Investigation of preinguinal approach for removal of urachal abscess in three Japanese black cattle older than 18 months of age.

This study investigated the diagnostic and surgical management of urachal abscessation involving the urinary bladder in three cattle aged >18 months. While the abdominal floor or paralumbar fossa are typically considered for accessing the urachus and bladder in calves and heifers, the distance is too great to perform the procedure under direct vision in adult cows. Therefore, a novel preinguinal approach was used for access in cows with urachal abscesses after 18 months. Access was successfully achieved in all the three cows through a preinguinal incision to the urachal abscess at the apex of the bladder. However, in cases wherein the abscess and adhesions are severe, removal may be challenging or may necessitate a combined median or paramedian approach.

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.

A Giant Urachal Accessory Spleen: Case Report.

Accessory spleen (AS) refers to single or multiple splenic tissues which appear outside the relative normal spleen position results from embryonic dysplasia similar in structure and function to the spleen. AS is frequently observed in the splenic hilus and or adjacent to the tail of pancreas, and only a few cases occurred in the pelvic cavity. We present an extremely rare AS case in urachus, which was initially considered as an urachal neoplasm revealed on CT images with big mass. However, the postoperative pathology confirmed it was an AS that had not been reported at urachal before. Urachal AS can be misdiagnosed as a tumor, so it is vital to make an accurate imaging preoperative diagnosis to avoid unnecessary biopsy and surgery.

Transperitoneal laparoscopic umbilical resection of urachal remnants: a feasible surgical method.

BACKGROUND: To date, there is no standard established laparoscopic surgical method for managing urachal remnants because of their rarity, and several questions remain unanswered. Are there any problems for considering the operative indications about patients' factors for example, body mass index and so on? This study aimed to determine the feasible surgical method for managing urachal remnants and presents the operative outcomes of our cases in relation to the findings from the existing literature. METHODS: We analyzed the data of 16 patients (7 women and 9 men; age range, 19-48 years) who underwent surgery for urachal remnants between January 2013 and March 2019 at our institution. RESULTS: In our cases, all urachal remnants were urachal sinuses, and the primary complaints were umbilical pain and pus discharge. Most of these symptoms were controlled using umbilical drainage and oral antibiotic intake; however, incisional drainage was required in two cases. In all cases, we performed a laparoscopic resection of the urachal remnants; one patient underwent an open conversion due to a very thick abdominal wall. Therefore, "peri-umbilical distanse" was proposed as an index to verify the periumbilical abdominal wall thickness. This index may clear the difficulties of the laparoscopic resection of the urachal remnunts. A postoperative complication-local infection that was treated using re-suturing-was observed in one patient. No adverse events occurred in the other cases. Our method was appropriate because it allowed for complete urachal resection with good cosmetic results, i.e., a small and natural scar appearance. Additionally, if bladder injury occurred, bladder re-suturing was easily possible because of the laparoscopic port's position. CONCLUSIONS: We present an feasible method for laparoscopic urachal resection. This method may be recommended for young patients with an peri-umbilical distanse of < 2 cm.

Surgical treatment of urachal remnants in an adult population-a single-centre experience.

