Laparoscopic treatment of urachal cysts. Tunisian series of 28 cases

BEN AMEUR Hazem |

La tunisie chirurgicale - 2019 ; Vol 2019

Resumé

Introduction:The persistent patency of the urachus after birth is a rare anomaly. Lack of appropriate treatment exposes the patients to the risks of symptoms recurrence, infectious complications or adenocarcinomatous degeneration. . In the adult, the most frequent form is the cyst (30.7%) which is the result of a partial defect of obliteration of the urachus channel after the fifth month of gestation. The classical management of urachal remants consists in surgical resection by laparotomy. The purpose of this study is to determine the role of  laparoscopic surgery in the treatment of this pathology.

Material and methods:We performed a retrospective single-center studyof all patients managed for urachal cyst by a laparoscopic approach between January 2008 and December 2017.

Results:Twenty eight patients have been treated laparoscopically during the study period (19 girls and 9 boys).Mean age at surgery was 27 years old (range 19–40 years). Twenty-six patients were referred due to symptoms whereas 2 were discovered incidentally (by imaging exams). No case of conversion was noted.The mean surgical time of laparoscopic management was 50 minutes (range 40-90).Mean length of staywas 1.5 days. There were no early postoperative complications. Postoperative follow-up ranged from 6 to 24 (median: 15 months) with no evidence of recurrence.

Conclusion

Laparoscopiy is an interesting technique for management of urachal cysts: safe with nil morbidity and mortality; effective with very low rate of recurrence, aesthetic with preservation of the umbilicus.

Mots Clés

cyst, urachus, infection, laparoscopy

Introduction :

Urachus is the embryonal duct connecting the dome of the urinary bladder to the umbilical ring. Normally the lumen of this canal obliterates itself during fetal life and closes completely after birth giving rise a fibrous cord:the median umbilical ligament. Urachal remnant is a rare congenital anomaly which refers to a failure of this involution process.Different portions of the urachus may not be fully obliterated, however, which can lead to the formation of an urachal cyst, sinus, diverticulum, or patent urachus.

Urachal remnants (most commonly cysts) occasionally require intervention when they become infected and symptomatic. Intervention is recommended over drainage of the abscess cavity and antibiotic therapy to prevent the risk of recurrence and the potential for malignant transformation of the urachal remnant. Traditionally, urachal anomalies have been managed by open surgery with a lower midline laparotomy or hypogastric transverse incision.However, open surgery is associated with increased morbidity and longer convalescence.Laparoscopic surgery seems to be an interesting route for this intervention. We report our experience in the laparoscopic management of urachal cysts.

Article

Materials and Methods

Between January 2008 and December 2017, the records of patients that had been treated with laparoscopic surgery approach for urachal cysts at the Department of General Surgery, Habib Bourguiba’s Teaching Hospital, Sfax, Tunisia, were retrospectively reviewed. We excluded from this study urachal cancersand all other malformations of the urachus(sinus, diverticulum, or patent urachus).

The variables recorded were demographic characteristics of the patients (age,sex), their symptoms, preoperative imaging results (abdominal ultrasound (US) and computed tomography (CT) scan), operative time, hospital stay length,mortality, postoperative complications, and disease recurrence.

Surgical approach       

After the induction of general anesthesia, patients were placed in the supine position, in 25–30 degree Trandelenburg with the legs lightly spread and descended. A Foley catheter was inserted into the bladder. Which be distended partially or fully to assist with the exposition especially in the obese.The surgeon and the camera surgeon stand on the left side of the patient with the monitor at the footof the patient.The first trocar (10 mm), used for the passage of a camera 0 ° or 30° angled lens (according the surgeon’s preference), is inserted at the level of the umbilicus just medial to the left anterior axillary line via direct visualization through the trocar (fig 1) . Once the port is placed inside the peritoneal cavity, is created an appropriate pneumoperitoneum with CO2 pressures, which range from 10 to 12 mmHg according to the patient’s weight. Under direct vision, 5-mm trocars are placed similarly medial to the anterior axillary line at the level of the left anterior iliac spine and two fingerbreadths inferior to the costal margin with care taken to ensure adequate spacing between all three ports to avoid crowding of instruments and enable triangulation(Fig. 1).The urachus is usually easily identified midway between the umbilicus and the urinary bladder in the midline. Once identified the urachus we proceed with dissecting forceps and a combination of hook and monopolar scissors or ultrasonic scissors for the opening of the anterior parietal peritoneum and the dissection of the urachal remnant and adjacent tissues should be dissected off the transversalis fascia cranially until the umbilicus and caudally until the space of Retzius, where the urachal remnants insert into the dome of the bladder is clipped with 5-mm hem-o-lock and transected as close to the dome of the bladder as possible.

Results

This study included 28 patients treated with laparoscopic approach for urachal cysts in our hospital for a prevalence of 2.8 cases /year. There were nine men (32.1%) and nineteen women (67.9%) with a mean age was 27 years (range 19–40 years).

The most common presentation was a low abdominal infraumbilical mass seen in twenty one patients (75%) with or without fever. fifteen patients (53%) had a local abdominal pain and in only two patients (7.1 %), the urachal cyst was discovered incidentally on imaging exams for abdominal discomfort.

Abdominal Ultrasound was the initial imaging performed in all patients associated with CT scanning or MRI imaging if indicated. The most described radiological aspect is a median extra-peritoneal and infraumbilical fluid mass that is plated against the anterior abdominal wall.

All patients were operated on, using laparoscopic technique with 3 trocars in lateral position. Intraoperative findings were similar to imaging data. In all cases, a complete dissection of the cyst was performed by proceeding from the anterior abdominal cavity to the bladder dome. Laparoscopic excision was successfully completed in all cases without conversion. The ombilicus was preserved in all cases. The diagnosis of urachal cyst was confirmed in all cases by histopathological examination of resected specimens and no case of adenocarcinomatous degeneration was noted

The mean operating time was 50 min (range 40–90 min). No intra- or postoperative complications were noted. Mortality was nil. The patients were all discharged after 1.5 days (range, 1–2 days). Postoperative follow-up ranged from 6 months to 2 years (median 1 year and 3 months) with no evidence of recurrence.

Discussion

The urachus is a vestigial structure arising from the anterior bladder wall and extending cranially to the umbilicus, serves to excrete urine from the bladder via the umbilicus during the intrauterine life of a fetus [1,2]. Embryologically, the urachus is said to arise as a result of the separation of the allantois from the ventral cloaca during the midtrimester [3]. With progressive fetal development, the urachus tends to lose its attachment to the umbilicus and the tract obliterates completely shortly after birth (approximately 98% of the urachus is obliterated), giving rise to the median umbilical ligament. The failure of obliteration causes various types of benign urachal anomalies Urachal cysts are the most common remnants in all the age group.Clinical presentation of urachal remnants is variable and a specific representing diagnostically a challenge.

The diagnosis may be incidental such as during the execution of abdominal ultrasound for various other reasons; or may be entertained during the evaluation of symptoms such as acute abdominal pain, fever, abdominal mass, or others [4-5]. Ultrasonography is the most accurate modality (accuracy varies from 61.1% to 91.3%) [6-8] for diagnosis in these patients, noninvasive, easily and performed. Computed tomography with its multiplanar images and high spatial resolution capability is a good diagnostic imaging modality and can reveals the type of urachal anomaly with a sufficient degree of accuracy.

In our series, all patients diagnosed initially by ultrasound and CT or MRI utilized to provide the detailed anatomy when required.

