Urachal remnant diseases: spectrum of CT and US findings

Urachal abscess mimicking malignant tumor: can imaging tell them apart?

The urachus is an embryonic remnant that usually involutes before birth. Abnormal persistence of this structure can lead to infectious or neoplastic complications later in life. We report a case of an 84-year-old man that presented with a urachal complex mass which, after proper investigation, revealed to be a urachal abscess. Urachal abscesses are rare and usually occur in severe infections. Urachal abscesses can be indistinguishable from urachus carcinoma on imaging studies. This article reviews the clinical and imaging aspects of urachal abscess and carcinoma and possible differentiating elements in imaging. However, definitive diagnosis usually depends on a biopsy or fluid aspiration.

Urachal remnant with heterotopic sinus in an adult male: A case report

INTRODUCTION

Urachal remnant with heterotopic sinus is an extremely rare congenital anomaly, and usually coexists with other congenital anomalies. We report the case of a 32-year-old adult male with urachal remnant with heterotopic sinus.

PATIENT CONCERNS

A 32-year-old adult male presented with purulent secretion in the heterotopic sinus on the dorsal side of the normal external urethral orifice and pain in the balanus since 5 months.

DIAGNOSIS

The computed tomography scan demonstrated a 4 cm cystic mass next to the anterior wall of the urinary bladder. Retrograde urethrography was performed, which demonstrated that this mass communicated with the heterotopic sinus on the dorsal side of the normal external urethral orifice. Cystoscopy showed that there was no communication between the mass and the bladder. Pathology results confirmed that this mass was urachal tissue.

INTERVENTIONS

The patient underwent a laparoscopy surgery to undertake the cystic mass, part of the anterior wall of urinary bladder and the epithelium of channel which communicated with the cystic mass.

OUTCOMES

The patient was discharged without any complications after 6 months and follow-up was continued in the clinic.

CONCLUSIONS

Urachal remnant with heterotopic sinus is rare, and we recommend that urachal remnant should be considered when a patient presents with a mass in the retropubic space.

Infection of Previously Closed Urachus Mimicking Malignancy: A Case Report and Literature Review of Radiological Findings to the Diagnosis

The urachus is a vestigial structure of the allantois and cloaca. It involutes as fetal development progresses to become a fibrous cord, which courses between the umbilicus and bladder dome within the retropubic space. Infection occasionally occurs in patients with congenital patent urachus. Here, we report a patient with infection of a previously closed urachal tract presenting as an abdominal mass. This has rarely been described in the literature. Current knowledge on imaging findings to the diagnosis is discussed.

Urachal Mucinous Cystadenocarcinoma

A 57-year-old man presented with a 6-month history of pelvic fullness. He had no lower urinary tract symptoms or altered bowel habits. On examination, there was a non-tender pelvic mass which extended from the pubic symphysis to the level of the umbilicus. CT scan of the abdomen demonstrated a 22×11×11 cm cystic mass arising from the pelvis extending into the midline and superiorly to the umbilicus. Other than raised carcinoembryonic antigen of 7.6 ng/mL (<5.0), the remainder of his blood test were unremarkable. Flexible cystoscopy demonstrated a convex deformity of the bladder wall in keeping with the compression and displacement as seen on the CT. The patient underwent an open excision of the cystic structure (urachal remnant), partial cystectomy, partial excision of anterior abdominal wall and pelvic lymphadenectomy. A check cystogram performed 12 days following the initial operation was unremarkable.

A Large Urinary Bladder Hemangioma Mimicking Urachal Cancer: A Case Report and Literature Review

Urinary bladder hemangiomas are rare, especially in children and adolescents. We present a case of a 17-year-old young man with persistent gross hematuria for 1 month. Computed tomography revealed a 3.6 cm mass on the superior anterior wall of the urinary bladder, which was highly suspected as an urachal tumor. We carried out an en bloc resection of the urachus and bladder tumor. The pathologic report indicated a cavernous hemangioma of the urinary bladder. No tumor recurrence or bleeding was found during the 2-year follow-up. Urinary bladder hemangioma is an important differential diagnosis in young patients with hematuria.

