Urachal cysts and their complications

URACHAL CYSTS AND THEIR COMPLICATIONS LESLIE L . NUNN, M .D. Vancouver, Wasbington

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TRACHAL cysts, especially those accompanied with complications, are of sufficient rarity to warrant this report of two cases observed within the past few years . These developmental defects are not particularly uncommon but seldom, if ever, are they brought to the attention of the physician until drainage from the umbilicus occurs or an inflammatory mass appears at the umbilicus, or somewhere between the umbilicus and the dome of the urinary bladder . In embryonic life the allantois is a component of the umbilical cord, forming a direct connection between the placenta and the cloaca ; the latter structure later becomes divided ; that portion to which the allantois is attached forms the urinary bladder ; the allantois becomes obliterated and is then known as the urachus . Some writers' hold that this structure remains more or less patent and lined with epithelium, which may account for the foulsmelling discharge from the navel, usually the symptom which brings the patient to the physician . Vaughan (quoted by Herbst') classified urachal anomalies as follows : (i) the duct being completely patent between bladder and navel ; (2) the blind internal, that is, the navel remaining closed, the duct communicating with the bladder ; (3) the blind external, the bladder being closed, the duct communicating with the navel ; and (q,) the blind, both ends being closed and the middle remaining open .

a connection with the descending colon, it was thought to represent a large diverticulum . The urachal cyst without infection usually presents no symptoms and is evidenced only by the tumor mass ; infection, however, or blockage of the umbilical opening leads to extension of the mass along fascial planes and those phenomena associated with inflammatory masses elsewhere, for example, pain, tenderness, local heat and redness, chills, fever, leukocytosis and, if connected with the bladder, pyuria and cystitis . TREATMENT

Treatment is entirely surgical, but before excision is decided upon it is imperative that it be determined which type of urachal anomaly one is dealing with, whether this is a blind cyst or whether it connects with bowel or bladder . In numerous early case reports cited by Herbst 2 the treatment in infants was ligation and/or compression of the umbilical mass, frequently with recurrence . In all cases cystoscopy should be carried out previous to surgery . Excision of the tract or cyst is the method of choice, although in one of the two cases herein reported it was deemed advisable, due to the exigencies of war, to treat the cyst by marsupialization in much the same manner of the Buie exteriorization of pilonidal cyst . In excising the cyst it is desirable to avoid entering the peritoneal cavity ; but if the involvement is extensive, it is usually necessary to do so .

SYMPTOMATOLOGY AND DIAGNOSIS

Herbst,' in an exhaustive study of patent urachus, collected one hundred forty-eight cases which had been reported from 1550 to 1937 and found that the predominant symptom was an umbilical tumor mass . Next in frequency was discharge from the umbilicus ; this is usually thick, mucopurulent and offensive and in certain classes of individuals is often mistakenly diagnosed as an inflammatory condition resulting from uncleanliness . In some cases the mass reaches such proportions that it may be taken for an ovarian cyst or in the instance of Sawyer's' case, in which there was

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CASE REPORTS CASE I . J . J ., a white male, officer, age twenty-seven, entered the Barnes General Hospital September 1, 194,1, because of a discharge from the umbilicus which had been present for three weeks ; associated with the discharge were pain, tenderness and an inflammatory periumbilical mass and swelling extending downward from the umbilicus for a distance of 2 inches . Upon close questioning he denied having previously experienced any discharge from the umbilicus . He recently had been on maneuvers during which time sanitary

American Journal of Surgery

Nunn-Urachal Cysts and Their Complications conditions had been very undesirable and bathing facilities practically nil . Previous medical history revealed the usual common childhood diseases and otherwise nothing of importance relative to the present condition .

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right lower abdominal quadrant, fever, pyuria and drainage from the umbilicus . This mass had first appeared in 1944 and was thought to be an incisional hernia as a result of an appendectomy performed in 1941 . In 1948 the patient had a bout of fever pyuria, hematuria

FIG . I . Case ii . Schematic representation of urachal cyst which involves both bladder and ileum .

A diagnosis of infected urachal cyst was made and urologic consultation was requested which resulted in a completely negative survey . A sinus opening at the umbilicus was probed for a distance of 4 cm . resulting in foul-smelling purulent material which upon culture revealed Staphylococcus aureus . Hot packs and repeated probing resulted in diminution of the mass and subsidence of the acute cellulitis . On September 15th the mass was incised in its entire length and was found to consist of a pouch about i cm . in diameter and extending downward from the umbilicus a distance of 4.5 cm . This was treated by curettage and packing . The wound healed by granulation and epithelization within two weeks and the officer was returned to duty . CASE II . In 1949 H . S ., a white man, age forty-one years, complained of a mass in the August, 195 .2

and weight loss . This chain of events recurred several times during 1948 and 1949 previous to his coming under my observation and on several occasions he stated he passed gas by urethra and more lately through the umbilical sinus . Examination on December 14, 1949, showed an emaciated white man obviously quite ill, weighing 112 pounds . He was alert and cooperative . Examination of head, neck and chest was normal . The abdomen was scaphoid, revealing an old, right rectus scar and a draining sinus of the umbilicus surrounded by a zone of cellulitis. There was a mass approximately 4 by 9 cm . extending from the umbilicus downward and beneath the right rectus muscle, which mass was attached to the abdominal wall proper and moderately tender . No other mass or organs were palpable . Rectal exami-

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Nunn--Urachal Cysts and Their Complications

Fic .

