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Urachal remnant perforation during umbilical vein catheterization in a newborn
Journal of Pediatric Surgery (2007) 42, 722 – 724
www.elsevier.com/locate/jpedsurg
Urachal remnant perforation during umbilical vein catheterization in a newborn Peter Mattei* General, Thoracic, and Fetal Surgery, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA Index words: Perforation; Umbilical vein; Urachal remnant
Abstract Urachal remnants are uncommon congenital anomalies of the bladder that can be injured during attempted catheterization of an umbilical artery or vein. We present the case of a newborn boy who developed urinary ascites after undergoing an attempted umbilical vein catheterization. He subsequently underwent successful surgical repair of a perforated urachal remnant. D 2007 Elsevier Inc. All rights reserved.
Cannulation of the umbilical vessels is a very useful technique in the management of critically ill newborns and is generally safe and easy to perform [1]. The procedure is typically done in the intensive care nursery and requires minimal anesthesia. An umbilical vein catheter (UVC) provides convenient central venous access for at least 1 week, whereas an umbilical artery cannula provides direct arterial access without the risk of injuring a peripheral artery. When placement directly into the artery is not successful, a cutdown technique can be performed with local anesthesia. In addition to the umbilical arteries and vein, the umbilicus of a newborn infant sometimes also contains a remnant of the urachus, the lumen of which is usually obliterated [2,3]. The patent urachus is at risk for injury during attempted umbilical catheterization [4,5]. The dome of the distended bladder of a newborn infant is also at risk for perforation given its proximity to the umbilicus. We report on the case of a newborn boy who developed urinary ascites after undergoing an attempted umbilical vein catheterization. * Thoracic, and Fetal Surgery, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA. Tel.: +1 215 590 4981(office); fax: +1 215 386 4036. E-mail address: [email protected]. 0022-3468/$ – see front matter D 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2006.12.007
1. Case report A 3910-g boy was born at 37 weeks’ gestation to a 27-year-old G1P0 mother (blood type B positive, group B streptococcus positive, hepatitis B negative, HIV negative, and rapid plasma reagin negative). The mother was known to have anti-Kell antibodies as a result of a blood transfusion. The pregnancy was complicated by anti-Kell sensitization, and fetal anemia was suggested by an ultrasound examination. Labor was induced at 37 weeks, and the infant was delivered with the assistance of vacuum extraction. The total bilirubin level was 2.1 mg/dL at birth, rising to 3.1 mg/dL at 6 hours and then to 4.2 mg/dL at 11 hours. The hemoglobin level was 12.0 g/dL. Phototherapy was initiated, and an attempt was made to place a UVC for possible exchange transfusion. The catheter passed with some difficulty, and there was no blood return. The catheter was removed; a second attempt to cannulate the vein was made. This appeared to be successful, and proper positioning was confirmed by radiography. The infant remained clinically well but was noted to have clear yellowish fluid draining from the umbilicus, with no urine from the urethra, at 5 hours of life. The UVC was removed, blood cultures were sent, and the infant was given intravenous ampicillin and gentamicin.
Urachal remnant perforation during UVC in a newborn
723
2. Discussion
Fig. 1 Lateral view of the abdomen during VCUG. The patent urachus (U) can be seen as a tapered extension of the dome of the bladder going toward the umbilicus (Umb). Contrast can be seen cephalad to the urachus as it extravasates into the preperitoneal space (arrow) and eventually into the peritoneum. These findings were confirmed at operation.
On examination, the infant was well perfused and in no distress. The abdomen was mildly distended and diffusely tender. The umbilicus was moist, but frank drainage could not be appreciated. The serum creatinine level had risen to 1.4 mg/dL. A voiding cystourethrogram (VCUG; Fig. 1) was performed and revealed a collection of urine adjacent to the dome of the bladder that was consistent with a urachal remnant and extravasation of contrast into the peritoneal cavity. The infant remained stable and was prepared for surgery. Laparotomy was performed through a small transverse incision centered on the midline midway between the umbilicus and the pubic symphysis after sterile placement of a Foley catheter. The fascia was incised, and the rectus muscles were separated in the midline. This allowed for access to the anterior aspect of the bladder. The dome of the bladder could be seen tapering into a funnel-shaped process toward the umbilicus, consistent with a urachal remnant. There was a perforation of this narrow segment with free extravasation of urine. The urachus was excised, and the dome of the bladder was repaired in 2 layers with absorbable suture. The bladder was filled with saline under gentle pressure, and the repair was noted to be watertight. The abdomen was irrigated with normal saline solution; the incision was closed in standard fashion. The postoperative course was uneventful. Antibiotic therapy was discontinued on the second postoperative day, and the Foley catheter was removed after 5 days. The infant was discharged home after voiding spontaneously without difficulty. His hemoglobin level upon discharge was 10.4 g/dL without having required a transfusion.
