this study.

[A man with abdominal pain and pollakisuria]. / Een man met buikpijn en pollakisurie.

An 18-year-old male presented in the emergency department with abdominal pain since two days and complaints of pollakisuria. Laboratory results showed increased infection parameters and ultrasound revealed an abscess in the abdominal lower right quadrant. The patient underwent diagnostic laparoscopy. We found an infected cyst, most likely an infected urachal remnant considering its location and the histological findings in the resected tissue.

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

BACKGROUND: Rare 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. OBJECTIVES: Determine the incidence of symptomatic urachal remnants in patients presenting to the emergency department (ED), including common presenting findings and method of diagnosis. METHODS: A 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. RESULTS: There 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. CONCLUSIONS: Although 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.