Urachal remnant diseases: spectrum of CT and US findings

Imaging and Clinical Findings of Xanthogranulomatous Inflammatory Disease of Various Abdominal and Pelvic Organs: A Pictorial Essay

Xanthogranulomatous (XG) inflammatory disease is a rare benign disease involving various organs, including the gallbladder, bile duct, pancreas, spleen, stomach, small bowel, colon, appendix, kidney, adrenal gland, urachus, urinary bladder, retroperitoneum, and female genital organs. The imaging features of XG inflammatory disease are nonspecific, usually presenting as a heterogeneous solid or cystic mass. The disease may also extend to adjacent structures. Due to its aggressive nature, it is occasionally misdiagnosed as a malignant neoplasm. Herein, we review the radiological features and clinical manifestations of XG inflammatory diseases in various organs of the abdomen and pelvis.

Surgical treatment of urachal remnants in an adult population-a single-centre experience

BACKGROUND

Urachal remnants are a rare congenital defect resulting from failure of obliteration of a fibrous tube that connects the umbilicus to the bladder dome during embryological development. Oftentimes a urachal remnant will go undiagnosed, but occasionally a patient may present with a variety of symptoms, ultimately leading to the identification of the remnant. Given its rarity, there is very limited literature available on the management of symptomatic urachal remnants, especially in adults. Surgical resection has been the first-line management of urachal remnants for years, especially given the risk of the development of urachal adenocarcinoma secondary to recurrent infection, persistent irritation, and urinary stasis associated with some urachal remnants.

AIM

We present our experience in the management of symptomatic urachal remnants in adults at our institute and perform a brief literature review of the same.

METHODS

A retrospective review of all cases who underwent surgical management of symptomatic urachal remnants between December 2015 and January 2022 was performed. Seven cases of urachal remnant excision in total were identified over the time period. Patient characteristics and perioperative parameters were analysed. Post-operative complications were measured in accordance with the Clavien-Dindo grading system.

RESULT

In total, 7 cases of urachal remnants were treated at our institute over the study period. Four patients were treated with a TURBT and 3 patients were treated with a laparoscopic partial cystectomy. There were no intraoperative complications and one post-operative complication requiring readmission for intravenous antibiotics. There was one mortality but this was not as a direct result of the operative procedure. Mean length of stay was 1.71 days. Two of patients had histologically confirmed urachal adenocarcinoma and the remaining five patients had benign histology. Each patient was seen in the outpatients department 6 weeks post-operatively for clinical review and review of histology. No further follow-up was required for the patients with benign histology given resolution of symptoms and follow-up for the malignant histology was arranged appropriately following MDM.

CONCLUSION

There is a paucity of data available on the management of urachal remnants in the adult population; however, an endoscopic or laparoscopic approach is a safe and effective method of excising symptomatic urachal remnants.

Low-Grade Urachal Cystadenoma With Abundant Calcification Removed Using Robot-Assisted Laparoscopy: A Case Report

Neoplasms of the urachus are an extremely rare entity consisting of incompletely obliterated tissue of the urachal canal during embryonic development, which sometimes remains into adulthood in the urinary bladder. The treatment of choice for these entities is surgical excision, which maximizes patient survival should the lesion prove to be malignant. In this case, we describe a 57-year-old female who presented with a one-year history of left lower quadrant pain. The patient underwent robot-assisted surgery to remove the mass, bladder dome, and median longitudinal ligament en bloc without evidence of recurrence to date.

Primary urachal leiomyosarcoma: a case report and literature review of clinical, pathological, and medical imaging features

Background

Urachal tumors are exceedingly rare, and adenocarcinoma is the most common malignant urachal neoplasm. Here, an especially rare patient of primary urachal leiomyosarcoma from our hospital was reported, and only five patients have been reported thus far since 1981.

Case description

A 24-year-old man was admitted due to urinary tract symptoms. Both urogenital ultrasonography and contrast-enhanced computed tomography showed a mass at the dome of the urinary bladder. Laparoscopic surgical resection was performed, and histopathologic examination of the mass confirmed the diagnosis of urachal leiomyosarcoma. No recurrence was noted after one and a half years.

Conclusions

Because the leiomyosarcoma located in the extraperitoneal space of Retzius and may manifest with nonspecific abdominal or urinary symptoms, early and definitive preoperative diagnosis is challenging. Partial cystectomy with complete excision of the urachus is recommended. Because only a few patients have been recorded, clinical outcomes and recurrence risks are difficult to assess.

Bladder Distention Demonstrating Vesicourachal Diverticulum on 18 F-FDG PET/CT Images of a Lung Cancer Patient

ABSTRACT

A 58-year-old man with lung cancer was referred for an 18 F-FDG PET/CT scan for pretreatment staging. The FDG PET/CT scan revealed focal uptakes in the lower abdomen. We differentiated the etiology of the lesions by performing a delayed scan with urine retention and bladder distension. The delayed scan demonstrated a tubular, radioactivity-filled structure arising above the urinary bladder. Combining the FDG PET/CT scan, clinical findings, and ultrasonography, we made the diagnosis of vesicourachal diverticulum.

Peritoneal Surface Malignancies Originating From Urachal Carcinoma: Case Reports and Review of the Literature

Urachal carcinoma (UC) is a rare and aggressive tumor arising from the urachal remnants, with the potential for peritoneal dissemination. Patients diagnosed with UC often have a poor prognosis. To date, there is no standardized treatment. Our objective is to present two cases of patients with peritoneal carcinomatosis (PC) secondary to an UC, who were treated with cytoreductive surgery (CRS) and hyperthermic peroperative intraperitoneal chemotherapy (HIPEC). A review of the literature on CRS and HIPEC in UC suggests CRS and HIPEC to be a safe and viable treatment option. Two patients with PC of UC underwent CRS and HIPEC in our institution. All available data were gathered and reported on. A literary search was carried out to find all available cases of patients with PC secondary to UC treated with CRS and HIPEC. Both patients underwent CRS and HIPEC and are currently free of recurrence. Literature research revealed nine other publications adding up to a total of 68 additional cases. CRS and HIPEC can provide satisfactory long-term oncological outcome with acceptable morbidity and mortality rates in patients with PC of urachal origin. It should be considered as a safe and feasible treatment option with curative potential.

Laparoscopic Excision of a Symptomatic Urachal Cyst (UC) in an Adult

Urachal cysts (UCs) are rare congenital anomalies, especially in adults. They often mimic a variety of intra-abdominal pathologies, making the diagnosis difficult. Laparotomy and excision of the cyst along with the umbilicus has been the traditional technique. A 33-year-old female presented with painful umbilical swelling. A CT scan was suggestive of a UC. We performed an umbilicus-preserving laparoscopic excision of the cyst. We describe this rare case and review literature related to the surgical treatment of UCs.

Preoperative accuracy of diagnostic evaluation of urachal carcinoma

BACKGROUND

We analyzed the clinical data of patients with urachal carcinoma (UrC) in order to strengthen urologists' understanding of UrC and improve preoperative diagnosis.

METHODS

The clinical data of 37 patients with UrC admitted to our hospital from October 2005 to April 2022 were retrospectively analyzed, and 40 patients with urothelial carcinoma (UCa) of bladder were enrolled as the control group. We compared and analyzed the imaging, cystoscopy and immunohistochemistry, serum tumor markers, fluorescence in situ hybridization (FISH) of UrC and bladder UCa for early diagnosis and evaluation of diagnostic accuracy.

RESULTS

A total of 37 patients with UrC were enrolled in this study, including 30 males and seven females, with a median age of 52.00 (44.50-63.50) years. Imaging and cystoscopy suggest that UrC grows primarily outside the bladder cavity and is found in the middle line of the dome or anterior wall of the bladder. There was a significant difference in tumor location between the UrC group and the UCa group (10.13 mm vs. -7.06 mm, p < 0.001). Immunohistochemistry revealed that CK20 and CDX-2 were both diffusely and strongly positive. β-catenin was strongly positive in cytoplasm and membrane, but negative in nuclear staining. Carcinoembryonic antigen (CEA) and carbohydrate antigen 72-4 (CA724) expression levels were significantly higher in the UrC group than in the UCa group (p < 0.05). In the diagnosis of UrC, the area under the curve (AUC) of CEA combined with CA724 was the greatest. FISH's sensitivity in diagnosing UrC (5/7, 71.43%) was not significantly different from that of UCa (71.43% vs. 77.50%, p = 0.659). Imaging examination has the highest sensitivity and specificity among the accuracy evaluation of different diagnostic methods.

CONCLUSIONS

Imaging and cystoscopy are the powerful diagnostic methods for UrC. Serum tumor markers may assist in diagnosis, prognosis, and monitoring. Positive urine FISH can easily misdiagnose UrC as UCa.

Treatment options and prognostic risk factors for urachal carcinoma: A multicetnter retrospective study

PURPOSE

Urachal carcinoma (UC) is a rare genitourinary cancer with an insidious onset, high risk of recurrence, and a poor prognosis. Surgical resection alone has difficulty in controlling the tumor. We aim to explore treatment options and prognostic risk factors for UC based on a multicenter cohort and long-term follow-up database.

MATERIALS AND METHODS

The clinical data, treatment and follow-up results of 163 patients with UC in 6 medical centers were analyzed retrospectively. Kaplan-Meier analysis and a Cox proportional hazards model were used to assess the treatment options and prognostic risk factors for UC.

RESULTS

Kaplan-Meier analysis showed no difference in the 5-year recurrence-free survival rate (P =0.282) or overall survival rate (P =0.673) between extended partial cystectomy (EPC) and radical cystectomy (RC) for patients at stage III and below. Whether bilateral pelvic lymph nodes were dissected was also not significantly correlated with the patient's recurrence (P =0.921) or prognosis (P =0.741). Postoperative adjuvant chemotherapy significantly reduced the recurrence rate of patients with stage Ⅲb or below (P =0.005). Combined treatment of postoperative recurrence patients prolonged the survival time of patients compared with single chemotherapy or conservative treatment (34.022±5.031 vs. 12.837±2.349 or 6.192±0.875 months, P <0.001). Kaplan-Meier and univariate Cox regression analyses showed that age >55 years, Sheldon stage, carbohydrate antigen 19-9 (CA19-9) >9.935 U/mL, carbohydrate antigen 72-4 (CA724) >6.02 U/mL, and postoperative adjuvant chemotherapy were closely related to the overall survival and recurrence-free survival of patients (P <0.05). Multivariate Cox proportional hazard regression confirmed that the Sheldon stage and CA724 >6.02 U/mL were independent recurrence risk factors.

