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Patent urachus
PATENT DONALD
URACHUS C.
GEIST,
M.D.
Philadelphia, Pennsylvania
C
ONGENITAL anomalies about the umbiIicus have interested physicians for many years. One of the more frequent of these is patent urachus. BarthoIomaeus Cabrolius is credited with reporting the first case of this anomaIy in 1550. Dudgeon states that there were no further reports of this condition unti1 the eighteenth century when four cases were reported. It was not unti1 the nineteenth century that appreciable series of patients with this anomaIy were coIIected. In 1916 CuIIen tabuIated sixty-two cases of patent urachus in his treatise on diseases of the umbiIicus. In 15,000 admissions to the Brady UroIogicaI Institute onIy three were concerned with the urachus. OnIy three instances of this anomaIy were recorded in 200,000 admissions to the ChiIdren’s and Infant’s HospitaI of Boston, Massachusetts. Mahoney and Ennis report that persistent urachus was an incidenta finding on six occasions in 3,446 autopsies performed from 1914 to 1935. In none of these was there an umbilicovesica1 fistuIa. Herbst gave an exceIIent and compIete review of the subject of patent urachus in 1937 and coIIected 154 instances reported in the Iiterature unti1 the time of writing his own paper. One case was added by him, bringing the tota to 155 patients. A fairIy compIete review of the accessible Iiterature since Herbst’s paper reveaIs thirty-seven more instances of patent urachus. The authors and the number of cases presented by them are Iisted in TabIe I. It wouId appear, therefore, that approximateIy 192 cases of patent urachus have been reported in the accessibIe surgica1 literature. Much of the interest in this subject centers about the embryoIogic and anatomic factors concerned. There is stiI1 no compIete agreement in the Iiterature concerning these matters. CuIIen states that the urachus is formed by the intra-abdomina1 part of the aIIantois as it continues upward from the bIadder to the umbiIicus and then to the cord. The bIadder, according to CuIIen, deveIops from the Iower part of the aIIantois. The urachus and aIIantois
soon become soIid but they frequentIy tend to deveIop spindIe-like diIatations in them. CuIIen believed that these diIatations account for the cysts often seen Iater in life and that the urachus occasionaIIy remains patent. Numerous other authors have expressed similar opinions. REPORTED
TABLE I 1936 TO JULY, 1950 No. of Cases Author
CASES
FROM
Vertan (1936). . .. . Mahoney and Ennis (1936). Rintelen (1937) Eiras (1937). Gros (1938) Slavik (1940). Dudgeonp(1940). ............... Drevfuss and Fliess ( 104 I 1. ...... Mikhelson (1941). .I .:: .‘. Meyers (1942). . POWerS (1942). . . NichoIs and Lowman (1944). . Atcheson (1944). . ... . Trimingham and McDonaId (1945) WiIIiams (1946). . . McCIeIIand and Davis (1047). Boccazzi ( I 948) Garvin (1948). . Cherry (1950). _.li
2
3
2
5 2
I
I 4 I
Begg, however, beIieves that the urachus is merely the superior extremity of the bIadder and owes nothing to the aIIantois. As the bIadder descends, it drags the urachus with it as a fibrous cord. Begg beIieves, therefore, that onIy the pathoIogic or undescended urachus extends to the umbiIicus. In 33.3 per cent of his specimens a connection between the bIadder and urachus was found. He states that the urachus extends onIy 3 to IO cm. above the bIadder apex, in most cases 5 cm. Begg consequentIy distinguishes between vesico-umbilical and uracho-umbiIica1 fistuIas. He beIieves that acquired umbiIica1 fistuIas are not due to a patent or persisting urachus but deveIop as the resuIt of urine extending upward through the tissues of the abdomina1 waI1, anterior to the peritoneum with the formation of an acquired fistuIa. In a more recent paper Hammond, YgIesias and Davis considered the probIem with somewhat different views. Their paper incIuded a 118
American
Journal
of Surgery
Geist-Patent
FIG. I. X-ray
photographs
of patent
urachus
