Pediatric robot-assisted laparoscopic excision of urachal cyst and bladder cuff

Robot-assisted excision of urachal cyst: case report in a child

Background

The urachus is an embryological structure of the urogenital sinus and allantoid that connects the allantois to the early bladder in fetal life and then remains as the median umbilical ligament connecting the umbilicus to the dome of the bladder. An early laparoscopic procedure could trigger a quiescent urachal remnant to become symptomatic, causing a lesion or infection either during carbon oxide contamination or insufflation or a periumbilical or suprapubic port placement.

Case presentation

A 15-year-old girl complaining of supra-pubic abdominal pain. About 2 months previously, she had undergone laparoscopic appendectomy for acute appendicitis, and early postoperative period was uneventful. She underwent a robotic-assisted excision of a urachal cyst.

Conclusions

It has been suggested that early laparoscopic procedures could trigger previously asymptomatic urachal remnants to become symptomatic. Robot-assisted excision of a urachal cyst is a safe, effective alternative to open surgery in children.

Laparoscopic management of urachal cysts

BACKGROUND

The urachus and the urachal remnants represent a failure in the obliteration of the allantois at birth that connects the bladder to the umbilicus. After birth it obliterates and presents as the midline umbilical ligament. Urachal cyst are the most common urachal anomaly in the pediatric population. The traditional surgical approach is a semicircular infraumbilical incision or a lower midline laparotomy.

METHODS

In a 10 years period at Pediatric Surgery Department of Vicenza 16 children were diagnosed with urachal anomalies presenting as abdominal or urinary symptoms. Eight underwent open excision; eight were treated by laparoscopic surgery. The average age was 5.5 years (range, 4 months-13 years) in open group and 10 years (range, 1 month-18 years) in laparoscopic group.

RESULTS

Mean operative time was 63 minutes (range, 35-105 minutes) in open group, 50 minutes (range, 35-90 minutes) in laparoscopic group. There were no postoperative complications. The patients of laparoscopic group were all discharged after few days (range, 2-4 days). Pathological examination confirmed a benign urachal remnant in all cases. Reporting our experience since comparing the two surgical approaches we want to describe the technique step by step of laparoscopic urachal cyst excision as minimally invasive diagnostic and surgical techniques.

CONCLUSIONS

Laparoscopy represents a useful alternative for the management of persistent or infected urachus, in particular when there's the suspect despite the lack of radiological evidence. The morbidity associated with this approach is very low as the risk or recurrence. Laparoscopy in the management of urachal cyst is safe effective and ensures good cosmesis with all the advantages of minimally invasive approach.

The current strategy for urachal remnants

BACKGROUND

Optimal therapy for urachal remnant (UR) in children is controversial. Nonoperative management for symptomatic UR is an alternative. Many papers support the laparoscopic approach but the indication for this is unclear. We review our experience to determine the optimal management of UR.

MATERIALS AND METHODS

A retrospective chart review of patients from 1990 to 2013 with UR was performed. Patients were analyzed according to age, gender, initial symptoms, type of UR, treatment, and outcome.

RESULTS

We identified 27 patients (M:F = 17:10). A urachal sinus was found in 16 cases (59%), a urachal cyst in 5 (18%) and a urachal duct in 6 (22%). Eleven (A) were under 1 year, with 16 over 1 year (B). In Group A, the commonest symptom was umbilical granulation (n = 6, 54%). Group B was dominated by abdominal pain (n = 12, 75%). Six cases in Group A needed operation for repeated infections. In 5 cases, the UR disappeared. In Group B, 2 cases were followed conservatively. The others required surgery. From 2009, we utilized a laparoscopic approach (LA, n = 7) rather than the classical umbilical approach (UA, n = 13). The operation time was not significantly different (LA = 124 min: UA = 110 min, P > 0.05). There was a tendency for shorter hospital stay following LA (LA = 7.5 days: UA = 10.9 days). Complete resection was always possible using UA in Group A but a more caudal incision (mean 3.6 cm) was required in group B. LA enabled confirmation of the complete resection with three 5 mm ports in Group B. There were no operative complications after LA against two wound infections, one of which suffered a disruption, after UA.

CONCLUSION

Conservative follow-up is recommended for UR under 1-year old except when there are repeated infections. The umbilical approach is enough for infants. Laparoscopic surgery is recommended in older children.

Umbilical laparoendoscopic single-site technique for complete excision of urachal remnant

BACKGROUND

Infected urachal remnant is an uncommon benign disease but is generally symptomatic and commonly recurs. The standard of care for this disease is complete resection of all anomalous tissue including a bladder cuff to avoid recurrence. Recent minimally invasive laparoscopic techniques can effectively manage this disease, but multiport laparoscopic techniques are reported to still leave scars outside the umbilicus.

SUBJECTS AND METHODS

A novel technique of umbilical laparoendoscopic single-site (LESS) surgery for 2 patients with symptomatic urachal remnant is presented in this study.

RESULTS

In both cases, the entire urachal tissues from the umbilicus to the anterior bladder dome were successfully excised by the umbilical LESS technique without any extra ports or needlescopes. An articulating needle holder enabled water-tight bladder closure, resulting in early removal of the indwelling catheter. Without any signs of infection, the wound healings were completed 4 weeks after surgery in both cases. The patients had no complaints of symptoms at 6 months and 4 months, respectively, after surgery,and they were quite satisfied with their cosmetic results.

CONCLUSIONS

We propose that the umbilical LESS technique is a promising surgical option for patients with a symptomatic urachal remnant and that this technique provides satisfactory cosmetic results.