CONCLUSIONS

EPC or RC provides similar oncologic results for UC, but bilateral pelvic lymph node dissection is not necessary in early-stage patients. Postoperative adjuvant chemotherapy can significantly reduce the recurrence rate, and combination therapy may provide better survival outcomes. CA724 can predict tumor recurrence or metastasis at an early stage.

Preoperative imaging contributes to pathologically complete resection of the urachal remnant by determining an appropriate surgical approach without unnecessary and excessive surgical invasion: a retrospective study

BACKGROUND

The urachus is an embryonic structure that connects the bladder to the allantois during early embryonic development. Occasionally, it fails to disappear at birth, leading to a case of urachal remnant (UR). This study aimed to determine whether our policy for selecting an appropriate UR resection approach is valid. We performed preoperative imaging to examine whether UR continued toward the bladder apex. If so, the UR and bladder apex were excised using the trans-umbilical approach, in addition to laparoscopy, if necessary. If preoperative imaging indicated that the UR ended near the umbilicus, the UR from the umbilicus to the duct end was resected. Pathological evaluations were performed to determine the appropriateness of the surgical approach indicated by preoperative imaging.

METHODS

We retrospectively reviewed pediatric patients with UR who underwent surgery between 2015 and 2021. Their background characteristics and surgical outcomes were evaluated.

RESULTS

Twenty patients with UR were included (median age, 7 [interquartile range, 2-10.25] years). UR continued toward the bladder apex in 10 patients and ended near the umbilicus in 10 patients. Urachus tissue at the bladder site was observed when the UR and bladder apex were excised. When UR was resected from the umbilicus to the duct end, urachus tissue was not pathologically detected at the resection margin.

CONCLUSION

Our policy results in complete resection without excessive surgical invasion.

An Unusual Case of Urachal Cyst Misdiagnosed as a Paraovarian Cyst: Ultrasound Assessment and Differential Diagnosis

The urachus is an embryologic remnant of the cloaca that usually degenerates after birth, resulting from the obliteration of the allantois, whose role is to connect the bladder to the umbilicus. Incomplete removal of the lumen may give rise to different malformations of the median umbilical ligament after birth. Although in the pediatric population urachus are common, most cases are asymptomatic and may go unrecognized until adulthood and give rise to cysts, rarely reported in the literature. Thus, in this manuscript we present the circumstances of a 43-year-old Romanian woman showing hypogastric pain of moderate intensity for three weeks, radiation in the left lower limb, menstrual cycle abnormalities, and dysmenorrhea. Based on the initial examinations, a paraovarian cyst measuring 80 mm was noted. Through the subsequent magnetic resonance imaging (MRI) conducted, a hypoechoic mass was detected, and the patient underwent a tumorectomy and partial cystectomy. A 9.7/7.5-cm tumor was excised, and the anatomopathological result was urachal mucinous cystadenoma. It came to our attention that relatively scarce data were found in the literature, with only seven studies with the diagnosis of the urachal cyst.

Current management of the urachal anomalies (UA). Lessons learned from the clinical practice

PURPOSE

It has been suggested that symptomatic UA requires surgical excision. However, the management of asymptomatic urachus is still controversial. We aimed to evaluate the clinical presentation, the efficacy of current modalities used, and postoperative pathology in patients with UA.

MATERIALS AND METHODS

We have performed a retrospective review of all patients diagnosed with UA and treated surgically or conservatively over 18 years. Demographic data, clinical presentation, imaging modalities, pathology, treatment, and postoperative complications were analyzed.

RESULTS

Twenty-five symptomatic patients (18 males and seven females) with a median age of 13 years (1 month to 37 years) were identified. 15 (60%) were diagnosed with a urachal cyst, 4 (16%) with sinus, 3 (12%) with urachal diverticulum, and the remaining 3 (12%) with patent urachus. Of those, 20 (80%) underwent surgical repair, and the remaining five (20%) patients were managed conservatively. 4 (20%) underwent laparotomy, 7 (35%) laparoscopic incision, and the remaining 9 (45%) laparoscopic robotic-assisted surgery. Nine patients required bladder cuff excision. The median operative time was 75 min (42-140 min). One patient developed Clavien-Dindo grade IIIA complication resulting in infected hematoma, which resolved after drainage. Another patient with a complication of grade IIIB needed reoperation as a result of recurrent events of an abscess. 13 (65%) demonstrated epithelium lining of the urachus on postoperative pathology.

CONCLUSIONS

Our data show that most of the patients with UA presented with epithelial lining, which might lead to the later malignant transformation. It might cause a shift from the conservative management of asymptomatic patients to surgical intervention. Robotic-assisted surgery appears beneficial in these patients, especially when the bladder cuff excision is required.

Incidental findings on prostate MRI: a close look at the field of view in this anatomical region

Magnetic resonance imaging (MRI) has been widely used as an advanced imaging modality to detect prostate cancer and indicate suspicious areas to guide biopsy procedures. The increasing number of prostate examinations with MRI has provided an opportunity to detect incidental lesions, and some might be very significant to elucidate patient symptoms or occult neoplastic process in the early stages. These incidental lesions might be located in the prostate gland, adjacent tissues, or organs around the prostate gland or out of the genitourinary system. The field of view of prostate MRI includes not only the prostate gland but also other critical pelvic organs in this specific anatomical region. Some of these incidental lesions might cause the same symptoms as prostate cancer and might explain the symptoms of the patient, and some might indicate early cancer stages located outside the prostate. Reporting these lesions might be life-saving by initiating early disease treatment. Awareness of the predicted locations of congenital anomalies would also be beneficial for the radiologists to mention these incidental findings.

