Esther H Cha, MD, David Lisle, MD, P. Jeffrey Ferris, MD. Medstar Health Baltimore
Introduction: Urachal ramnants result from a failure in the obliteration of the allantois at 4 – 5th week of gestation which connects the bladder to the umbilicus. This congenital anomaly occurrence is rare occurring about 1.6% in children and less than 1% in adults. We present a rare case of adult patent urachus presenting as a colovesical fistula complicated by chronic sigmoid diverticulitis managed by laparoscopy.
Case Presentation: A 63-year-old gentleman referred to a colorectal surgeon’s office from his urologist for evaluation of symptoms consistent with pneumaturia. He described passing occasional gas during urination and feculent urine. However, he denied having any night sweats, fever, chills, or unintentional weight loss. As his preoperative work-up, patient obtained contrast-enhanced computed tomographic (CT) cystogram which revealed thickened bladder dome and adjacent sigmoid colon inflammation, and air in the bladder concerning for colovesical fistula. Subsequently, he underwent colonoscopy which had to be aborted due to severe inflammation at the proximal sigmoid colon due to diverticular disease. Then the patient was taken to the operating room for a laparoscopic resection. Once splenic flexure was mobilized laparascopically, it was noted that the thickened sigmoid colon was adherent to the lower mid-abdomen entering a triangular structure located superior to the dome of bladder. This patent urachus along with the segment of adherent sigmoid colon were resected and extracted with small midline incision. Final surgical pathology revealed chronic diverticulitis of the sigmoid colon and colo-urachus fistula without any malignancy. Patient had uncomplicated postoperative recovery course and was discharged home on postoperative day 7.
Discussion: The persistent urachal lumen has variety of clinical presentations, most commonly as periumbilical skin infection. Involution of this allantoic duct and cloaca becomes fibrotic cord known as the median umbilical ligament. There are four variants of urachal anomalies: cysts, sinus, diverticulum or a patent urachus. Urachal remnants progressing to malignancy are rare, less than 1%, and most common malignancy type is urachal adenocarcinoma. Surgery remains as the primary treatment option. The traditional surgical approach to resection involves excision with low midline laparotomy or semicircular infraumbilical incision. Few reports include laparoscopic and robotic approaches with safe, successful outcomes.
Conclusion: Adult urachal remnant is rare and surgery is the treatment of choice as it prevents both recurrence of symptoms and malignant transformation. Laparoscopy is a useful and safe technique for the management of persistent or complicated urachus.
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Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 93591
Program Number: P304
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster