A remnant never forgotten: the utility of circulating tumor DNA in treatment guidance of urachal cancer

Urachal cancer is a rare malignancy of the urachus that is treated with surgical resection if localized and systemic chemotherapy for metastatic disease. Circulating tumor DNA (ctDNA) is a single-stranded or double-stranded DNA released by tumor cells into the blood and harbored the mutations of the original tumor, shedding new light on molecular diagnosis and monitoring of cancer. We report a case of resected localized urachal cancer with clear surgical margins and negative lymph node dissection but elevated ctDNA that progressed to metastatic disease. We also highlight the possibility of using ctDNA levels to assist in adjuvant therapy.

Single-Port Robotic-Assisted Excision of the Urachal Remnant in an Adult Female: A Case Report

Urachal anomalies and their associated disease processes are quite rare in pediatric populations and even rarer in adults. Although often asymptomatic, patients with symptoms can be treated with a combination of surveillance, antibiotics, and sometimes surgical resection. In this case, we describe our experience using the single-port robotic approach for the excision of a symptomatic urachal remnant. The patient presented with a chief complaint of urinary frequency, dysuria, intermittent hematuria, and right flank pain. A CT scan of the abdomen and pelvis revealed a bladder wall thickening at the dome of the bladder measuring 2.6 x 3.6 x 1.5 cm with concerns for adenocarcinoma. The patient subsequently underwent a biopsy, which was benign. The patient's symptoms persisted, and she elected to undergo surgical resection. Postoperatively, her symptoms resolved, and she was satisfied with her treatment outcome. This case exemplifies the feasibility of the single-port robotic approach to urachal remnant excision, with further applicability to simple transabdominal robotic bladder surgery.

A case of mucosal-associated lymphoid tissue lymphoma of the urachus

Introduction

Urachus carcinoma is a rare malignancy with an aggressive potential and a poor prognosis, and evidence is limited for its diagnosis and treatment.

Case presentation

A 75-year-old man underwent fluorodeoxyglucose positron emission tomography/computed tomography for staging prostate cancer, and a mass (standardized uptake value max 9.5) was observed on the outside of the urinary bladder dome. T2-weighted magnetic resonance imaging showed the urachus and a low-intensity tumor, which suggested a malignant tumor. We suspected urachal carcinoma and performed total resection of the urachus and partial cystectomy. Pathological examination revealed mucosa-associated lymphoid tissue lymphoma with cells positive for CD20 and negative for CD3, CD5, and cyclin D1. After the surgery, no recurrence has been observed for more than 2 years.

Conclusion

We encountered an extremely rare case of mucosa-associated lymphoid tissue lymphoma of the urachus. Surgical resection of the tumor provided an accurate diagnosis and good disease control.

A Huge Asymptomatic Urachal Mucinous Cystic Carcinoma: A Case Report With Differential Diagnosis and Surgical Considerations

Cystic mucinous neoplasms of urachal origin cover a wide spectrum of benign and malignant lesions arising from the remnants of the urachus. They display various degrees of tumor cell atypia and local invasion, with no reported cases of metastasis or recurrence after complete surgical resection. We present a 47-year-old man who referred to our Surgical Department due to an abdominal cystic mass incidentally found upon abdominal ultrasound. He underwent en block resection of the cystic mass along with partial bladder dome cystectomy. The histopathology of the resected specimen revealed a cystic mucinous epithelial tumor of low malignant potential with areas of intraepithelial carcinoma. The patient showed no evidence of disease recurrence or distant metastasis 6 months after resection and is scheduled for follow-up with serial MRI or CT scans and blood tumor markers over the next 5 years.

A case of perforated Meckel's diverticulitis tethered to the umbilicus associated with a urachal remnant

Meckel's diverticulum (MD) occurs in 2% of the population and is often asymptomatic. It is an embryological remnant of the oomphalomesenteric duct and can be associated with another embryonic structure-the urachus. A 23-year-old male presented with generalized abdominal pain and fever on a background of chronic abdominal pain and recurrent urinary infections. A CT scan of the abdomen and pelvis revealed an inflamed MD. Next day, the patient deteriorated and was taken to theatre. The MD was found to be both perforated and tethered to the umbilicus, which itself was directly related to an abnormal extra-peritoneal structure-shown to be a urachal remnant. Such cases pose diagnostic and therapeutic challenges. Young males with chronic abdominal pain and recurrent urinary infections should be thoroughly investigated for such pathology. Laparoscopic approach to such cases should be undertaken with caution due to possible umbilical tethering.