Prevalence of urachal remnants in children according to age and their anatomic variants

PURPOSE

The aim of this study was to elucidate the prevalence of urachal remnants in children in relation to patient age as well as to identify their anatomic variants, using a laparoscopic view.

METHODS

The medical records of 394 pediatric patients who underwent laparoscopic inguinal hernia repair were reviewed. Patients were divided into four groups based on their age at surgery. Using laparoscopic visualization, the presence and anatomic variants of urachal remnants were analyzed.

RESULTS

A urachal remnant was confirmed in 140 children (35.5%). Although the prevalence was significantly higher in the group of children aged < 1 year (63.2%) than in any other group, no significant difference in the prevalence was observed between the groups aged ≥ 1 year. In 42 cases (10.7%), the urachal remnant merged into the lateral umbilical ligament.

CONCLUSIONS

Our results suggest a recommendation of nonoperative management of asymptomatic urachal remnants, especially in patients less than 1 year of age due to its probable spontaneous resolution. Knowledge of the anatomic variants could improve the accuracy of diagnosis of urachal remnants and the comprehension of its structure and localization for the achievement of accurate and complete excision.

Urachal Carcinoma, An Unusual Possibility of Hematuria; Case Report and Literature Review

Urachal cancer is very rare, accounting for only 0.5–2% of bladder-associated malignancies and 0.01% of all cancers in adults. It has an insidious appearance, an aggressive behavior and a poor prognosis. The most common symptoms are hematuria and the presence of a palpable hypogastric mass. The scarcity of cases and the low number of studies carried out explains the lack of an evidence-based management strategy, but it seems that surgical treatment (open, laparoscopy or robot-assisted) represents the gold standard, while neoadjuvant and adjuvant chemotherapy or radiotherapy has a limited impact on overall survival. Since mucinous cystadenocarcinoma of urachal origin is a very uncommon pathological condition the differential diagnosis may be difficult and pathological investigations have to elucidate this disorder. It is worth mentioning the psychological impact on the patient in addition to the medical aspects. A rare condition is associated with heightened risk for mental health and psychosocial difficulties and this must be taken into account in the subsequent follow-up of the patient. In order to increase awareness of this rare entity we report a case of a 40-year-old male with a urachal adenocarcinoma who was treated surgically, with a favorable outcome. We also perform a brief literature review about this type of tumor.

Transurethral suturing of bladder following transurethral excision of female vesico-urachal diverticula: a novel technique with long-term follow-up results

BACKGROUNDS

This study aims to describe and evaluate outcomes of transurethral surgery-natural orifice transluminal endoscopic surgery (TUS-Notes) technique in patients treated with transurethral excision of vesico-urachal diverticula (VD).

METHODS

Patients who underwent TUS-Notes following transurethral VD excision due to recurrent urinary tract infection (rUTI) since 2013 were included in this prospective non-randomized cohort study. Under cystoscopic guidance VD and surrounding bladder wall was resected until the fatty tissue using monopolar resectoscope. The specimen was removed with a grasper through the cystoscope. TUS-Notes technique was performed with Minimal Suturing Device (MSD-Ney®). The needle of the suture was shaped according to suturing position and loaded into MSD-Ney. They were inserted into the bladder under cystoscopic guidance transurethrally. Once the defect was sutured properly, an extracorporeal knot was prepared and tied. The length of the operation (LOO), and perioperative complications according to the Clavien-Dindo grading system were noted. The integrity of the bladder was checked with cystography to assess objective cure. Subjective cure was evaluated with Patient Global Impression of Improvement (PGI-I) scale.

RESULTS

The follow-up period of 65 participants varied from three months to eight years. The median LOO was 37 min. A Clavien grade-3 complication was observed in one patient. Peroperative failure was not noted. The median duration of hospital stays, and catheterization time was three days. Objective cure rate and subjective cure rates were 100%. UTI was not noted after surgery.

CONCLUSIONS

Transurethral complete excision of VD is an acceptable technique to prevent rUTI. The TUS-Notes technique provides a successful minimal invasive treatment option for the treatment of bladder defects.

CONCISE

Transurethral suturing of urinary bladder.

Concurrent urachal abscess and florid cystitis glandularis masquerading as malignancy: a case report and literature review

BACKGROUND

The urachus is the embryological remnant of the cloaca and allantois. Failure of its regression can cause diseases any time after birth. It is difficult to differentiate an abscess from urachal adenocarcinoma based on the clinical presentation and image findings. Cystitis glandularis reflects chronic irritation of the bladder urothelium, and tumor-like florid cystitis glandularis can be misdiagnosed as malignancy. We report a patient with concurrent urachal abscess and florid cystitis glandularis which increased the resemblance of malignancy.

CASE PRESENTATION

A 57-year-old female was incidentally found to have a heterogeneous pelvic mass abutting the urinary bladder. A cystoscopy examination revealed protruding tumors located in the bladder dome. Her blood test results were all normal, and urinalysis showed microscopic hematuria. Urachal cancer was diagnosed and en bloc excision of the umbilicus, tumor, and the involved bladder dome was performed. Pathology revealed urachal abscess with concurrent cystitis glandularis within the urinary bladder. No malignancy was identified in the resected specimen.