2.

Case

II.

nation was normal . Temperature was loo ° F ., pulse 9o, respirations 20 . Examination of the blood showed erythrocytes 4,520,000 per cu . mm ., hemoglobin 13 .0 gm . per cent, leukocytes 17,250 per cu . mm ., small lymphocytes 14 per cent, neutrophiles 71 per cent, staff cells 15 per cent, sedimentation rate 5/54 . The urine showed a trace of albumin and a centrifuged specimen was packed with pus cells and motile bacteria . Urine culture resulted in a heavy growth of Escherichia coli ; culture of drainage from an umbilical sinus also resulted in a growth of the same organism . A cystogram was made on December 21, 1949, which did not reveal a "connection between the bladder and any opening which could be classified as a urachus ." "There were some irregularities in the surface of the dome of the bladder compatible with inflammatory changes ." The sinus was injected with sodium iodide and was found to spread out in a wide irregular manner deep within the right lower abdominal quadrant over an area io to 12 cm . in different directions . A diagnosis of urachal cyst with probable communication with bowel and bladder was made . (Figs . i and 2 .) Operation was performed on December 28, 1949. A ureteral catheter was first inserted into

Coronal section .

the umbilical sinus, 5 cc . of methylene blue injected and the catheter left in place . An incision was made around the umbilicus to excise this area and extending down to the symphysis pubis . Upon incising the deep fascia a cord-like mass was revealed extending from umbilicus to bladder . Great difficulty was encountered in dissecting this structure because of surrounding inflammatory reaction . The peritoneum was incised to the left of the midline and the mass was found to be adherent to several loops of ileum with an apparent sinus tract into one loop . Further dissection proved that the mass extended downward over the anterior wall of the bladder and a cord-like structure was attached at the dome . The sinus tract continued downward into the space of Retzius at which point it was detached from the bladder wall releasing a quantity of methylene blue . The bladder wall was repaired and at the advice of Dr. Robert Fitzgerald a large Pezzar catheter was sutured into the bladder . The mass was then reflected upward and detached from the terminal ileum leaving a defect in the bowel which also contained methylene blue . Repair of this defect resulted in such a narrowing of the lumen it was deemed advisable to establish an ileocecostomy around the mass of adherent, thickened loops of terminal ileum American Journal of Surgery



Nunn-Urachal Cysts and Their Complications rather than subject the patient to resection in the face of his then rather poor condition . A cecostomy tube was brought out through a stab wound . Careful closure was accomplished with catgut throughout . (Fig . 3 .) This patient's convalescence was completely

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Vaughan and can be very easily cured by exteriorization or marsupialization and simple packing. The second case represents the completely open urachus complicated by communication with the bowel and bladder and with abscess formation . It is difficult to explain why

FIG . 3 . Case u, Cyst has been resected ; note anastomosis between terminal ileum and ascending colon because of strictured ileum .

without incident . Dr . Fitzgerald supervised the care of the bladder for a few days and removed the catheter on the fifth day at which time the patient voided clear urine spontaneously . The cecostomy tube was removed on the eighth day at which time the patient was having normal bowel movements . He was discharged from the hospital on the fourteenth day after operation in excellent condition . One year after operation he had gained 40 pounds in weight and was completely free from any symptoms referable to bowel or bladder . Blood and urine examinations were normal . COMMENTS

The first case herein reported conforms to the so-called "blind external" cyst described by August, 1952

repeated attempts to demonstrate a communication between the bladder and cyst failed unless some sort of valve-like fold existed at the point of entrance . In this type of case it is believed that resection en bloc without opening into the sinus is the operation of choice . It is extremely important that the bladder be given a great deal of care both before and after operation and that antibiotics be used freely . REFERENCES i . DREYFUSS, M . L . Benign and malignant lesions of the urachus, with special reference to colloid carcinoma of the bladder . Virginia M. Monthly, 70 : 200204, 1943 . 2 . HERBST, W . P . Patent urachus . South . M. J ., 3o : 7 : 1937 ; 711-719 . 3 . SAWYER, C . F . Cysts of the urachus, Arcb . Surg ., 50 : 174-176, 1945 .