Diagnosis of congenital and acquired focal lesions in the neck, abdomen, and pelvis with contrast-enhanced ultrasound: a pictorial essay

Contrast-enhanced ultrasound (CEUS) is a versatile imaging modality that improves the diagnostic potential of conventional ultrasound. It allows for portable imaging at the bedside. In this paper, we illustrate how CEUS can be used in evaluating several focal lesions in the pediatric population, including liver hemangioma, telangiectasias, splenic hamartomas, and bladder lesions. We describe the ultrasound findings and contrast enhancement patterns associated with these lesions. Findings are correlated with MRI, CT, and/or pathology when available. This paper demonstrates the value of CEUS in improving characterization of many focal lesions in the pediatric population.

CONCLUSION

CEUS is a valuable bedside technique for use in the pediatric population to evaluate focal lesions in various organs, and will allow for safe, more efficient diagnostic imaging. What is Known: • CEUS offers many advantages over CT and MRI and is underutilized in the United States. • It is only FDA approved for vesicoureteral reflux and liver in the pediatric population. However, off label uses are well described. What is New: • This pictorial essay describes ultrasound findings and contrast enhancement patterns associated with liver hemangioma, liver telangiectasia, splenic hamartoma, hemorrhagic ovarian cyst, urachal remnant, spinning top urethras, and kaposiform hemangioendothelioma. • We demonstrate the utility of CEUS in expanding the diagnostic potential of conventional ultrasound.

Urachal mucinous adenocarcinoma in the pelvic wall mimicking endometriosis

We report the case of a 30-year-old woman who complained of a painful palpable mass. Magnetic resonance imaging revealed an ill-defined mass approximately 8 cm in diameter with internal microcytic components. The mass diffusely involved the subcutaneous tissues, the muscles of the pelvic wall, and urinary bladder via a postoperative scar and resembled endometriosis. The histopathologic diagnosis was mucinous adenocarcinoma arisen from the urachal remnant. This is a very rare case of urachal adenocarcinoma arising mainly in the pelvic wall and mimicking endometriosis on MRI.

Umbilical Lesions: Clinicopathologic Features of 99 Tumors

Background. Umbilical lesions are rare, and can be benign or malignant. This retrospective study was conducted to assess the epidemiological, clinical, and histologic characteristics of umbilical masses. Methods. Cases of umbilical masses from January 1994 to August 2016 were retrieved from our institution’s pathology databases, and their clinicopathological features were reviewed. Results. There were a total of 99 cases of umbilical masses, 78 women (78.8%) and 21 men (21.2%). Of these, 59 were malignant (59.6%) and 40 were benign (40.4%). Among the malignant cases, 48 were women with a mean age of 65 years and 11 were men with a mean age of 66 years. All malignant lesions were secondary tumors. Twenty-five patients (42.3%) had a metastatic tumor to the umbilicus with an average of 7 months from the original diagnosis (12 gynecological, 8 pancreatic/gastrointestinal, 2 lymphomas, and a case each of breast, prostate, and melanoma). Of the patients with a benign diagnosis, 30 were women (75%) with a mean age of 52 years and 10 were men (25%) with a mean age of 43 years. The benign lesions included epidermal inclusion cysts (15/40), endometriosis (11/40), lipomas (3/40), neurofibromas (3/40), fibromas (3/40), abscesses (2/40), and 1 case each of tubular apocrine adenoma, serous cystadenoma, and calcified nodule. Conclusion. The most common metastatic tumors to the umbilicus are from the adjacent organs with the gynecologic tract as the most frequent primary followed by the gastrointestinal system. Primary malignant tumors of the umbilical region are rarely identified in clinical practice.

Urachal remnant causing umbilical in-drawing during micturition

The urachus is a vestigial remnant of the allantois, which is normally obliterated during fetal life to become the median umbilical ligament, which runs between the urinary bladder and umbilicus in adults. Failure of obliteration leaves a tubular urachal remnant, which may present with disease. We report a unique case of a urachal remnant causing umbilical pain and in-drawing on micturition in a nine-year-old boy. There was no urine discharge from the umbilicus and in-drawing did not occur on defecation. His urinary stream was normal. High frequency ultrasonography revealed a thick band with a narrow, anechoic, fluid filled central channel. Exploration via an infraumbilical curvilinear incision identified a thick urachal band that could be traced to the dome of the bladder. This was excised flush with the bladder. The patient remains well at nine months following surgery with complete cessation of symptoms.