CONCLUSIONS

It is challenging to distinguish urachal abscess from a malignant tumor based on the clinical presentation and imaging studies. As in our case, the coexistence of urachal abscess and tumor-like florid cystitis glandularis increased the resemblance to a malignancy. This is the first reported case of the concurrence of these two disease entities, and emphasizes that the detection of bladder tumors on cystoscopy is not sufficient to make the diagnosis of urachal cancer with bladder involvement.

Small Bowel Obstruction Due to Metastatic Urachal Adenocarcinoma: A Rare Presentation

Urachal adenocarcinoma is a rare but highly malignant epithelial cancer that accounts for <1% of all bladder malignancies and commonly presents with hematuria. We report a case of metastatic urachal adenocarcinoma presenting as bowel obstruction. A 54-year-old male patient with a history of alcohol abuse presented to the emergency with acute-onset, diffuse, cramping abdominal pain, worst in the epigastrium and lasting one day. Abdominal examination revealed moderate guarding and generalized tenderness with hypoactive bowel sounds. Imaging confirmed an evolving small bowel obstruction and a urachal remnant with a superimposed mass lesion. The patient underwent an exploratory laparotomy and a high-grade small bowel obstruction due to the mass was identified. An intraoperative frozen section identified adenocarcinoma. A biopsy of the urachal mass confirmed urachal adenocarcinoma. The final diagnosis was moderately differentiated urachal adenocarcinoma. The tumor was deemed unresectable due to the involvement of multiple loops of the small bowel and the mesentery of the small and large bowels. Systemic chemotherapy with 5-fluorouracil (5-FU), leucovorin, and oxaliplatin (modified FOLFOX-6) was initiated. Our patient did not report any prior urinary symptoms or recurrent abdominal pain, which are the common symptoms that urachal adenocarcinoma presents with. Bowel obstruction is a rare presentation of urachal adenocarcinoma since the spread of the disease to the viscera occurs much later in the course. This case report highlights a rare presentation of an even rarer malignancy.

A Rare Case of Allantoic Cyst with Patent Urachus in Fetus with a Microdeletion in 1q21.1q21.2 Region

An allantoic cyst is a rare malformation with a frequency of 3 in 1,000,000 that may be seen antenatally by ultrasound assessment when the connection between the cloaca (future bladder) and the allantois fails to regress. A patent urachus that presents as a cyst (allantoic) is usually considered not to be associated with chromosomal abnormalities, but if it is not repaired after birth this leads to complications such as urinary tract infections and stone formation. We present a case of a fetus diagnosed with allantoic cyst at the first trimester ultrasound assessment at 12 weeks gestation. The follow up scans showed a decrease in size of the allantoic cyst with no other obvious major defects and, when invasive testing (amniocentesis with microarray analysis) was performed, a rare microdeletion, 1q21.1q21.2 was identified (1.82 Mb deletion).

Vesicourachal Diverticulum: A Rare Cause of Recurrent Urinary Tract Infections

Urinary tract infection is a common medical condition encountered in outpatient clinics and emergency departments. Recurrence of urinary tract infections is common. The recurrence can arise from behavioral, mechanical, and physiological factors. Urachal anomalies are very rare congenital clinical entities. We present the case of a 41-year-old woman who presented to the emergency department with dysuria, frequency, urgency, and incontinence. There was no history of fever or flank pain. Physical examination revealed no abnormalities. Initial laboratory markers were within the normal range. However, urinalysis findings showed numerous white blood cells and positive leukocyte esterase and nitrite. While these findings are suggestive of acute simple cystitis, the patient had a concerning history of recurrent urinary tract infections. The urology team advised performing an abdominal computed tomography scan to rule out any structural abnormalities. The patient underwent a computed tomography scan, which demonstrated the presence of a fluid-filled structure arising from the dome of the bladder and extending superiorly toward the umbilicus, representing a vesicourachal diverticulum. The patient underwent surgical resection after antibiotic therapy. The vesicourachal diverticulum is a very rare type of urinary tract anomalies. The case highlights the importance of considering congenital urachal anomalies in patients with recurrent urinary tract infections. A computed tomography scan can make the diagnosis of such anomalies with high accuracy.

Calcified Urachal Cancer Managed by Partial Cystectomy: A Case Report

This report presents the case of a rare and aggressive cancer originating from the urachus in a 73-year-old female. After 12 years of observation due to a cystic lesion in the bladder dome, the patient rapidly developed haematuria and mucinuria. The use of multiple diagnostic measures suggested urachal malignancy. Partial cystectomy and urachal excision along with pelvic lymphadenectomy were performed. Urachal adenocarcinoma with negative surgical margins and lymph nodes was reported in pathology. Follow-up after 12 months did not reveal any cancer relapse. Epidemiological, clinical and therapeutic features of this disease are also discussed.

Clinical and Radiological Features of Urachal Carcinoma and Infection

PURPOSE

To explore the clinical and radiological differences between urachal carcinoma and urachal infection.