Laparoendoscopic single-site surgery for urachal remnant with extraperitoneal approach through a suprapubic port

INTRODUCTION

No standard procedure has been established for laparoendoscopic single-site surgery for urachal remnants (LESS-U). This study aimed to report the novel surgical techniques and initial outcomes of laparoendoscopic single-site surgery with an extraperitoneal approach through a suprapubic port for urachal remnants (spLESS).

METHODS

Fifty-five patients (median age, 27 years; range, 15-69 years) who underwent LESS-U were analyzed. To overcome the limitations inherent in the conventional procedure (LESS-U through an umbilical port: uLESS), we modified the port placement and approached via the extraperitoneal space. spLESS is a novel procedure which reduces intestinal damage caused by the extraperitoneal approach and overcomes incomplete resection of the urachal remnant, especially in the bladder dome. Three trocars are inserted into the extraperitoneal space through a suprapubic port in spLESS, and complete resection of the urachal remnant from the umbilicus to the bladder is performed with an appropriate incision line. Patient characteristics and perioperative results were retrospectively collected. Cosmetic outcomes were prospectively evaluated using self-administered questionnaires (body image and photo-series questionnaire).

RESULTS

spLESS and uLESS were performed in 43 and 12 patients, respectively. No differences were observed between the perioperative results. The cosmetic outcomes were compared between the groups using body image and photo-series questionnaires. No patient developed major complications; there was no recurrence in either group.

CONCLUSIONS

spLESS is a novel procedure which can completely resect the urachal remnant and reduce the risk of intestinal damage. spLESS is a safe, effective, and feasible procedure with high postoperative cosmesis.

Evaluation and management of urachal remnants in children

BACKGROUND

This study aimed to evaluate the diagnosis and treatment of pediatric patients with urachal remnants.

METHODS

Medical records of patients diagnosed with urachal remnants between 2015-2019 were evaluated retrospectively. Age, gender, admission complaints, diagnosis, size of cysts, the complications that developed, and treatment modalities were recorded.

RESULTS

The study population consisted of 15 cases including seven girls. Most of the cases were asymptomatic. The urachal remnants were detected by ultrasonography. The most common symptom in symptomatic patients was abdominal pain and umbilical discharge. Three patients required surgery and most of them were conservatively followed up. Complication, infection, and bladder rupture were observed in one case.

CONCLUSIONS

Follow-up of patients with urachal remnants can be performed conservatively. The type of complaint and the presence of clinical and radiological regression (if any) are important for deciding the treatment during the follow-up. However, conservative follow-up is more prominent today, as shown in this study.

Early Outcomes of Laparoscopic Versus Open Surgery for Urachal Remnant Resection in Children: A Retrospective Analysis Using a Nationwide Inpatient Database in Japan

Background: There was no large study that assessed the surgical safety of laparoscopic surgery (LS) for urachal remnant resection. This study compared early postoperative outcomes between LS and open surgery (OS) for pediatric urachal remnant resection, using a national inpatient database. Patients and Methods: Using the Diagnosis Procedure Combination database in Japan, we compared postoperative complications, duration of anesthesia, postoperative length of stay, and total hospitalization cost between LS and OS for children undergoing urachal remnant surgery from April 2015 to March 2017. Propensity score-adjusted analyses were performed for outcomes. Results: Among 882 eligible patients (306 LS; 576 OS), there were no significant differences between LS and OS for postoperative complications (odds ratio: 1.02; 95% confidence interval [CI]: 0.48-2.18; P = .96) and postoperative length of stay (difference: 0.14 day; 95% CI: -0.27 to 0.54; P = .39). Compared with OS, LS had significantly longer duration of anesthesia (difference: 51 minutes; 95% CI: 42-60; P < .001) and significantly higher total hospitalization cost (difference: US$824; 95% CI: 399-1249; P < .001). Conclusions: In this large nationwide cohort study, LS for urachal remnant resection was associated with longer duration of anesthesia and higher total hospitalization cost. However, no differences were detected between LS and OS regarding postoperative complications and length of stay. LS for urachal remnant resection is equivalent to OS in terms of surgical safety.

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.

Is excision necessary in the management of adult urachal remnants?: a 12-year experience at a single institution

OBJECTIVES

To determine the ideal management of uncomplicated adult urachal remnants and to confirm if conservative management with repeated imaging is acceptable.

PATIENTS AND METHODS

This is a retrospective review of clinical notes and imaging of 45 patients with a mean age of 54.6 years who had been diagnosed with urachal anomalies at a single urology tertiary centre from January 2005 to December 2016. Patients who underwent surgical intervention and findings from patients managed non-operatively, with a mean follow up of 31 months, were evaluated.