study of thirty-five autopsy specimens from premature and term fetuses and one young child, and a carefuI examination of IOO aduIt cadavers. These authors found that the urachus couId be traced as a definite tubuIar structure from the apex of the bIadder to the umbiIicus in al1 of the fetuses. In 25 per cent of the ad& specimens the urachus was a grossIy tubuIar structure, and in another 25 per cent it was a fibrous cord. In the remaining 50 per cent the upper half of the urachus was tubuIar and the remainder formed an atrophic cord. Gross continuity of the Iumen from the bIadder to the umbiIicus couId be demonstrated in on1y two specimens, a distinct contrast to the findings in the fetal specimens. These authors cou1d not corroborate the theory of the descent of the bIadder with the urachus forming a fibrous cord. It would appear, therefore, that the findings in any individua1 patient wou1d depend greatIy on deveIopmenta1 factors occurring as the individual grew from feta1 to adu1t Iife. This wouId offer a much more p1ausibIe explanation of the varied embryo1ogic and anatomic findings and the different opinions concerning them in the surgicaI Iiterature. The symptomatoIogy, physica findings, diagnosis and treatment of this condition have been compIete1y covered in many presentations
July, ‘952
Urachus
after injection
119
with radiopaque
substance.
on the subject. Diagnosis is seIdom diffIcuIt and compIete excision is the present accepted method of treatment. The foI1owing case report is presented as an i1Iustration of a successfuIIy treated patent urachus in an infant: CASE
REPORT
M. V. W., a three month oId fema1e infant, was admitted to the pediatrics service of Misericordia HospitaI, PhiIadeIphia, on May 13, 1950. The chiId had had intermittent vomiting, moderate in frequency since birth and somewhat more marked the week before admission. The parents beIieved the child had had fever for two days prior to admission. There was nothing eIse of note in the present history and the chiId’s past medica and famiIy histories were negative. PhysicaI examination reveaIed a recta1 temperature of IOO’F. Examination was entirely norma except for the umbiIicus which showed a tluctuant area covered with a thin, greenist skin. ShortIy after admission to the hospitaI this area ruptured and thereafter drained smaI1 amounts of cIear ffuid through a tiny aperture in the lower part of the umbiIicus. This Auid had an appearance much Iike urine. UrinaIysis showed a trace of aIbumin and many white
Geist-Patent
120
blood blood
celIs. The hemoglobin was 9 gm., red cells 2,600,000 and white blood cells 25,000. Culture of the urine reveaIed Aerobactrr aerogencs. S-rag of the chest was normal, as was Ilat s-ray plate of the abdomcu. S-ray taken after injection of the opening in the umbilicus with diodrast was reported by the radiologist as showing “a somewhat tubular tract extending from the umbilicus downward and backward toward the upper margin of the bladder in the mid-sagittal plane. The appearances are characteristic of patent urachus which does not evidently communicate with the bladder.” The diagnosis of patent urachus was agreed with by the attending pediatrician and the author as surgical consuItant. The infant was given a blood transfusion and operated upon May 22, 1950. (Fig. I.) ExpIoration reveaIed a sinus tract extending from the tiny opening in the lower part of the umbilicus down to the bladder along the anterior surface of the peritoneum. The lumen was about 4 mm. in diameter and the lower end did not open into the bIadder but extended to the bIadder waI1. The entire sinus was excised, necessitating removal of a small portion of the peritoneum with it as we11 as the overlying skin. The wound was cIosed in Iayers. The child made a compIeteIy uneventfu1 recovery with primary wound healing and was discharged on the eighth postoperative day. UrinaIysis became normal without further therapy and the blood count remained norma following the bIood transfusion. The pathologist reported the specimen as being “a fistulous tract in which a bristle has been pIaced. A probe passes freeIy through the tract and the tract has a covering of skin. Sections at various IeveIs of the tract show a Iumen surrounded by marked numbers of chronic inflammatory cells and new capillaries. There is no remaining epithelium. Diagnosis: Consistent with patent urachus.” This chiId has grown normaIIy, remained we11 and has had no further symptoms or signs referabIe to the umbiIicus or urinary tract to the date of this report. REFERENCES I. ATCHESON, D. W. Patent urachus: with a report of two additionat cases. J. &I/., 5 I : 424-430, 1944. 2. BEGG, R. C. The urachus and umbiIica1 f%tuIae. Surg., Gynec. @ Obst., 45: 165-178, 1927.