BACKGROUND: Urachal remnants are a rare congenital defect resulting from failure of obliteration of a fibrous tube that connects the umbilicus to the bladder dome during embryological development. Oftentimes a urachal remnant will go undiagnosed, but occasionally a patient may present with a variety of symptoms, ultimately leading to the identification of the remnant. Given its rarity, there is very limited literature available on the management of symptomatic urachal remnants, especially in adults. Surgical resection has been the first-line management of urachal remnants for years, especially given the risk of the development of urachal adenocarcinoma secondary to recurrent infection, persistent irritation, and urinary stasis associated with some urachal remnants. AIM: We present our experience in the management of symptomatic urachal remnants in adults at our institute and perform a brief literature review of the same. METHODS: A retrospective review of all cases who underwent surgical management of symptomatic urachal remnants between December 2015 and January 2022 was performed. Seven cases of urachal remnant excision in total were identified over the time period. Patient characteristics and perioperative parameters were analysed. Post-operative complications were measured in accordance with the Clavien-Dindo grading system. RESULT: In total, 7 cases of urachal remnants were treated at our institute over the study period. Four patients were treated with a TURBT and 3 patients were treated with a laparoscopic partial cystectomy. There were no intraoperative complications and one post-operative complication requiring readmission for intravenous antibiotics. There was one mortality but this was not as a direct result of the operative procedure. Mean length of stay was 1.71 days. Two of patients had histologically confirmed urachal adenocarcinoma and the remaining five patients had benign histology. Each patient was seen in the outpatients department 6 weeks post-operatively for clinical review and review of histology. No further follow-up was required for the patients with benign histology given resolution of symptoms and follow-up for the malignant histology was arranged appropriately following MDM. CONCLUSION: There is a paucity of data available on the management of urachal remnants in the adult population; however, an endoscopic or laparoscopic approach is a safe and effective method of excising symptomatic urachal remnants.

Transumbilical Reduced-port Laparoscopic Urachal Resection for Pediatric and Adolescent Patients.

BACKGROUND: Port placement in laparoscopic urachal resection has not yet been standardized. We herein report an approach for transumbilical reduced-port laparoscopic urachal resection for pediatric and adolescent patients. METHODS: We retrospectively reviewed the outcomes of pediatric and adolescent patients for urachal remnant treated with reduced-port laparoscopic urachal resection from 2016 to 2020 in our department. Regarding our surgical procedure, a skin incision was made around the umbilicus, and the urachus was dissected partially under direct vision. Two transumbilical 5 mm ports and a 3.5 mm port in the right lateral abdomen were placed. In the laparoscopic view, the urachus was dissected from the abdominal wall and resected at the bladder dome. The defect of the peritoneum was closed by suturing. RESULTS: Sixteen patients underwent the procedure. The median patient age was 12.5 years old. Surgery was performed by trainee surgeons in all patients without intraoperative complications or conversion to open surgery. The median postoperative hospital stay was 2 days. CONCLUSIONS: Our transumbilical reduced-port laparoscopic urachal resection technique has advantages in terms of safety, operability, and cosmetic appearance.

Giant umbilical cord in a normal preterm infant: a case report and review of the literature.

BACKGROUND: Giant umbilical cord, defined as a cord diameter of more than 5 cm, is an extremely rare malformation. There are few case reports of giant umbilical cord often associated with patent urachus duct or cystic malformation. These cases are usually managed by surgical excision and repair of patent urachus or cyst resection. CASE PRESENTATION: We report the case of a 1-day-old Iranian boy with giant umbilical cord detected postnatally. The pregnancy course was uneventful, except for preterm premature rupture of the membrane and preterm delivery. There was no relevant family history. The patient was delivered by vaginal delivery with a good Apgar score. On clinical examination, the umbilical cord was very thick (about 6 cm in diameter), and huge fluctuating Wharton's jelly was observed. Other organs were normal. During the hospital stay, the patient did not develop any complications except borderline hyperbilirubinemia, which improved with conventional phototherapy. Since the umbilical cord had no discharge and was dried, the newborn was discharged with advice for cord drying care. CONCLUSION: The newborn was well, and the dried umbilical stump was detached after 32 days, leaving a granulomatous structure without discharge. The patient was followed up for 4.5 months and had no problems except delayed separation of the umbilical cord.

A novel extraperitoneal approach exploration for the treatment of urachal mass: a retrospective observational single-center study.