RESULTS

Thirty (66.7%) patients had incidental findings, while 15 (33.3%) were symptomatic. Eight underwent excision, one underwent an incision and drainage of abscess, while 34 of the 36 remaining patients elected to undergo surveillance with repeated ultrasound imaging. Two were lost to follow-up. Malignancy was confirmed in three patients. There was interval stability of the urachal remnant in all the patients in the non-operative cohort. The small sample size, limited follow-up, and retrospective nature of the study are recognised limitations.

CONCLUSIONS

It was found that simple and asymptomatic lesions can be monitored with ultrasound, but effort must be made on initial diagnosis to ensure that malignancy is excluded using CT imaging and flexible cystoscopy where possible. Long-term follow-up of this cohort is required to assess the natural history of observed urachal anomalies.

Umbilical resection during laparoscopic surgery for urachal remnants

INTRODUCTION

Because urachal remnants are rare, no standard therapeutic guidelines have been established for this lesion. In recent years, laparoscopic surgery (LS) has been performed by many surgeons and urologists to treat urachal remnants. The prevention of postoperative umbilical infection and late malignant transformation are major issues in the treatment of urachal remnants. Adequate resection of the urachal epithelial tissue is required, and therefore, umbilical resection (UR) is performed. We retrospectively assessed the feasibility of this modality for urachal remnants by examining cases we have experienced as well as 210 Japanese surgical cases found through literature review.

METHODS

From January 1998 to March 2016, we experienced 14 operative cases of urachal remnants who underwent LS at Shimane Prefectural Central Hospital. We examined the types of urachal remnants and patients' ages, symptoms, surgical methods, and pathological findings.

RESULTS

We performed UR in 6 of these 14 LS patients to achieve appropriate resection of the urachal epithelial tissue. The main indication for UR was a long history of preoperative therapies for umbilical infection. The average observation period after the operation was 3.95 years, and no patients developed recurrent umbilical infection or cancer. No patients complained about the aesthetic outcome after umbilicoplasty.

CONCLUSION

We recommend that UR with LS be performed for urachal remnants to prevent any recurrent umbilical infection or malignant transformation in the future.

Villous adenoma of the urachal remnant: A diagnostic conundrum

Villous adenoma is a rare pathology seen in the urinary tract; it is mostly found in the large bowel. When encountered in the urinary tract, it mainly originates from intestinal segments of urinary reconstruction. Villous adenoma is commonly seen in patients more than 50 years and has a male predominance. In the urinary tract, it has been reported in the urachus, bladder dome and trigone. A few cases of villous adenoma have been described in the literature. We report a case of primary villous adenoma in the remnant of the urachus and discuss the pathophysiology, investigation and management.

Pediatric Xanthogranulomatous Cystitis: The First Described Case in a Pre-pubertal Male and Review of the Literature

Xanthogranulomatous cystitis (XC) is a rare condition affecting the bladder thought to be caused by chronic inflammation. Fewer than 30 cases have been reported in the literature since being first described in 1932. We present the first reported case of XC in a pre-pubertal male and review the literature. A 10-year-old boy presenting with dysuria subsequently developed frequency. After failure of conservative management, an ultrasound of the bladder revealed a mass. The patient underwent partial cystectomy. Pathology showed XC. At 10 months postoperatively, the patient remained asymptomatic and without evidence of recurrence.

Robotic-Assisted Excision of a Urachal Diverticulum

STUDY OBJECTIVE

To demonstrate a combined robotic-assisted laparoscopic technique with concomitant cystoscopy use for excision of a urachal diverticulum to ensure complete resection of diverticulum and bladder cuff.

DESIGN

Step-by-step demonstration and explanation of the procedure using video illustration. Institutional Review Board/Ethics Committee ruled that approval was not required for this case report; however, patient consent was obtained (Canadian Task Force Classification III).

SETTING

Vesicourachal diverticula account for approximately 3% to 5% of congenital urachal anomalies. Although usually asymptomatic, the diverticulum may be associated with an increased risk of urinary tract infections, intraurachal stone formation, and an increased prevalence of carcinoma after puberty. When diverticula become symptomatic or infected, surgical management is warranted.

PATIENT

A 68-year-old gravida 0 woman was evaluated with cystoscopy for recurrent culture-proven urinary tract infections. A suspected vesicourachal diverticulum was identified on cystoscopy, and the diagnosis was confirmed on computed tomography. She was counseled on management options and elected to undergo robotic-assisted excision of the urachal remnant with concomitant cystoscopy.