Umbilical vein catheterization is a safe bedside procedure performed routinely in many intensive care nurseries [1]. Potential complications have been well characterized and are relatively uncommon [6]. Injury to the bladder or urachus during umbilical vessel catheterization is extremely rare and more commonly described after an attempted umbilical artery cannulation [7]. Urachal remnants are believed to result from incomplete obliteration of the allantois, which connects the yolk sac to the cloaca in the embryo. The bladder forms from the ventral aspect of the cloaca and descends into the lower abdomen by the fifth month of gestation. The urachus is an epithelialized, tubular, and fibromuscular cord between the umbilicus and the dome of the bladder that gradually narrows and becomes a fibrous band (the median umbilical ligament) by late gestation. The clinical presentation depends on which portion of the urachus remains patent [2,3]. Persistence of the entire urachus results in a congenital patent urachus, which usually presents in infancy with drainage of urine from the umbilicus (Fig. 2). A large patent urachus is sometimes referred to as a vesicoumbilical fistula and is probably caused by incomplete descent of the bladder. Persistence of the umbilical portion of the tract results in a urachal sinus, which can present with intermittent serous drainage from the umbilicus or recurrent infection, often with granulation
Fig. 2 Four commonly seen variants of urachal remnants: A, urachal sinus; B, urachal cyst; C, bladder diverticulum; D, patent urachus.
724
Fig. 3 Illustration of the cross-section of the umbilicus in a newborn with patent urachus. The urachus could be mistaken for a vein but is usually situated in the caudal portion of the cord, where it is more commonly injured during attempts to cannulate one of the umbilical arteries.
tissue at the umbilicus. Persistence of the mid portion of the urachal tract results in a urachal cyst, which is often asymptomatic but can become infected. A urachal diverticulum results from persistence of the portion of the urachus adjacent to the dome of the bladder; it is usually asymptomatic but can accompany other urachal remnants. Symptoms from a urachal diverticulum can develop in adulthood owing to infection, calculus, or carcinoma. Umbilical drainage, recurrent infection, or persistent granulation tissue should raise suspicion for a urachal remnant. The differential diagnosis also includes an omphalomesenteric duct remnant. Although VCUG has been used more frequently in the past, ultrasound is now the preferred diagnostic study for patients suspected of having a urachal remnant. It is noninvasive and accurate. A VCUG was chosen as the initial test for our patient because of the clinical concern about urinary extravasation. In some cases, a sinogram can be useful in confirming the presence of a urachal sinus or when an omphalomesenteric duct remnant is suspected. Injury of a urachal remnant is more commonly associated with attempted umbilical artery catheterization, presumably because of its proximity to the inferior aspect of the umbilicus (Fig. 3). The urachus can also be injured during umbilical arterial catheterization by surgical cut down and during laparoscopy [8]. The bladder in neonates is intraabdominal and can be close to the umbilicus when distended, placing it at risk for injury, especially during
P. Mattei umbilical artery cut down. Urinary ascites can also result from perforation of the bladder during urethral catheterization [9,10] or from manual decompression of the bladder [11], particularly in premature newborn infants. The initial treatment of perforation with urinary ascites involves placement of a Foley catheter to minimize urinary extravasation and to prevent additional injury to the bladder during manipulation of the urachus. Intravenous antibiotics are usually given, and serum electrolytes should be monitored. Any complication of a urachal remnant is best treated surgically. The operation should include excision of the remnant with meticulous closure of the defect in the bladder wall in 2 or more layers. The approach is generally via a small lower midline or transverse abdominal incision, although laparoscopic approaches have been described. With the more traditional open approach, the operation is largely extraperitoneal, which should minimize postoperative ileus and potential intraabdominal complications.
References [1] Moller JC, Reiss I, Schaible T. Vascular access in neonates and infants—indications, routes, techniques and devices, complications. Intensive Care World 1995;12(2):48 - 53. [2] McCollum MO, MacNeily AE, Blair GK. Surgical implications of urachal remnants: presentation and management. J Pediatr Surg 2003; 38(5):798 - 803. [3] Yu JS, Kim KW, Lee HJ, et al. Urachal remnant diseases: spectrum of CT and US findings. Radiographics 2001;21:451 - 61. [4] Dmochowski RR, Crandell SS, Corriere Jr JN. Bladder injury and uroascites from umbilical artery catheterization. Pediatrics 1986;77(3): 421 - 2. [5] Mata JA, Livne PM, Gibbons MD. Urinary ascites: complication of umbilical artery catheterization. Urology 1987;30(4):375 - 7. [6] Omene JA, Odita JC, Diakparomre MA. The risks of umbilical vessel catheterization in a neonatal intensive care unit. Afr J Med Sci 1979; 8(3-4):115 - 23. [7] Kaufman JM, Pai S, Austin TL, et al. Neonatal bladder injury occurring after umbilical artery catheterization by cutdown. JAMA 1983;250(21):2968 - 70. [8] McLucas B, March C. Urachal sinus perforation during laparoscopy. J Reprod Med 1990;35(5):573 - 4. [9] O’Brien WJ, Ryckman FC. Catheter-induced urinary bladder rupture presenting with pneumoperitoneum. J Pediatr Surg 1994;29(10): 1397 - 8. [10] Raupp P. Urethral catheterization in neonates—how far is too far? J Perinat Med 2002;30:440 - 1. [11] Salama H, AlJuFairi M, Rejjal A, et al. Urinary bladder perforation in a very low birth weight infant. J Perinat Med 2002;30:188 - 91.
www.elsevier.com/locate/jpedsurg
Urachal remnant perforation during umbilical vein catheterization in a newborn Peter Mattei* General, Thoracic, and Fetal Surgery, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA Index words: Perforation; Umbilical vein; Urachal remnant
Abstract Urachal remnants are uncommon congenital anomalies of the bladder that can be injured during attempted catheterization of an umbilical artery or vein. We present the case of a newborn boy who developed urinary ascites after undergoing an attempted umbilical vein catheterization. He subsequently underwent successful surgical repair of a perforated urachal remnant. D 2007 Elsevier Inc. All rights reserved.