Urachus 3. BEGG, R. C. The urachus: its anatomy, histoIogy and development. J. Anat., 64: 170-183, 1930. 4. BoccAzzl, C. Pathology of pntcnt urachus. Urologin, 15: ZX%ZQ2, 104x. 5. (ZIJLLEN, T. S. The Iirnbilicus and Its IXseascs. Philadt~lphia, 10 16. \I’. H. Saunders (10. 6. (:HERRY, J. I\‘. Patent urachus: review and report of a case. J. Ural., 63: 693-697, ,950. 7. DREYF~SS, M. 1_ and FLIESS, hl. hr. Patent urachus with stone formation. J. Ural., 46: 7781, 1941. 8. DUDGEON, H., JR. Patent urachus. Texas State J. Med., 34: 401-404, 1938. g. Idem. Treatment of patent urachus with report of seven cases. Surg., Gynec. P Obst., 71: 302-306 ‘940. IO. EIRAS, A. A. Vesico-umbilical fistula due to persistence of urachus: case. Rev. Ural. de Sao Paula, 4: ‘97-209, 1937. I I. GKOS, G. Persistent urachus with suppurative crachus fistula. Gybgydszat, 78: 508-5 IO, 1938. I 2. GARVIN, E. J. Patent urachus. J. UroL, 42: 463-469, 1939. 13. Idem. Patent urachus. J. Internat. Coil. Surgeons, 11: 511-516, 1948. 14. HERBST, W. P. Patent urachus. South. M. J., 30: 711-719, 1937. 15. HAMMOND, G., YCILESIAS, L. and DAVIS, J. E. Urachus, its anatomy and associated fasciae. Anat. Rec., 80: 271-287, 1941. 16. MAHONEY, P. J. and ENNIS, D. Congenital patent urachus. New England J. Med., 215: 193-195, 1936. 17. MCCLELLAND, J. C. and DAVIS, K. F. Patent urachus associated with urinary tubercuIosis. Tr. Am. A. Genito-Urin. Surgeons, 38: 13-17, 1947. 18. Idem. Patent urachus associated with urinary tubercuIosis. J. Ural., 57: 270-273, 1947. 19. MEYERS, H. A. Patent urachus. M. BuU. Vet. Admin., Ig: 233-236, 1942. 20. MIKHELSON, A. I. Late fistulas in children (umbilical). Sovet. med., 5: 37-39, 1941. 21. NICHOLS, R. W. and LowMAN, R. M. Patent urachus. Am. J. Roentgenol., 52: 615-619, 1944. 22. POWERS, H. J. M. Patent urachus with chronic suppuration. M. Bull. Vet. Admin., 19: 233-235, 1942. 23. RINTELEN, G. Persistent urachus and intraperitoneal dermoid cyst: case. Zentralbl. f. Cbir., 64: 622-624, 1937. 24. SLAVIK, J. Persistent urachus and omphatomesenteric duct: two cases. casop. /Xk. Eesk., 79: 769744. 1940. 25. TRIMINGHAM, H. L. and MCDONALD, J. R. Connenita1 anomaties in region of the umbiIicus. hrg., Gynec. +Y Obst., 80: 152-163, 1945. 26. VERTAN, E. SurgicaI therapy of congenita1 fistulas. Zentralbl. f. Cbir., 63: 145-147, 1936. 27. WILLIAMS, C. Unusual surgica1 Iesions of umbilicus: cases of congenital origin. Ann. Surg., 124: I ro8I I 24, 1946.