INTERVENTION

After identifying the diverticulum both laparoscopically and on cystoscopy, the anterior peritoneum was incised to dissect the diverticulum off the anterior abdominal wall. The dissection was carried down to the level of the bladder dome, necessitating entry into the retropubic space of Retzius. A partial cystectomy was performed to ensure complete resection of the diverticulum. The bladder was repaired in 2 layers. Concurrent laparoscopy and cystoscopy allowed for assurance of watertight closure by retrograde filling of the bladder and observing laparoscopically. Although entered, the space of Retzius is an avascular potential space between the pubic symphysis and the bladder and does not necessitate closure. Surgery was performed successfully without intraoperative or postoperative complications. On final pathology, a benign urachal diverticulum was completely excised. The patient's presenting symptoms resolved postoperatively.

CONCLUSION

Robotic-assisted excision of a vesicourachal diverticulum with concomitant use of cystoscopy is a safe, effective, and efficient technique for successful, minimally invasive, management of symptomatic urachal diverticula.

Influence of scars on body image consciousness with respect to gender following laparoendoscopic single-site versus conventional laparoscopic surgery

OBJECTIVE

The aim of this study was to evaluate and compare the cosmetic outcomes of laparoscopic single-site surgery (LESS) and conventional laparoscopy (CL) in the treatment of ureteropelvic junction obstruction (UPJO) and urachal remnant removal. LESS is thought to produce better cosmetic results than CL; however, patients' perception of their scars has not been assessed. This study compared the subjective body image and cosmesis ratings of patients who had undergone LESS or CL for UPJO and urachal remnant removal.

MATERIALS AND METHODS

Fifty patients who underwent LESS or CL for UPJO or urachal remnant removal between June 2008 and June 2015 were included. Cosmetic outcomes were evaluated using the Body Image Questionnaire (BIQ) and Photo-Series Questionnaire (PSQ).

RESULTS

The body image and cosmetic scores were significantly higher for patients who underwent LESS than for those who underwent CL, for both pyeloplasty and urachal remnant removal (p < .05 each). When performed for either a pyeloplasty or urachal remnant removal, significantly greater BIQ and PSQ scores were observed in females after LESS compared to CL, but not in males.

CONCLUSION

LESS for UPJO and urachal remnant removal has better self-reported body image and cosmesis ratings than CL. This trend is particularly strong in female patients.

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.

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.

Successful treatment of a patient with an infected urachal remnant via single-incision laparoscopic surgery: Report of a case

We report on a case of an infected urachal remnant successfully treated via a single-incisional laparoscopic technique. An 18-year-old woman was diagnosed with an infected urachal remnant. The center of the umbilicus was pulled and inverted from the skin, and the cephalic side of the urachus was dissected from the umbilicus. A single-incision laparoscopic technique employing ultrasonic coagulating shears was used to dissect the urachal remnant from the stump of the umbilicus to the caudal end. Single-incision laparoscopic excision of the urachal remnant can be used successfully as a minimally invasive technique with optimal cosmetic outcomes.

[Laparoscopic resection of persistent patent urachus]

The urachus in the foetus is a fibromuscular duct, which connects the allantois to the bladder and it is usually occluded in the 4-5th gestation months. Incomplete occlusion of the urachus at the time of birth is considered to be physiological, but later it can lead to recurrent discharge and inflammation of the umbilicus. To establish the diagnosis, ultrasound is the first examination of choice. A 19-year old obese female patient presented with umbilical discharge, and a persistent urachus was detected by ultrasound. After incision of the peritoneum the duct was excised from the umbilicus to the dome of the bladder by 3-port laparoscopy where the duct was clipped. The operation time was 38 minutes. The patient required minor analgesia on one single occasion in the postoperative period and was discharged on the first postoperative day. The authors recommend laparoscopic operation for the urachal remnant; the enlarged duct on the ventral abdominal wall can be better detected from the umbilicus to the Retzius spatium with 30-degree camera, and the cosmetic outcome is also more favourable.

Extensive xanthogranulomatous cystitis mimicking bladder cancer

Xanthogranulomatous cystitis (XC) is a rare benign disease of unknown etiology. A 39-year-old female presented with 2 month history of urgency, dysuria, lower abdominal mass. On physical examination a hard hypogastric mass was present fixed to the rectus muscle. Computerized tomography (CT) abdomen showed heterogeneous enhancing mass arising from the anterior bladder wall with infiltration of the overlying parietal wall. Cystoscopy revealed extensive growth involving the entire wall of the bladder. A biopsy showed cystitis with focal areas suggestive of urothelial neoplasia of unknown malignant potential. Suspecting bladder cancer, we proceeded with radical cystectomy with ileal conduit. Histopathology revealed cystitis cystica with XC of the entire bladder. This is, to our knowledge, the first time that a case has been found to be so extensive with infiltration of the parietal wall and second time that radical cystectomy has been performed for XC.