BACKGROUND: To explore the extraperitoneal laparoscopic urachal mass excision technique and its safety and efficacy in treating urachal mass. METHODS: Baseline characteristics were collected from patients who underwent surgery to diagnose a urachal cyst or abscess in our hospital between January 2020 and August 2021. The full-length of the urachus and part of the top bladder wall were completely removed through the extraperitoneal approach. Patient outcomes were collected to evaluate surgical safety and efficacy, including operation time, intraoperative blood loss, drainage tube removal time, length of stay (LOS), and postoperative complications. RESULTS: All 20 surgeries were successfully performed laparoscopically, and no case was converted to open surgery. The mean body mass index of the patients was 24.6 ± 2.2. The mean patient age was 49.3 ± 8.7 years. The mean size of the cysts was 3.0 ± 0.4 cm. The mean operation time was 56.3 ± 12.0 min. The mean intraoperative blood loss was 28.0 ± 6.4 mL. The mean drainage tube removal time was 3.0 ± 0.5 days. The mean LOS was 5.2 ± 0.4 days. The mean follow-up was 13.4 ± 2.1 months. No postoperative complications were observed during the follow-up period. The short-term follow-up and small patient cohort limited our outcome evaluation. CONCLUSION: Our results indicated that the extraperitoneal laparoscopic approach was a safe and effective method to treat urachal mass. Given the limitations of the study, further multiple and larger sample-sized trials are required to confirm our findings.

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.

[External-internal sigmoid-vesical fistula following sigmoid diverticulum perforation into the patent urachus]. / Naruzhno-vnutrennii sigmovidno-mochepuzyrnyi svishch kak oslozhnenie perforatsii divertikula sigmovidnoi kishki v nezarashchennyi urakhus.

A patient with external-internal sigmoid-vesical fistula is presented. The authors describe surgical intervention (urachus excision, removal of infiltrate with resection of bladder bottom and fistula-related segment of sigmoid). Surgical challenges due to localization of fistula and appropriate literature data are discussed.

[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.

Preoperative imaging contributes to pathologically complete resection of the urachal remnant by determining an appropriate surgical approach without unnecessary and excessive surgical invasion: a retrospective study.

BACKGROUND: The urachus is an embryonic structure that connects the bladder to the allantois during early embryonic development. Occasionally, it fails to disappear at birth, leading to a case of urachal remnant (UR). This study aimed to determine whether our policy for selecting an appropriate UR resection approach is valid. We performed preoperative imaging to examine whether UR continued toward the bladder apex. If so, the UR and bladder apex were excised using the trans-umbilical approach, in addition to laparoscopy, if necessary. If preoperative imaging indicated that the UR ended near the umbilicus, the UR from the umbilicus to the duct end was resected. Pathological evaluations were performed to determine the appropriateness of the surgical approach indicated by preoperative imaging. METHODS: We retrospectively reviewed pediatric patients with UR who underwent surgery between 2015 and 2021. Their background characteristics and surgical outcomes were evaluated. RESULTS: Twenty patients with UR were included (median age, 7 [interquartile range, 2-10.25] years). UR continued toward the bladder apex in 10 patients and ended near the umbilicus in 10 patients. Urachus tissue at the bladder site was observed when the UR and bladder apex were excised. When UR was resected from the umbilicus to the duct end, urachus tissue was not pathologically detected at the resection margin. CONCLUSION: Our policy results in complete resection without excessive surgical invasion.

Prenatally Ruptured Patent Urachus: A Case Report and Review of Literature.

Patent urachus is a type of urachal anomaly in which the urachus does not tail off but remains connected to the bladder in the umbilicus. The prevalence of patent urachus is very low. Herein, we report a case of patent urachus ruptured and exposed to amniotic fluid in utero. In this case, the size decreased after the second trimester, which was thought to be due to rupture in utero. After delivery, patent urachus was confirmed by inserting a foley catheter, which runs through a ruptured cyst on umbilical cord insertion. The day after delivery, the neonate underwent surgical excision of the urachal cyst and closing umbilicus. The mechanism of patent urachus rupture is unknown. As the fetus matures, it is thought that the higher intravesical pressure may affect the rupture of the cyst. Patent urachus could be ruptured in the uterus spontaneously, and surgical correction is needed. Therefore, prenatal differential diagnosis is important.

Complications associated with patent urachus in starting of peritoneal dialysis.