American
Journal
of Surgery
URACHUS C.
GEIST,
M.D.
Philadelphia, Pennsylvania
C
ONGENITAL anomalies about the umbiIicus have interested physicians for many years. One of the more frequent of these is patent urachus. BarthoIomaeus Cabrolius is credited with reporting the first case of this anomaIy in 1550. Dudgeon states that there were no further reports of this condition unti1 the eighteenth century when four cases were reported. It was not unti1 the nineteenth century that appreciable series of patients with this anomaIy were coIIected. In 1916 CuIIen tabuIated sixty-two cases of patent urachus in his treatise on diseases of the umbiIicus. In 15,000 admissions to the Brady UroIogicaI Institute onIy three were concerned with the urachus. OnIy three instances of this anomaIy were recorded in 200,000 admissions to the ChiIdren’s and Infant’s HospitaI of Boston, Massachusetts. Mahoney and Ennis report that persistent urachus was an incidenta finding on six occasions in 3,446 autopsies performed from 1914 to 1935. In none of these was there an umbilicovesica1 fistuIa. Herbst gave an exceIIent and compIete review of the subject of patent urachus in 1937 and coIIected 154 instances reported in the Iiterature unti1 the time of writing his own paper. One case was added by him, bringing the tota to 155 patients. A fairIy compIete review of the accessible Iiterature since Herbst’s paper reveaIs thirty-seven more instances of patent urachus. The authors and the number of cases presented by them are Iisted in TabIe I. It wouId appear, therefore, that approximateIy 192 cases of patent urachus have been reported in the accessibIe surgica1 literature. Much of the interest in this subject centers about the embryoIogic and anatomic factors concerned. There is stiI1 no compIete agreement in the Iiterature concerning these matters. CuIIen states that the urachus is formed by the intra-abdomina1 part of the aIIantois as it continues upward from the bIadder to the umbiIicus and then to the cord. The bIadder, according to CuIIen, deveIops from the Iower part of the aIIantois. The urachus and aIIantois
soon become soIid but they frequentIy tend to deveIop spindIe-like diIatations in them. CuIIen believed that these diIatations account for the cysts often seen Iater in life and that the urachus occasionaIIy remains patent. Numerous other authors have expressed similar opinions. REPORTED
TABLE I 1936 TO JULY, 1950 No. of Cases Author
CASES
FROM
Vertan (1936). . .. . Mahoney and Ennis (1936). Rintelen (1937) Eiras (1937). Gros (1938) Slavik (1940). Dudgeonp(1940). ............... Drevfuss and Fliess ( 104 I 1. ...... Mikhelson (1941). .I .:: .‘. Meyers (1942). . POWerS (1942). . . NichoIs and Lowman (1944). . Atcheson (1944). . ... . Trimingham and McDonaId (1945) WiIIiams (1946). . . McCIeIIand and Davis (1047). Boccazzi ( I 948) Garvin (1948). . Cherry (1950). _.li
2
3
2
5 2
I
I 4 I
Begg, however, beIieves that the urachus is merely the superior extremity of the bIadder and owes nothing to the aIIantois. As the bIadder descends, it drags the urachus with it as a fibrous cord. Begg beIieves, therefore, that onIy the pathoIogic or undescended urachus extends to the umbiIicus. In 33.3 per cent of his specimens a connection between the bIadder and urachus was found. He states that the urachus extends onIy 3 to IO cm. above the bIadder apex, in most cases 5 cm. Begg consequentIy distinguishes between vesico-umbilical and uracho-umbiIica1 fistuIas. He beIieves that acquired umbiIica1 fistuIas are not due to a patent or persisting urachus but deveIop as the resuIt of urine extending upward through the tissues of the abdomina1 waI1, anterior to the peritoneum with the formation of an acquired fistuIa. In a more recent paper Hammond, YgIesias and Davis considered the probIem with somewhat different views. Their paper incIuded a 118
American
Journal
of Surgery
Geist-Patent
FIG. I. X-ray
photographs
of patent
urachus
