LAPAROSCOPIC MANAGEMENT OF URACHAL CYSTS IN ADULTHOOD:

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.

The urachal pathology with umbilical manifestation: overview of laparoscopic technique

BACKGROUND

The persistent patency of the urachus after birth is a rare anomaly, especially because most of the cases are asymptomatic. The guiding symptom for urachal-umbilical sinus and urachal cyst is the presence of umbilical discharge. Even if today we tend to laparoscopic treatment, in scientific literature there is still no evidence, because the reports are rare and often they are clinical cases.

METHODS

Thirteen patients with a symptomatic urachal pathology were evaluated; 12 of these were affected by umbilical discharge and 1 by periumbilical discomfort. Five of 13 were prospectively treated by laparoscopy and the remaining 8 patients, who had been previously treated with conventional surgery, formed the control group. The authors report the laparoscopic technique used, which allowed the complete excision of the urachus.

RESULTS

The operation time was lower for the patients treated by conventional surgery (71.9 minutes versus 101 minutes; P=.002), whereas the control pain (P=.05) and, above all, the excised urachus length (11.6 versus 8.7 cm; P=.03) were in favor of the patients treated by laparoscopic surgery. We registered only one recurrence in a patient treated by conventional surgery.

CONCLUSION

In the rare international scientific literature, only one study report comparative data, as our study. The results that we obtained seem to be in favor of the laparoscopic procedure, although prospective, randomized trials are needed to get stronger evidence.

Continuing robotically? The completion of a robot-assisted radical prostatectomy after laparotomy

The laparoscopic management of difficult adhesions can be quite challenging for even the most experienced of laparoscopic surgeons. We describe a case of managing a suspected enterotomy with a laparotomy during a robot-assisted radical prostatectomy and the surgical options after repair. The case was complicated by a Meckel's diverticulum fused and continuous with a urachal cyst, itself a rare occurrence. After the excision of the Meckel's diverticulum–urachal complex, the laparotomy incision was closed, and the prostatectomy was performed robotically. We discuss the controversies regarding continuation of a planned robotic procedure after a midline laparotomy.

Laparoscopic excision of symptomatic urachal anomalies: a technique to restore the natural appearance of the umbilicus

BACKGROUND

Recent reports on laparoscopic surgery for urachal anomalies have not described any techniques to restore the natural appearance of the umbilicus. In this report, we present a simple technique that enables complete resection of urachal anomalies while preserving the natural appearance of the umbilicus.

MATERIALS AND METHODS

Laparoscopic excision of symptomatic urachal anomalies was performed for 4 men and 2 women. After dissecting the urachal lesion along the preperitoneal plane toward the umbilicus, the cephalic side of the lesion was ligated and the skin at the base of the umbilicus was divided while compressing the anterior abdominal wall to ensure complete removal of the lesion.

RESULTS

The laparoscopic procedure was successfully completed with minimal blood loss, and the umbilicus could be restored to its natural appearance in all the cases.

CONCLUSIONS

This is the first report to describe a procedure for restoring the natural appearance of the umbilicus. This simple, alternative approach yields better cosmetic results and, therefore, will be useful, especially in younger patients.

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

Urachal cysts are the most common urachal anomaly in the pediatric population. There is an increasing body of literature documenting successful management of urachal cysts using laparoscopic techniques. There may be an advantage, however, with the use of robot-assisted laparoscopy for reconstructive cases. We describe the techniques used for robot-assisted laparoscopic excision of a urachal cyst and bladder cuff with bladder repair in a female child. This approach is a safe and effective option for the minimally invasive management of pediatric urachal cysts.

Laparoscopic excision of urachal cyst in pediatric age: report of three cases and review of the literature

OBJECTIVE

To determine the role of laparoscopic surgery in the treatment of pediatric urachal disorders.

METHODS

Case reports and a literature review of laparoscopic excision of urachal remnants.

RESULTS

In a five-year period, three children were diagnosed with urachal anomalies presenting as abdominal or urinary symptoms, and were treated by laparoscopic surgery. The average age was 8.3 years (range, 4-13),and there were two girls and one boy. Mean operative time was 90 minutes (range, 60-120), and there were nopostoperative complications. The three patients were all discharged by postoperative day four.

CONCLUSION

Laparoscopy is an effective and safe minimally invasive technique in the management of pediatricurachal anomalies. It is effective even in cases of infected urachal cysts.

Laparoscopic management of complicated urachal remnants

OBJECTIVE

To report our experience with a laparoscopic approach to managing symptomatic urachal anomalies.

PATIENTS AND METHODS

Five patients (median age 19 years, range 2-43) had a laparoscopic excision of a complicated urachal remnant between 2001 and 2004. Three ports were routinely used, although their positioning varied as our technique developed with experience. The urachal remnant was dissected from the umbilicus to the bladder dome and then removed intact.

RESULTS

All five operations had no serious immediate complications and minimal blood loss. One patient developed a small peri-umbilical haematoma after surgery and another had a persistent umbilical discharge at follow-up, and required open excision of residual remnant tissue.

CONCLUSIONS

The laparoscopic approach appears to be a safe and effective alternative to open surgery for this condition. Despite the slight risk of incomplete excision, the reduced morbidity of this procedure and better cosmetic result would appear advantageous.

Laparoscopic radical excision of urachal sinus

Persistent urachus is a rare congenital anomaly. Various types of remnants have been described including cyst, alternating sinus, patent urachus, diverticulum, and sinus. The most common presenting symptom of urachal sinus is umbilical discharge. Radical excision of the remnant, with or without a bladder cuff, is essential to prevent future malignant degeneration or recurrence of the remnant. Although open surgical excision has been the treatment of choice for many years, the laparoscopic approach has become an attractive alternative because of its association with less postoperative pain, better cosmesis, and rapid convalescence. Laparoscopic radical excision of a urachal sinus was performed in a 16-year-old female patient who presented with umbilical discharge.

Excision of a urachal sinus with use of a voice-controlled laparoscope

A 34-year-old man with an umbilical urachal sinus underwent a voice-controlled robot-assisted laparoscopic excision. In the operational procedure, three trocars were inserted into the peritoneal cavity. Exploration with a laparoscope revealed a cystic lesion at the middle part of the lower abdomen that extended about 4 cm in the major axis just from the umbilicus. The caudal stump of the urachus was ligated with an absorbable clip and divided. The cephalic side of the lesion was ligated just at the umbilicus with an Endo-Loop and divided. The lesion was then peeled from the peritoneum and taken from the peritoneal cavity. The robot allowed a safer and more secure movement of the scope. The postoperative course was uneventful, the surgical wound scars were very small, and the cosmetic results were satisfactory. There was no recurrence and no transformation of the navel. Our experience was encouraging enough to suggest that voice-controlled robot-assisted laparoscopic excision in patients with urachal disease is a beneficial therapeutic option that is easy, safe, and minimally invasive, with excellent cosmetic results.