METHODS

Clinical and imaging information for 13 cases of urachal carcinoma and 14 cases of urachal infection confirmed by pathology were retrospectively analyzed. The size, location, shape, margin, lesion composition, calcification, T1 and T2 signal intensity, peripheral lymph nodes, degree of enhancement, adjacent bladder wall, and apparent diffusion coefficient (ADC) value were examined in both groups, and distinguish features were determined. The student t-test or Mann-Whitney U test was used for quantitative data, and Fisher's exact test was used for qualitative data. Kappa coefficient consistency test was used to evaluate the interobserver agreement.

RESULTS

Sex, hematuria, abdominal pain, calcification, and thickening of adjacent bladder wall can distinguish between urachal carcinoma and urachal infection (p < 0.05). There were no statistical differences in age (p = 0.076), size (p = 0.797), location (p = 0.440), shape (p = 0.449), margin (p = 0.449), lesion composition (p = 0.459), T1 signal intensity (p = 0.196), T2 signal intensity (p = 0.555), peripheral lymph nodes (p = 0.236), degree of enhancements (p = 0.184) and ADC value (p = 0.780) between two groups.

CONCLUSION

The following clinical and imaging features help distinguish urachal carcinoma from urachal infection: sex, hematuria, abdominal pain, calcification, and thickening of the adjacent bladder wall.

Urachal Abscess: A Rare Etiology of Acute Abdominal Pain in Adults

Abdominal pain is a common cause of emergency department visits. It often poses a diagnostic challenge for physicians given the broad spectrum of its possible medical and surgical etiologies. We report the case of a 32-year-old man who presented to the emergency department with a complaint of lower abdominal pain for one week. Abdominal examination revealed suprapubic mass and tenderness. Laboratory investigation revealed elevated leukocyte count and inflammatory markers. An abdominal ultrasound examination showed a collection with poorly defined borders. Additionally, CT demonstrated a soft tissue mass adjacent to the anterior abdominal wall with an upward track to the umbilicus, conferring the diagnosis of a urachal abscess. The patient underwent successful management of the abscess with surgical excision. This case highlights the importance for clinicians to be aware of congenital urachal anomalies since early recognition of the urachal cyst is essential to determine the proper surgical management.

Approach to the postnatal sonographic evaluation of prenatally detected abdominopelvic cysts

Prenatally detected abdominal and pelvic masses are commonly cystic in morphology and usually seen on mid-trimester sonography. Sonography is the favored imaging modality for the postnatal evaluation of these lesions in newborns, given its availability, low cost, lack of ionizing radiation, lack of sedation, and high spatial resolution in small patients. The differential diagnosis of abdominopelvic cystic masses in newborns is broad given that they can arise from many organs and may have overlapping features on imaging. This article illustrates an approach to the postnatal sonographic evaluation of prenatally detected cystic abdominal and pelvic masses based on their anatomic location and distinctive sonographic characteristics, which can aid in an accurate diagnosis and guide appropriate management.

A rare case of urachal adenocarcinoma with bone marrow metastasis

Urachal cancer is a rare and aggressive cancer that often presents in advanced stages. Given the rarity of this malignancy, medical case studies provide one of the few sources of literature available through which clinicians can guide medical management. Surgery is widely considered to be the mainstay of therapy when disease is localised and surgically resectable, therefore most current case studies on urachal cancer focus on surgical management, occasionally with adjuvant chemotherapy. However, few case studies discuss chemotherapy alone in the treatment of metastatic disease. Most studies indicate a median overall survival between 12 and 24 months for metastatic urachal adenocarcinoma. Bone marrow metastasis of solid tumours, when considered alone, portends a poor prognosis. The patient in this case study represents a rare case of stage IV urachal adenocarcinoma metastatic to the bone marrow without progression of disease after 6 months of treatment.

Imaging of Bladder Cancer: Standard Applications and Future Trends

The evolution in imaging has had an increasing role in the diagnosis, staging and follow up of bladder cancer. Conventional cystoscopy is crucial in the diagnosis of bladder cancer. However, a cystoscopic procedure cannot always depict carcinoma in situ (CIS) or differentiate benign from malignant tumors prior to biopsy. This review will discuss the standard application, novel imaging modalities and their additive role in patients with bladder cancer. Staging can be performed with CT, but distinguishing between T1 and T2 BCa (bladder cancer) cannot be assessed. MRI can distinguish muscle-invasive from non-muscle-invasive tumors with accurate local staging. Vesical Imaging-Reporting and Data System (VI-RADS) score is a new diagnostic modality used for the prediction of tumor aggressiveness and therapeutic response. Bone scintigraphy is recommended in patients with muscle-invasive BCa with suspected bony metastases. CT shows low sensitivity for nodal staging; however, PET (Positron Emission Tomography)/CT is superior and highly recommended for restaging and determining therapeutic effect. PET/MRI is a new imaging technique in bladder cancer imaging and its role is promising. Texture analysis has shown significant steps in discriminating low-grade from high-grade bladder cancer. Radiomics could be a reliable method for quantitative assessment of the muscle invasion of bladder cancer.

Mucinous urachal adenocarcinoma: A potential nonfluorodeoxyglucose-avid pitfall on 18fluorine-fluorodeoxyglucose positron emission tomography/computed tomography

Mucinous adenocarcinoma of the urachal remnant is a nonurothelial malignancy that may be asymptomatic until locally advanced or metastatic. We describe a 37-year-old woman with invasive ductal breast carcinoma who underwent ¹⁸Fluorine-fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography (PET) computed tomography (CT) demonstrating a non-FDG avid pelvic mass, initially suspected to represent a pedunculated uterine fibroid. Magnetic resonance imaging revealed a mixed solid-cystic mass separate from the uterus, suspicious for urachal neoplasm, confirmed as mucinous adenocarcinoma on histopathology. Urachal tumors may not be FDG-avid and represent a potential pitfall on FDG PET/CT.