Traditionally, the principal treatment of urachal anomalies has been surgical excision consisting of the complete excision of the urachal remnants from the umbilicus to the bladder, to avoid recurrence and possible, even if rare (0.01%), malignant transformation later in life [9]. This requires a lateral expanded incision, a midline vertical incision or a hypogastric transverse incision which inevitably causes the cosmetic disadvantage of a conspicuous scar[10]. To alleviate this drawback, laparoscopic excision of the urachal remnant was first described by Trondsen in 1993 [11]. Since 2010, six small case serieshave been reported [3, 9, 12-15] which are summarized in Table 1.

The location of the working ports is important in facilitating proper dissection and ensuring complete removal of the remnant. However, various port placement techniques have been described. Most of reports have adopted a 3-port approach: one camera and two working ports.[6] The most common port positions are both either epigastric or supraumbilical for the camera port, using a 30° telescope With the right and left midabdominal wall positions of the working ports forming the triangulation[15-17].

Another placement technique is based on the position of the three ports in the right or left lateral abdominal wall [9-12, 13, 15-17]. Accordingly, we adopted this technique, which affords excellent ergonomy during dissection of the median umbilical ligament from the umbilicus to the dome of the bladder.

We prefer to start the dissection from the umbilicus to the bladder in the midline. In addition, we favored the use of a laparoscopic hook over other instruments as it allows a steep angle dissection along the posterior abdominal wall.

According to a review of the literature there is no consensus about the need for routine resection of the urachal remnant en bloc with a cuff of the bladder, especially in adult reports.

However, most agree that excision of a bladder cuff is appropriate if there is an adherent urachal cyst attached to the dome of the bladder with communication between the cyst and bladder, especially if this is demonstrated by imaging[3,9,13]. Bladder cuff excision is also performed if there is suspicion of urachal carcinoma in patients who present with a midline abdominal mass with stippled calcification radiographically.

Including 28 patients, our series is the largest series described in the literature. The mean operative time was 50 minutes, lower than reported previously [10]. The mean postoperative duration of hospital stay was 1,5 days. There was no perioperative mortality or morbidity and all the patients underwent follow-up (mean: 15 months; range: 6–24 months); no patient registered a recurrence of theurachal disease.

This experience demonstrates that the laparoscopic approach is is feasible, safe, and effective, particularly with regard for hospital stay, morbidity, convalescence, cosmetics, and not least, the almost complete absence of relapse

Okegawa et al compared open and laparoscopic surgeryand they showed better results for the second one,both in terms of duration of hospitalization andof time to return to the activities of daily life [18]. Several others series confirmed also thesepositive results [12, 14, 19, 20].

Despite the increasing evidence,we still believe that prospective randomized trials and multicentric studies, which compare the two techniques, are necessaryto definitively confirm laparoscopic surgery as the reference technique for treatment of remnant disease.

Conclusion

Laparoscopic surgery is an interesting technique : safe with nil morbidity and mortality; effective withvery low rate of recurrence, aesthetic with preservation of the umbilicus.

 

Références

1. Larsen WJ. Human Embryology. 3rd edn. New York: Churchill Livingstone 2001: 258.

2. Naiditch JA, Radhakrishnan J, Chin AC. Current diagnosis and management of urachal remnants. JPediatr Surg 2013; 48: 2148-52.

3. Jeong HJ, Han DY, Kwon WA. Laparoscopic management of complicated urachal remnants. Chonnam Med J 2013;49:43-7.

4. Chiarenza SF, Scarpa MG, D'Agostino S, et al. Laparoscopic excision of urachal cyst in pediatric age: report of three cases and review of the literature. J Laparoendosc Adv Surg Tech A 2009;19 Suppl 1:S183-6.

5. Bertozzi M, Nardi N, Prestipino M, et al. Minimally invasive removal of urachal remnants in childhood. Pediatr Med Chir 2009;31:265-8.

6. Chiarenza SF, Bleve C. Laparoscopic management of urachal cysts. Transl Pediatr 2016;5(4):275-281.

7. McCollum MO, Macneily AE, Blair GK. Surgical implications of urachal remnants: Presentation and management. J Pediatr Surg 2003;38:798-803.