Urachal mucinous adenocarcinoma with pseudomyxoma peritonei: A case report

RATIONALE

Pseudomyxoma peritonei is an unusual clinical condition, and the appendix and ovaries are reported as the primary sites.

PATIENT CONCERNS

A 44-year-old man who was reported a 3-month history of lower abdominal pain and distention, along with increased abdominal girth, was admitted with a palpable tender mass in the central lower abdomen.

DIAGNOSIS

Ultrasonography showed a large well-circumscribed cystic-solid mass with lobulated margin, extending from the anterosuperior dome of the urinary bladder to the anterior abdominal wall. A computed tomography (CT) scan revealed a midline heterogeneous, hypodense, irregular polycystic-solid mass adjacent to the anterior wall of the abdomen and anterior to the dome of the urinary bladder. fluorodeoxyglucose positron-emission tomography/CT showed intense fluorodeoxyglucose uptake in the thickened wall of the mass. Intraperitoneal laparoscopic exploration also revealed a midline abdominal mass adjacent to the dome of the urinary bladder. Laparotomy showed that the mass originated from the dome of the urinary bladder and was disconnected with the urinary bladder lumen. The final histopathological diagnosis was urachal mucinous adenocarcinoma associated with high-grade pseudomyxoma peritonei.

INTERVENTIONS

The patient underwent surgical cytoreductive procedure and the perioperative intraperitoneal chemotherapy.

OUTCOMES

The patient made an uneventful recovery, and 7 months later had no recurrence.

LESSONS

The urachus is a tubular structure, which extends medially from the apex of the bladder to the allantoid during fetal development, and it usually obliterates after birth. Urachal remnants can cause urachal carcinoma or bladder cancers. Pseudomyxoma peritonei originating from mucinous neoplasm of the urachus is extremely rare.

"Look Before You Leap": Urachal Mass in Adults

Diseases of the urachal remnant can present at any age. Urachal adenocarcinoma is the most frequent cause of urachal mass in adults, albeit infected urachal cyst constitutes a significant number. Lack of typical clinical and imaging findings combined with absence of definitive guidelines makes evaluation of urachal mass in adults very challenging. We present a case of a 58-year-old man presenting with an urachal mass with overlapping clinical and imaging findings mimicking urachal malignancy which later turned out to be an infected urachal cyst.

Costello Syndrome and Umbilical Ligament Rhabdomyosarcoma in Two Pediatric Patients: Case Reports and Review of the Literature

Costello syndrome is caused by heterozygous de novo missense mutations in the protooncogene HRAS with tumor predisposition, especially rhabdomyosarcoma. We here report two pediatric patients with Costello syndrome and umbilical ligament rhabdomyosarcoma. A review of the literature published in English in MEDLINE from January 1971 to June 2016 using the search terms “Costello syndrome” and “rhabdomyosarcoma” was performed, including two new cases that we describe. Twenty-six patients with Costello syndrome and rhabdomyosarcoma were recorded with mean age of diagnosis of 2 years and 8 months. The most common tumor location was the abdomen/pelvis, including four out of ten of those in the umbilical ligament. The most common histological subtype was embryonal rhabdomyosarcoma. Overall survival was 43%. A total of 17 rhabdomyosarcomas in pediatric patients arising in the umbilical ligament were recorded with mean age of diagnosis of 3 years and 4 months. Overall survival was 69%. Costello syndrome is a poorly known disorder in pediatric oncology but their predisposition to malignancies implies the need for a new perspective on early diagnosis and aggressive medical and surgical treatment.