Embryology of the urogenital tract; a practical overview for urogynecologic surgeons

INTRODUCTION AND HYPOTHESIS

Urinary tract anomalies are one of the most common birth defects. Nevertheless, they prove challenging to diagnose as a result of variable presenting symptoms. We aimed to perform a review of urogenital tract development, highlight common congenital upper urinary tract anomalies encountered by urogynecologists and tools to facilitate diagnosis.

METHODS

Multiple searches were performed utilizing resources such as PubMed and the TriHealth library database to access publications related to embryology of the urinary tract and urinary tract anomalies. Each citation was reviewed.

RESULTS

Congenital urinary tract anomalies account for up to 20% of all birth defects and occur more often in females. The true incidence of these malformations is unknown as some can remain clinically insignificant throughout life. In addition, patients may present with non-specific complaints such as urinary tract infections, nephrolithiasis or urinary incontinence. Therefore, unsuspected anomalies pose a risk of delayed diagnosis and potential injury during urogynecologic surgery. Imaging modalities such as computed tomography or magnetic resonance imaging are the most common diagnostic tests. Management and treatment options range from observation to surgical resection with the goal of optimizing long-term functionality and prevention of chronic sequelae.

CONCLUSION

Patients with urinary tract anomalies can present with vague complaints often encountered by urogynecologists. It is crucial to understand the embryologic development of urinary tract anomalies to help facilitate diagnosis and guide care within the office and operating room setting.

Management of an Infected Vesicourachal Diverticulum in a 42-Year-Old Woman

Urachal remnant anomalies are uncommon in adults and can be confused with a variety of clinical conditions when symptomatic or infected. Vesicourachal diverticulum is the rarest type, accounting for approximately 3% to 5% of congenital urachal anomalies. We report the case of a 42-year-old female patient, who presented to the emergency department with lower abdominal pain and a palpable abdominal mass. An infected vesicourachal diverticulum was diagnosed after imaging studies and was initially treated with intravenous antibiotic therapy and drainage of the urachal diverticulum to the urinary bladder through a JJ stent. Finally, the patient underwent open surgical excision of the urachal remnant. The postoperative course was uneventful, and the histopathological examination confirmed the diagnosis of vesicourachal diverticulum. We recommend drainage of an infected vesicourachal diverticulum through the bladder by JJ stent placement inside its lumen during cystoscopy, as an alternative to percutaneous drainage reported in the literature.

Congenital and hereditary cystic diseases of the abdomen

Congenital and hereditary cystic lesions of the abdomen are relatively rare. Correct diagnosis is critical as they may simulate several other benign and malignant acquired diseases of the abdomen. With the correct and appropriate use of imaging, diagnosis may be relatively straightforward and clinical management may be implemented appropriately. The purpose of this article is to describe imaging findings of common and uncommon congenital and hereditary cystic disease of the abdominal organs.

Ultrasonographic Diagnosis of Urachal Anomalies in Cats and Dogs: Retrospective Study of 98 Cases (2009-2019)

This retrospective study investigated the prevalence of different urachal anomalies (UA) in cats (n = 60) and dogs (n = 38) and their association with clinical symptoms and urinalysis alterations. Among UA, the vesicourachal diverticulum was the most prevalent UA diagnosed in both cats (96.7%) and dogs (89.5%): the intramural vesicourachal diverticulum was diagnosed in 76.7% of cats and 71.1% of dogs, followed by extramural vesicourachal diverticulum (20.0% and 18.4% respectively). In both cats and dogs, bladder wall diffuse or regional thickening was the most prevalent alteration. The most common alterations of the urinary bladder content were urolithiasis sediment in cats (33.3%) and in dogs (31.6%). Dogs with UA were more often asymptomatic (p = 0.01). No difference was found in cats. Stranguria, hematuria, and urethral obstruction were the most frequently reported clinical signs, while hematuria and leukocyturia were the most prevalent abnormalities at urinalysis. In conclusion, our study confirmed UA as uncommon, and often incidental findings, with a high prevalence of animals without clinical signs.

Incidental vesicourachal diverticulum in a young female

A vesicourachal remnant is the rarest presentation of the congenital urachal remnant anomalies, occurring approximately in 3% of those who have them. We discuss a case where a vesicourachal anomaly is discovered incidentally in a pediatric patient by ultrasound and subsequently confirmed by MRI. The urachus connects the dome of the bladder to the umbilical cord in fetal life. After birth, this structure is obliterated and becomes the median umbilical ligament. When complete obliteration does not occur, a urachal remnant is created.

Transpubic variant of congenital prepubic sinus on magnetic resonance imaging

Congenital prepubic sinus is a very rare urogenital anomaly that manifests as a tubular structure of varying histological findings that drains to the skin overlying the pubic symphysis. This tract has been observed to course above, below or, in only a handful of cases, directly through the pubis. We report a case of congenital prepubic sinus with this unusual transpubic course in an 18-year-old man. The patient was initially taken to the operating room for excision of a presumed inclusion cyst. At the time of surgery, the collection was found to track proximally and was excised down to the level of the pubic symphysis. Subsequent magnetic resonance (MR) imaging established the diagnosis of congenital prepubic sinus. We describe the different anatomical courses of congenital prepubic sinus, hypotheses of its pathogenesis, and the use of MR imaging in both diagnosis and surgical planning.