8. Widni EE, Höllwarth ME, Haxhija EQ. The impact of preoperative ultrasound on correct diagnosis of urachal remnants in children. J Pediatr Surg 2010;45:1433-7.

9. Li Siow S, Mahendran HA, Hardin M. Laparoscopic management of symptomatic urachal remnants in adulthood.Asian Journal of Surgery (2015) 38, 85-90.

10. Sukhotnik I , Aranovich I, Mansur B, Matter I, Kandelis Y, Halachmi S. Laparoscopic Surgery of Urachal Anomalies: A Single-Center Experience. IMAJ 2016; 18: 673–676

11. Trondsen E, Reiertsen O, Rosseland AR. Laparoscopic excision of urachal sinus. Eur J Surg 1993;159:127-8.

12. Li Destri G, Schillaci D, Latino R, Castaing M, Scilletta B, Cataldo AD. The urachal pathology with umbilical manifestation: overview of laparoscopic technique. J Laparoendosc Adv Surg Tech A. 2011 Nov;21(9):809-14.

13. Araki M, Saika T, Araki D, et al. Laparoscopic management of complicated urachal remnants in adults. World J Urol 2012;30:647-50.

14. Ortiz Sánchez L, Alonso Prieto MA, Campanario Pérez F, Alvarez-Silva I, De Cabo Ripoll M, García Díez F. Treatment of urachal disorders: The open and laparoscopic surgery approach.Arch Esp Urol. 2017 Apr;70(3):357-360.

15. Patrzyk M, Wilhelm L, Ludwig K, Heidecke CD, von Bernstorff W. Improved laparoscopic treatment of symptomatic urachal anomalies. World J Urol. 2013;31:1475e1481.

16. Sato H, Furuta S, Tsuji S, Kawase H, Kitagawa H. The current strategy for urachal remnants. Pediatr Surg Int (2015) 31:581–587.

17. Cadeddu JA, Boyle KE, Fabrizio MD, Schulam PG, Kavoussi LR. Laparoscopic management of urachal cysts in adulthood. J Urol. 2000;164:1526e1528.

18. Okegawa T, Odagane A, Nutahara K, et al. Laparoscopic management of urachal remnants in adulthood. Int J Urol 2006;13:1466-9.

19. Sanchez-Ismayel A, Cruz-Gonzalez G, Sanchez R, Sa´nchez- Salas R, Rodrıguez O, Sanabria E, Sotelo R, Sa´nchez-Salas RE. Laparoscopic management of symptomatic urachal anomalies. Actas Urol Esp 2009;33:284–289.

20. Turial S, Hueckstaedt T, Schier F, Fahlenkamp D. Laparoscopic treatment of urachal remnants in children. J Urol 2007;177:1864-6.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Table 1: case series published aboutlaparoscopic excision of urachal anomalies in adult

since 2010

Author (year) Country

 

Number of

Patients

Mean age (years)

Mean operative time (min)

Mean hospital stay (days)

Mean time to retun normal activities (days)

Morbidity

Mortality

Li Destri et al. [12]

(2011) Italy

5

25.2

101

1.4

12

None

None

Araki et al. [13]

(2012) Japan

8

26.1

147.5

NR

16

None

None

Patrzyk et al. [15] (2013) Germany

21

28.5

55.7

≤4

NR

None

None

Jeong et al. [3] (2013) Korea

8

36.5

162

14.6

NR

None

None

Li Siow  et al. [9]

(2015)Malaysia

14

22.8

71.1

1.3

4.5

Bladder

injury

None

Ortiz Sanchez et al. [14] (2017)Spain

7

43.1

154.2

4.9

NR

None

None

Current series (2019) Tunisia

28

27

50

1.5

15

None

None

NR: not reported

 

 

 

 

Ouraque 005

Fig 1: intra operative view showing insertion of ports:  Camera port (in the middle); working port (from either side).