Neonatal ovarian cysts: ultrasound assessment and differential diagnosis

Ovarian cysts are the most common abdominal cysts in female fetuses and newborn girls. Ultrasonography is the imaging technique of choice for diagnosing ovarian cysts because it makes it possible to differentiate them from other cystic lesions. Although most neonatal ovarian cysts regress in the first few months after birth, complications can occur during gestation or after birth. The manifestations of ovarian cysts on ultrasonography will depend on the complications. The management is controversial, although the current trend favors watchful waiting. We describe the different presentations of neonatal ovarian cysts with their complications and their patterns of findings on ultrasonography. We also discuss the differential diagnosis with other cystic abdominal lesions, and finally we discuss the therapeutic management of neonatal ovarian cysts.

Urachal Cyst Causing Small Bowel Obstruction in an Adult with a Virgin Abdomen

Introduction. A patent urachus is a rare congenital or acquired pathology, which can lead to complications later in life. We describe a case of urachal cystitis as the etiology of small bowel obstruction in an adult without prior intra-abdominal surgery. Case Report. A 64-year-old male presented to the acute care surgery team with a 5-day history of right lower quadrant abdominal pain, distention, nausea, and vomiting. He had a two-month history of urinary retention and his past medical history was significant for benign prostate hyperplasia. On exam, he had evidence of small bowel obstruction. Computed tomography revealed high-grade small bowel obstruction secondary to presumed ruptured appendicitis. In the operating room, an infected urachal cyst was identified with adhesions to the proximal ileum. After lysis of adhesions and resection of the cyst, the patient was subsequently discharged without further issues. Conclusion. Although rare, urachal pathology should be considered in the differential diagnosis when evaluating a patient with small bowel obstruction without prior intraabdominal surgery, hernia, or malignancy.

Magnetic resonance imaging of fetal pelvic cysts

The detection of fetal anomalies has improved in the last years as a result of the generalization of ultrasound pregnancy screening exams. The presence of a cystic imaging in the fetal pelvis is a relatively common finding, which can correspond to a real congenital cystic lesion or result from the anomalous liquid accumulation in a whole pelvic organ, mainly the urinary bladder, the uterus, or the vagina. In selected cases with poor prognosis and/or inconclusive echographic findings, magnetic resonance may bring additional information in terms of the characterization, anatomical location, and real extension of the pathology. This pictorial essay describes the normal pelvic fetal anatomy, as well as the most common pelvic cysts. It also describes the causes of an anomalous distension of the whole pelvic organs detected in utero, with emphasis on prenatal magnetic resonance imaging exams. Moreover, it proposes practical teaching points to reduce the differential diagnosis of these lesions based on the sex of the fetus, the division of the pelvis in anatomical spaces, and the imaging findings of the pathology. Finally, it discusses the real utility of complementary MRI.

Surgical treatment of recurrent urachal carcinoma with liver metastasis: a case report and literature review

Background

Urachal carcinoma is a rare malignancy with poor prognosis due to late presentation of the disease and its aggressiveness. Surgery remains the mainstay of therapy even in cases of disease recurrence. To the best of our knowledge, this is the first report of salvage surgery in the case of urachal carcinoma with liver metastasis.

Case presentation

The patient was a young woman who suffered from locally advanced urachal carcinoma treated with en-bloc cystectomy, hysterectomy with bilateral adnexectomy, partial resection of the sigmoid colon, and partial resection of the rectus abdominis muscle with the fascia, skin, and umbilicus. Adjuvant chemotherapy with paclitaxel and carboplatin was applied. Two years after the treatment, she was diagnosed with a single liver metastasis and a local pelvic recurrence. In a two-step operation, the patient underwent right hemihepatectomy as well as resection of pelvic recurrence site and adjuvant chemotherapy with gemcitabine. Due to the disease progression, a complete resection of the lesions was not achieved and the response to chemotherapy was poor. The patient died of the disease after a year.

Conclusions

Surgery is the first line of treatment for urachal carcinoma and should be always considered as an option in cases of disease recurrence. Radical initial surgical management, close patient surveillance, and prompt treatment of disease relapse may all contribute to prolonging patient’s survival.

Beyond hernias: a multimodality review of abdominal wall pathology

The diagnosis of abdominal wall pathology is often obvious on clinical physical examination; however, multimodality imaging often yields incidental, and occasionally important, findings aiding in assessing the overall clinical picture. While various hernias are common, there are numerous other causes of abdominal wall pathology. Knowledge of these entities is crucial to avoid misinterpretation and assure proper radiological judgment.