Acute Presentation of Urachal Cyst: A Case Report

Urachus is an embryonic organ related to the bladder that degenerates after birth. Defective obliteration of the urachus leads to urachal malformations, the most common of which is a urachal cyst. A urachal cyst is often misdiagnosed due to its myriad presentations. Delay in diagnosis can lead to complications such as sepsis, fistula formation, and rupture of the cyst mimicking peritonitis. Hence, a high index of suspicion is required for the timely diagnosis and management of urachal cysts presenting in the emergency room. We report the case of a 32-year-old woman who presented with clinical features suggestive of an acute abdomen. The judicious use of imaging confirmed the diagnosis of an infected urachal cyst, which was surgically managed.

An infected urachal cyst presenting as acute abdominal pain in a child: A case report

INTRODUCTION

Urachal cyst is an exceptionally rare disease in children caused by the incomplete obliteration of the urachal remnant. Urachal cysts seldom cause symptoms unless a secondary infection occurs. The symptoms of an infected urachal cyst are nonspecific and may be similar to acute appendicitis or other acute abdominal conditions. However, complications attributable to a delayed diagnosis can endanger the life of a patient.

PATIENT CONCERNS

A 5-year-old boy presented with a 3-day history of severe intermittent lower abdominal pain.

DIAGNOSIS

Infected urachal cyst.

INTERVENTIONS

The patient was treated with surgical resection of the urachus, followed by intravenous antibiotics during the hospitalization.

OUTCOMES

The patient was discharged without incident 7 days after the operation. With his follow-up in our out-patient department, he recovered well without any sequelae in the 6 months post-surgery.

CONCLUSION

We suggested using the abdominal echo scan to differentiate the urachal cyst because of its high sensitivity and nonradioactive characteristic, and computed tomography is a typical diagnostic tool for urachal cysts. The mainstream management of an infected urachal cyst remains surgical excision. Complete excision of urachal cysts is relatively easy in a pediatric patient and the risk of subsequent infection is low; however, patients tend to have a low, although possible, risk of potential malignant transformation over their lifetimes.

Imaging Features of Urachal Cancer: A Case Report

Urachal adenocarcinoma originates from the space of Retzius. It is a rare but aggressive neoplasm. Typical imaging findings of urachal cancer are difficult to find; this report provides an ultrasonographic (US) and computed tomographic (CT) description of the above. We present a case of a 45-year-old male patient presenting with painless hematuria of 1 week's duration and display the US and CT images. Imaging shows: (1) a solid, ill-defined, irregularly shaped mass invading the bladder wall located between the dome of the bladder and the abdominal wall, and which underwent significant enhancement; (2) hypo-echoic, heterogeneous echopattern with some calcifications and (3) patchy and short-line blood flow signals within the mass. Final histopathology confirmed urachal adenocarcinoma.

Imaging of urachal anomalies

Urachal anomalies are classified into four types depending on the level of persistence of the embryonic urachal remnants between the urinary bladder and the umbilicus: patent urachus, umbilical-urachal sinus, urachal cyst, and vesico-urachal diverticulum. Due to the increasing use of cross-sectional imaging, urachal anomalies are frequently detected as incidental findings. Imaging plays a pivotal role in the initial diagnosis, evaluation of complications, treatment follow-up, and long-term surveillance of patients with urachal anomalies. Different urachal anomalies demonstrate characteristic imaging features that aid in a timely diagnosis and guide treatment. A patent urachus is visualized as an elongated tubular structure between the umbilicus and the urinary bladder. While umbilical-urachal sinus appears as focal dilatation at the umbilical end of the urachal remnant, the vesico-urachal diverticulum presents as a focal outpouching of the urinary bladder at anterosuperior aspect. Urachal cysts are identified as midline fluid-filled sacs most frequently located near the dome of the urinary bladder. Untreated urachal anomalies could progress into potential complications, including infection and malignancy. Knowledge regarding imaging features of urachal anomalies helps in timely diagnosis, treatment, follow-up, and early detection of complications.

Iatrogenic injury to a vesicourachal diverticulum during laparoscopic appendectomy successfully managed conservatively

A vesicourachal diverticulum is a rare congenital anomaly that arises from the incomplete closure of the urachus at the bladder end. We describe a 12-year-old boy who presented with severe persistent right iliac fossa pain associated with subjective fever, nausea, vomiting, and anorexia. A computed tomography (CT) scan of the abdomen and pelvis revealed findings consistent with appendicitis. The patient underwent a laparoscopic appendectomy; however, his postoperative course was remarkable for a low urine output and urine leakage from the suprapubic port site. A CT cystography showed a vesicourachal diverticulum and conservative management was offered. This management consisted of Foley catheter placement, hourly monitoring of the patient’s urine output, antibiotic prophylaxis, daily laboratory investigations and a cystography performed after 7 days. Overall, injury to the vesicourachal diverticulum is rare, and surgeons should be aware of this rare clinical entity and exercise caution during port placement. Surgeons should also have a high index of suspicion to identify these injuries and appropriately manage the condition early.