study of thirty-five autopsy specimens from premature and term fetuses and one young child, and a carefuI examination of IOO aduIt cadavers. These authors found that the urachus couId be traced as a definite tubuIar structure from the apex of the bIadder to the umbiIicus in al1 of the fetuses. In 25 per cent of the ad& specimens the urachus was a grossIy tubuIar structure, and in another 25 per cent it was a fibrous cord. In the remaining 50 per cent the upper half of the urachus was tubuIar and the remainder formed an atrophic cord. Gross continuity of the Iumen from the bIadder to the umbiIicus couId be demonstrated in on1y two specimens, a distinct contrast to the findings in the fetal specimens. These authors cou1d not corroborate the theory of the descent of the bIadder with the urachus forming a fibrous cord. It would appear, therefore, that the findings in any individua1 patient wou1d depend greatIy on deveIopmenta1 factors occurring as the individual grew from feta1 to adu1t Iife. This wouId offer a much more p1ausibIe explanation of the varied embryo1ogic and anatomic findings and the different opinions concerning them in the surgicaI Iiterature. The symptomatoIogy, physica findings, diagnosis and treatment of this condition have been compIete1y covered in many presentations
July, ‘952
Urachus
after injection
119
with radiopaque
substance.
on the subject. Diagnosis is seIdom diffIcuIt and compIete excision is the present accepted method of treatment. The foI1owing case report is presented as an i1Iustration of a successfuIIy treated patent urachus in an infant: CASE
REPORT
M. V. W., a three month oId fema1e infant, was admitted to the pediatrics service of Misericordia HospitaI, PhiIadeIphia, on May 13, 1950. The chiId had had intermittent vomiting, moderate in frequency since birth and somewhat more marked the week before admission. The parents beIieved the child had had fever for two days prior to admission. There was nothing eIse of note in the present history and the chiId’s past medica and famiIy histories were negative. PhysicaI examination reveaIed a recta1 temperature of IOO’F. Examination was entirely norma except for the umbiIicus which showed a tluctuant area covered with a thin, greenist skin. ShortIy after admission to the hospitaI this area ruptured and thereafter drained smaI1 amounts of cIear ffuid through a tiny aperture in the lower part of the umbiIicus. This Auid had an appearance much Iike urine. UrinaIysis showed a trace of aIbumin and many white
Geist-Patent
120
blood blood
celIs. The hemoglobin was 9 gm., red cells 2,600,000 and white blood cells 25,000. Culture of the urine reveaIed Aerobactrr aerogencs. S-rag of the chest was normal, as was Ilat s-ray plate of the abdomcu. S-ray taken after injection of the opening in the umbilicus with diodrast was reported by the radiologist as showing “a somewhat tubular tract extending from the umbilicus downward and backward toward the upper margin of the bladder in the mid-sagittal plane. The appearances are characteristic of patent urachus which does not evidently communicate with the bladder.” The diagnosis of patent urachus was agreed with by the attending pediatrician and the author as surgical consuItant. The infant was given a blood transfusion and operated upon May 22, 1950. (Fig. I.) ExpIoration reveaIed a sinus tract extending from the tiny opening in the lower part of the umbilicus down to the bladder along the anterior surface of the peritoneum. The lumen was about 4 mm. in diameter and the lower end did not open into the bIadder but extended to the bIadder waI1. The entire sinus was excised, necessitating removal of a small portion of the peritoneum with it as we11 as the overlying skin. The wound was cIosed in Iayers. The child made a compIeteIy uneventfu1 recovery with primary wound healing and was discharged on the eighth postoperative day. UrinaIysis became normal without further therapy and the blood count remained norma following the bIood transfusion. The pathologist reported the specimen as being “a fistulous tract in which a bristle has been pIaced. A probe passes freeIy through the tract and the tract has a covering of skin. Sections at various IeveIs of the tract show a Iumen surrounded by marked numbers of chronic inflammatory cells and new capillaries. There is no remaining epithelium. Diagnosis: Consistent with patent urachus.” This chiId has grown normaIIy, remained we11 and has had no further symptoms or signs referabIe to the umbiIicus or urinary tract to the date of this report. REFERENCES I. ATCHESON, D. W. Patent urachus: with a report of two additionat cases. J. &I/., 5 I : 424-430, 1944. 2. BEGG, R. C. The urachus and umbiIica1 f%tuIae. Surg., Gynec. @ Obst., 45: 165-178, 1927.