Urachal adenocarcinoma that metastasized to breast was misinterpreted as primary breast mucinous carcinoma: A rare case report and literature review

BACKGROUND

The urachus is a vestigial tubular structure that connects the urinary bladder to the allantois during early embryonic development. Urachal carcinoma develops in the urachus, which is an embryological remnant of the urogenital sinus and allantois. The estimated annual incidence of urachal carcinoma in the general population is 0.01% of all cancers in adults. Moreover, urachal carcinoma accounts for 0.34% to 0.7% of all bladder carcinoma cases. And breast metastasis is extremely rarer.

METHODS AND RESULTS

A 42-year-old woman was admitted to our hospital with a palpable mass in the outer upper quadrant of the right breast, which was misinterpreted as a carcinoma that originated from the breast. Subsequently, she underwent surgery without any further meticulous examination. Immunohistochemistry analysis revealed positivity for CK20, Villin, and CDX-2 and negativity for CK7. After further inspection, a mass was found in the bladder dome using 18F-fluorodeoxyglucose positron emission tomography and computed tomography. The mass was surgically removed.

CONCLUSION

Pathologic and immunohistochemical examination confirmed that the mass was urachal mucinous adenocarcinoma and mucinous adenocarcinoma to the right breast. The patient has been followed up without recurrence for 8 months.

Abnormal appearance of the umbilicus: an indicator of urachal anomalies

The urachus is an intra-abdominal fibrous remnant of the allantois. The non-involution of the allantois can result in urachal anomalies. The abnormal appearance of the umbilicus may be a sign of such anomalies. We have observed 3 cases of term neonates with atypical appearance of the umbilical stump, all of which manifested urachal anomalies, as documented by ultrasound scan. These appearances are rarely described in the literature, and seem to regress at around 2 months. Therefore, it is important that healthcare professionals should be aware of the possible implications of atypical umbilical stumps, evaluate each case accordingly and, if an urachal anomaly is diagnosed, refer the patient to a paediatric surgery centre, as such malformations carry an underlying risk of infection or malignancy.

Urachal adenocarcinoma incidentally discovered in a young woman at elective caesarean section

Urachal adenocarcinoma is a rare non-urothelial malignancy that represents only 0.5% of all vesical cancers. Urachal adenocarcinoma most commonly occurs in the 5th to 7th decade. We describe a case of a 35-year-old woman (G3P1) who presented at 20 weeks pregnancy with two episodes of post-coital bleeding. Ultrasound demonstrated a uterine mass measuring 59×43×56 mm, presumed to be a leiomyoma. The decision was made to proceed to caesarean section at 38 weeks, given the progression of the presumed leiomyoma. A 2 cm bladder dome mass was incidentally discovered at the time of the caesarean section and an urgent intraoperative urology consult was sought. Resultantly, the bladder mass was dissected to the dome, and pathology returned urachal adenocarcinoma. This case report considers the treatment decisions involved when faced with urachal adenocarcinoma and reviews the literature surrounding this rare malignancy.

A Rare Case of Vesicourachal Diverticulum with Calculus in a 24-Year-Old Man

Background

Case Report

Conclusions

Infected urachal remnants: an unusual presentation

The urachus is the remnant of the cloaca and allantois, and attaches the umbilicus to the bladder dome. Urachal anomalies are symptomatically identified during childhood. It rarely occurs in adults, making diagnosis difficult. We present and discuss the case of an infected patent urachus in a 30-year-old male.

