During the development of the coelomic cavity, there is an accessible connection between the urinary bladder and the umbilical wall through the urachus. The persistence of this tract leads to urachal pathologies with different symptoms. We present a case of an infected urachal cyst presenting as an umbilical mass with a clear discharge in a 19-year-old man who underwent successful laparoscopic surgery.
introduction
Urachal anomalies are developmental abnormalities that arise during the formation of the urinary bladder and can lead to complications in the event of infection. These can occur at different ages. Adults may have different clinical features depending on the subtype of the abnormality. These cases benefit from early diagnosis, however, due to the rarity of occurrence and non-specific symptoms, achieving this can be challenging. These conditions are best treated through minimally invasive surgery. Our report highlights a case of urachus sinus and how it was treated with excellent results.
case presentation
A 19-year-old patient presented to our outpatient clinic with a history of excruciating umbilical pain; later the navel was swollen and a yellow, clear discharge with no smell of ammonia came out. The discharge was continuous, not associated with pain and had no periodicity. The patient also had three episodes of discharge-related fever, followed by resolution of both. The patient was evaluated elsewhere and referred with an abdominal ultrasound finding suggestive of an umbilical granuloma.
The patient was examined in our department. His vitals were stable and he was afebrile at presentation. Physical examination revealed a 1 cm x 1 cm umbilical swelling that was tender on deep palpation, irreducible, and without discharge or coughing. The patient had a soft abdomen with no generalized or localized tenderness, tenderness, or stiffness.
On routine abdominal ultrasound, a heterogeneous hypoechoic lesion measuring 5 cm x 4 cm in the umbilical region was noted with features suggestive of an umbilical granuloma seen without intraperitoneal extension of the lesion or collection. Contrast-enhanced computed tomography (CECT) of the abdomen was performed, which subsequently showed an umbilical cord soft-tissue nodule connecting to the preperitoneal space with no underlying collection suggestive of an infected urachal cyst (Fig 1).
The patient was prepared for diagnostic laparoscopy and assessed as suitable for anesthesia according to the American Society of Anaesthesiologists (ASA grade 1). Intraoperatively, an infected urachal cyst from the dome of the urinary bladder with a size of 5 cm x 4 cm with a persistent fistulous tract that opens into the umbilicus (Fig 2).
Laparoscopic excision of the urachal cyst with excision of the entire fistula tract up to the umbilicus. The integrity of the urinary bladder mucosa was checked intraoperatively after filling the bladder with physiological saline and no leakage was noted. A thin drain was placed in the pelvic cavity, the outflow of which was recorded daily: 180 cc on the first postoperative day gradually reduced to 50 cc on the third postoperative day when the drain was removed. On discharge from the hospital, the patient was asymptomatic. He was followed up for four months and resumed competing in competitive football tournaments. Histopathologic evaluation of our resected specimen with hematoxylin and eosin (H&E) staining revealed a partially patent cystic structure measuring 4.6 x 4.2 x 1.5 cm. The outer surface was covered with adipose tissue. The cut section showed a cyst wall lining with an irregular granular surface. The wall was variously thickened and solid. No growth was noted. Several representative sections were examined, showing predominantly fibro-adipose, fibromuscular tissue with focally flattened epithelium and mostly atrophically denuded lining. Few lymphoid aggregates and several swollen, dilated, and some thrombosed thin-walled vessels were seen within the cyst wall. There was no evidence of intestinal mucosal epithelium or malignancy. All findings were consistent with a benign urachal cyst (Fig 3–6).
discussion
An urachus is characterized by an embryonic connection between the dome of the bladder and the umbilicus. The urachus is an atrophied remnant of the cloaca, which is the cranial extension of the urogenital sinus, a precursor to the fetal bladder and the allantois, which is a derivative of the yolk sac. In urachal anomalies, this tract is partially obliterated and lies in the extraperitoneal plane below the umbilicus [1]. This isolated cyst can be identified by ultrasound [2]. This cyst is an inflammatory mass below the navel [3]. Delayed treatment can have serious consequences such as sepsis, fistula formation and rupture leading to peritonitis. The spectrum of urachal pathologies can present itself as one of the following five types: 1) open urachus, in which the entire tubular structure does not close; 2) Urachal cyst, in which both ends of the duct close, leaving an open central part; 3) urachus sinus draining proximally into the umbilicus; 4) vesicourachal diverticulum, where distal connection to the bladder remains; and 5) alternate sinus, which can drain to either the bladder or the navel [4]. Congenital urachal anomalies are rare, with different subtypes occurring in different age groups, with males being affected twice as often as females, with urachal cyst being the most common presentation in the adult age group [5]. presentation is atypical; Therefore, a high index of suspicion helps to make a diagnosis. A triad of lower midline mass, umbilical discharge, and sepsis are suspicious, although MRI confirms the diagnosis and defines the surrounding anatomical relationship. Complete excision is imperative as malignancy of the remnant is possible [6]. Histologically, a urachal cyst is usually seen as tubules separated by fibrous strands without marked tissue desmoplasia. The cyst consists of three layers: stratified columnar or urothelial lining epithelium, connective tissue, and external smooth muscle. Omphalomesenteric ductal remnants show intestinal mucosa rather than urothelium or a flattened, weakened epithelium [7,8].
Compared to the article by Sreepadma et al. our case is unique. We have clearly demonstrated that the laparoscopic technique of urachal cyst excision benefited the patient by providing excellent results in terms of surgery with early rehabilitation [9]. The variable presentation of a urachal cavity is a diagnostic challenge, so a high index of suspicion must be maintained to obtain an accurate diagnosis, and again laparoscopy is a useful adjunct to confirm the diagnosis.
Conclusions
This case was an unusual presentation of a urachal cavity in this age group, which was adequately diagnosed due to a high index of suspicion. The detailed histological sections confirm that most of these urachal cysts only become symptomatic after infection. Excision of the entire urachus-sinus tract from the bladder to the navel is the correct surgical principle to achieve complete healing and prevent recurrences. Laparoscopy not only helped this patient by aiding in the diagnosis but also aided in the early rehabilitation of this patient. Understanding the anatomy and imaging features of residual urachus disease, as well as the typical localization and distribution of these diseases, is essential for correct diagnosis and management.