Urachus is a tubular connection between the umbilical cord and the bladder of developing foetus and tends to degenerate during perinatal period to form an impatent median umbilical ligament. Failure to degenerate results in patent canal between the bladder and the umbilicus called "patent urachus" which may lead to serious of symptoms such as umbilical discharge, dermatitis, umbilical infection, abdominal pain or recurrent urinary tract infections. The Tenckhoff catheter is a tube used to perform peritoneal dialysis that is inserted through abdominal wall into peritoneum either by open surgery, minilaparotomy, laparoscopy or needle-guidewire technique. A CASE REPORT: A 57-years old man was admitted to the hospital after implantation of Tenckhoff catheter by percutaneous technique in order to start peritoneal dialysis treatment. His medical history was: endstage chronic kidney disease (diabetic nephropathy), type 2 diabetes and hypertension. After the infusion of dialysate the patient experienced sudden urine pressure and passed significant amount of urine. The CT scan showed the tip of catheter being placed inside the urinary bladder. The catheter was introduced through the abdominal wall into the canal of previously undiagnosed patent urachus. The decision about re-surgery was made to stitch urachal remnants and place new the Tenckhoff catheter. Awaiting the surgery patient temporary started hemodialysis. In ongoing observation patient did not present any complications associated with peritoneal dialysis treatment.

Current management of the urachal anomalies (UA). Lessons learned from the clinical practice.

PURPOSE: It has been suggested that symptomatic UA requires surgical excision. However, the management of asymptomatic urachus is still controversial. We aimed to evaluate the clinical presentation, the efficacy of current modalities used, and postoperative pathology in patients with UA. MATERIALS AND METHODS: We have performed a retrospective review of all patients diagnosed with UA and treated surgically or conservatively over 18 years. Demographic data, clinical presentation, imaging modalities, pathology, treatment, and postoperative complications were analyzed. RESULTS: Twenty-five symptomatic patients (18 males and seven females) with a median age of 13 years (1 month to 37 years) were identified. 15 (60%) were diagnosed with a urachal cyst, 4 (16%) with sinus, 3 (12%) with urachal diverticulum, and the remaining 3 (12%) with patent urachus. Of those, 20 (80%) underwent surgical repair, and the remaining five (20%) patients were managed conservatively. 4 (20%) underwent laparotomy, 7 (35%) laparoscopic incision, and the remaining 9 (45%) laparoscopic robotic-assisted surgery. Nine patients required bladder cuff excision. The median operative time was 75 min (42-140 min). One patient developed Clavien-Dindo grade IIIA complication resulting in infected hematoma, which resolved after drainage. Another patient with a complication of grade IIIB needed reoperation as a result of recurrent events of an abscess. 13 (65%) demonstrated epithelium lining of the urachus on postoperative pathology. CONCLUSIONS: Our data show that most of the patients with UA presented with epithelial lining, which might lead to the later malignant transformation. It might cause a shift from the conservative management of asymptomatic patients to surgical intervention. Robotic-assisted surgery appears beneficial in these patients, especially when the bladder cuff excision is required.

Prevalence of urachal remnants in children according to age and their anatomic variants.

PURPOSE: The aim of this study was to elucidate the prevalence of urachal remnants in children in relation to patient age as well as to identify their anatomic variants, using a laparoscopic view. METHODS: The medical records of 394 pediatric patients who underwent laparoscopic inguinal hernia repair were reviewed. Patients were divided into four groups based on their age at surgery. Using laparoscopic visualization, the presence and anatomic variants of urachal remnants were analyzed. RESULTS: A urachal remnant was confirmed in 140 children (35.5%). Although the prevalence was significantly higher in the group of children aged < 1 year (63.2%) than in any other group, no significant difference in the prevalence was observed between the groups aged ≥ 1 year. In 42 cases (10.7%), the urachal remnant merged into the lateral umbilical ligament. CONCLUSIONS: Our results suggest a recommendation of nonoperative management of asymptomatic urachal remnants, especially in patients less than 1 year of age due to its probable spontaneous resolution. Knowledge of the anatomic variants could improve the accuracy of diagnosis of urachal remnants and the comprehension of its structure and localization for the achievement of accurate and complete excision.