Urachus 3. BEGG, R. C. The urachus: its anatomy, histoIogy and development. J. Anat., 64: 170-183, 1930. 4. BoccAzzl, C. Pathology of pntcnt urachus. Urologin, 15: ZX%ZQ2, 104x. 5. (ZIJLLEN, T. S. The Iirnbilicus and Its IXseascs. Philadt~lphia, 10 16. \I’. H. Saunders (10. 6. (:HERRY, J. I\‘. Patent urachus: review and report of a case. J. Ural., 63: 693-697, ,950. 7. DREYF~SS, M. 1_ and FLIESS, hl. hr. Patent urachus with stone formation. J. Ural., 46: 7781, 1941. 8. DUDGEON, H., JR. Patent urachus. Texas State J. Med., 34: 401-404, 1938. g. Idem. Treatment of patent urachus with report of seven cases. Surg., Gynec. P Obst., 71: 302-306 ‘940. IO. EIRAS, A. A. Vesico-umbilical fistula due to persistence of urachus: case. Rev. Ural. de Sao Paula, 4: ‘97-209, 1937. I I. GKOS, G. Persistent urachus with suppurative crachus fistula. Gybgydszat, 78: 508-5 IO, 1938. I 2. GARVIN, E. J. Patent urachus. J. UroL, 42: 463-469, 1939. 13. Idem. Patent urachus. J. Internat. Coil. Surgeons, 11: 511-516, 1948. 14. HERBST, W. P. Patent urachus. South. M. J., 30: 711-719, 1937. 15. HAMMOND, G., YCILESIAS, L. and DAVIS, J. E. Urachus, its anatomy and associated fasciae. Anat. Rec., 80: 271-287, 1941. 16. MAHONEY, P. J. and ENNIS, D. Congenital patent urachus. New England J. Med., 215: 193-195, 1936. 17. MCCLELLAND, J. C. and DAVIS, K. F. Patent urachus associated with urinary tubercuIosis. Tr. Am. A. Genito-Urin. Surgeons, 38: 13-17, 1947. 18. Idem. Patent urachus associated with urinary tubercuIosis. J. Ural., 57: 270-273, 1947. 19. MEYERS, H. A. Patent urachus. M. BuU. Vet. Admin., Ig: 233-236, 1942. 20. MIKHELSON, A. I. Late fistulas in children (umbilical). Sovet. med., 5: 37-39, 1941. 21. NICHOLS, R. W. and LowMAN, R. M. Patent urachus. Am. J. Roentgenol., 52: 615-619, 1944. 22. POWERS, H. J. M. Patent urachus with chronic suppuration. M. Bull. Vet. Admin., 19: 233-235, 1942. 23. RINTELEN, G. Persistent urachus and intraperitoneal dermoid cyst: case. Zentralbl. f. Cbir., 64: 622-624, 1937. 24. SLAVIK, J. Persistent urachus and omphatomesenteric duct: two cases. casop. /Xk. Eesk., 79: 769744. 1940. 25. TRIMINGHAM, H. L. and MCDONALD, J. R. Connenita1 anomaties in region of the umbiIicus. hrg., Gynec. +Y Obst., 80: 152-163, 1945. 26. VERTAN, E. SurgicaI therapy of congenita1 fistulas. Zentralbl. f. Cbir., 63: 145-147, 1936. 27. WILLIAMS, C. Unusual surgica1 Iesions of umbilicus: cases of congenital origin. Ann. Surg., 124: I ro8I I 24, 1946.
American
Journal
of Surgery