Traitement cœlioscopique des kystes de l’ouraque

Ben Ameur Hazem | Turki Ahmed | Trigui Aymen | Kchaou Ali | Zouari Amine | Krichene Jihene | Affes Nejmeddine | Abid Bassem | Ben Amar Mohamed | Mzali Rafik |

La tunisie chirurgicale - 2022 ; Vol 2022

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 study of 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 stay was 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 cancers and 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 foot of 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 CO
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 mid trimester [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 series have 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 the urachal 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 relapseOkegawa et al compared open and laparoscopic surgery and they showed better results for the 
second one, both in terms of duration of hospitalization and of time to return to the activities 
of daily life [18]. Several others series confirmed also these positive 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 necessary to 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 with very 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 about laparoscopie excision ofurachal 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]

 

5

 

25.2

 

101

 

1.4

 

12

 

None

 

None

 

(2011) ltaly

 

 

 

 

 

 

 

 

Araki et al. [13]

 

8

 

26.1

 

147.5

 

NR

 

16

 

None

 

None

 

(2012) Japan

 

 

 

 

 

 

 

 

Patrzyk et al. [15]

 

(2013) Germany

 

21

 

28.5

 

55.7

 

<4

 

NR

 

None

 

None

 

Jeong et al. [3]

 

8

 

36.5

 

162

 

14.6

 

NR

 

None

 

None

 

(2013) Korea

 

 

 

 

 

 

 

 

Li Siow  et al. [9]

 

14

 

22.8

 

71.1

 

1.3

 

4.5

 

Bladder

 

None

 

(2015) Malaysia

 

 

 

 

 

..

mnjury

 

 

Ortiz Sanchez et al.

 

7

 

43.1

 

154.2

 

4.9

 

NR

 

None

 

None

 

[14] (2017) Spain

 

 

 

 

 

 

 

 

Current series (2019)

 

28

 

27

 

50

 

1.5

 

15

 

None

 

None

Tunisia

 

 

 

 

 

 

 

 

NR: not reported

 

 

 

Fig 1: intra operative view showing insertion of ports:   Camera port  (in the middle);

 

working port (from  either side).