Urachal Adenocarcinoma in a Dog

An 8-year-old neutered female Labrador retriever was presented with a 3-year history of intermittent haematuria. Ultrasonographic evaluation of the urinary bladder revealed a 2 × 3 × 0.5 cm intraluminal mass arising at the dome. The mass was excised via partial cystectomy. Histopathological examination revealed neoplastic epithelial cells arranged in sheets, irregularly-branching tubules and acini within a fibrovascular stroma. Neoplastic cells were cuboidal to polygonal with abundant foamy amphophilic cytoplasm, typically with a single, large, clear intracytoplasmic vacuole and eccentric nucleus ('signet ring' cells). Neoplastic tubules were often ectatic and contained abundant mucin. Immunohistochemically, the neoplastic cells had weak, cytoplasmic immunoreactivity for cytokeratin 7 and rare, but strong, nuclear immunoreactivity for CDX2. Based on the cellular morphology, immunolabelling characteristics and anatomical location, a diagnosis of adenocarcinoma of urachal origin was made. To the authors' knowledge, this is the first reported case of urachal adenocarcinoma in a dog.

Primary cystic peritoneal masses and mimickers: spectrum of diseases with pathologic correlation

Cystic lesions within the peritoneum have been classified classically according to their lining on histology into four categories-endothelial, epithelial, mesothelial, and others (germ cell tumors, sex cord gonadal stromal tumors, cystic mesenchymal tumors, fibrous wall tumors, and infectious cystic peritoneal lesions). In this article, we will proceed to classify cystic peritoneal lesions focusing on the degree of radiological complexity into three categories-simple cystic, mildly complex, and cystic with solid component lesions. Many intra-abdominal collections within the peritoneal cavity such as abscess, seroma, biloma, urinoma, or lymphocele may mimic primary peritoneal cystic masses and need to be differentiated. Clinical history and imaging features may help differentiate intra-abdominal collections from primary peritoneal masses. Lymphangiomas are benign multilocular cystic masses that can virtually occur in any location within the abdomen and insinuate between structures. Ultrasound may help differentiate enteric duplication cysts from other mesenteric and omental cysts in the abdomen. Double-layered wall along the mesenteric side of bowel may suggest its diagnosis in the proper clinical setting. Characteristic imaging features of hydatid cysts are internal daughter cysts, floating membranes and matrix, peripheral calcifications, and collagenous pericyst. Non-pancreatic psuedocysts usually have a fibrotic thick wall and chylous content may lead to a fat-fluid level. Pseudomyxoma peritonei appears as loculated fluid collections in the peritoneal cavity, omentum, and mesentery and may scallop visceral surfaces. Many of the primary cystic peritoneal masses have specific imaging features which can help in accurate diagnosis and management of these entities. Knowledge of the imaging spectrum of cystic peritoneal masses is necessary to distinguish from other potential cystic abdominal mimicker masses.

A Rare Case of Urachal Sinus

Abnormalities in the closure of the intraembryonic portion of the allatoic lumen result in urachal abnormalities. Urachal remnant diseases are rare in adults. Malignant urachal neoplasms, like adenocarcinoma which may probably occur due to metaplasia of the transitional epithelium of the urachal remnant are very rare. Surgical excision of the urachus is needed. The imaging features of the urachal abnormalities are important for correct diagnosis and surgical management.

Case Report: Pre- and postnatal management of an allantoic cyst with patent urachus and single umbilical artery

Patent urachus is a rare congenital abnormality. Since its first description by Cabriolus in 1550, few cases have been reported. A 26-year-old Vietnamese primigravida presented at 20 weeks of gestation for evaluation of a cystic mass in the umbilical cord, which was first discovered at week 13 of pregnancy by ultrasound scan. The cystic mass originated from the root of the umbilical cord, connected to the urinary bladder, and no intestinal contents were enclosed within. Doppler ultrasound assessment showed that the single umbilical artery existed within the normal range. The progression of the umbilical cyst continued to be screened, but the mass disappeared on ultrasound images at 27 weeks of gestation. This led to the consideration of the cyst’s rupture. After 38 gestational weeks, the pregnant woman delivered a 3350g male infant via cesarean section because of an obstructed vaginal labor. The following days, a stream of urine was recorded leaking out from the umbilical mass whenever he cried. Seven weeks after delivery, an open surgical approach was successfully performed. The baby is now 43 months of age, growing and developing normally. Since an allantoic cyst with patent urachus is a rare clinical entity, early discovery, close monitoring and accurate diagnosis through ultrasound in the prenatal period may consequently allow clinicians to have suitable attitudes towards management when the infant is born.