Cannulation of the umbilical vessels is a very useful technique in the management of critically ill newborns and is generally safe and easy to perform [1]. The procedure is typically done in the intensive care nursery and requires minimal anesthesia. An umbilical vein catheter (UVC) provides convenient central venous access for at least 1 week, whereas an umbilical artery cannula provides direct arterial access without the risk of injuring a peripheral artery. When placement directly into the artery is not successful, a cutdown technique can be performed with local anesthesia. In addition to the umbilical arteries and vein, the umbilicus of a newborn infant sometimes also contains a remnant of the urachus, the lumen of which is usually obliterated [2,3]. The patent urachus is at risk for injury during attempted umbilical catheterization [4,5]. The dome of the distended bladder of a newborn infant is also at risk for perforation given its proximity to the umbilicus. We report on the case of a newborn boy who developed urinary ascites after undergoing an attempted umbilical vein catheterization. * Thoracic, and Fetal Surgery, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA. Tel.: +1 215 590 4981(office); fax: +1 215 386 4036. E-mail address: [email protected]. 0022-3468/$ – see front matter D 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2006.12.007
1. Case report A 3910-g boy was born at 37 weeks’ gestation to a 27-year-old G1P0 mother (blood type B positive, group B streptococcus positive, hepatitis B negative, HIV negative, and rapid plasma reagin negative). The mother was known to have anti-Kell antibodies as a result of a blood transfusion. The pregnancy was complicated by anti-Kell sensitization, and fetal anemia was suggested by an ultrasound examination. Labor was induced at 37 weeks, and the infant was delivered with the assistance of vacuum extraction. The total bilirubin level was 2.1 mg/dL at birth, rising to 3.1 mg/dL at 6 hours and then to 4.2 mg/dL at 11 hours. The hemoglobin level was 12.0 g/dL. Phototherapy was initiated, and an attempt was made to place a UVC for possible exchange transfusion. The catheter passed with some difficulty, and there was no blood return. The catheter was removed; a second attempt to cannulate the vein was made. This appeared to be successful, and proper positioning was confirmed by radiography. The infant remained clinically well but was noted to have clear yellowish fluid draining from the umbilicus, with no urine from the urethra, at 5 hours of life. The UVC was removed, blood cultures were sent, and the infant was given intravenous ampicillin and gentamicin.
Urachal remnant perforation during UVC in a newborn
723
2. Discussion
Fig. 1 Lateral view of the abdomen during VCUG. The patent urachus (U) can be seen as a tapered extension of the dome of the bladder going toward the umbilicus (Umb). Contrast can be seen cephalad to the urachus as it extravasates into the preperitoneal space (arrow) and eventually into the peritoneum. These findings were confirmed at operation.
On examination, the infant was well perfused and in no distress. The abdomen was mildly distended and diffusely tender. The umbilicus was moist, but frank drainage could not be appreciated. The serum creatinine level had risen to 1.4 mg/dL. A voiding cystourethrogram (VCUG; Fig. 1) was performed and revealed a collection of urine adjacent to the dome of the bladder that was consistent with a urachal remnant and extravasation of contrast into the peritoneal cavity. The infant remained stable and was prepared for surgery. Laparotomy was performed through a small transverse incision centered on the midline midway between the umbilicus and the pubic symphysis after sterile placement of a Foley catheter. The fascia was incised, and the rectus muscles were separated in the midline. This allowed for access to the anterior aspect of the bladder. The dome of the bladder could be seen tapering into a funnel-shaped process toward the umbilicus, consistent with a urachal remnant. There was a perforation of this narrow segment with free extravasation of urine. The urachus was excised, and the dome of the bladder was repaired in 2 layers with absorbable suture. The bladder was filled with saline under gentle pressure, and the repair was noted to be watertight. The abdomen was irrigated with normal saline solution; the incision was closed in standard fashion. The postoperative course was uneventful. Antibiotic therapy was discontinued on the second postoperative day, and the Foley catheter was removed after 5 days. The infant was discharged home after voiding spontaneously without difficulty. His hemoglobin level upon discharge was 10.4 g/dL without having required a transfusion.
Umbilical vein catheterization is a safe bedside procedure performed routinely in many intensive care nurseries [1]. Potential complications have been well characterized and are relatively uncommon [6]. Injury to the bladder or urachus during umbilical vessel catheterization is extremely rare and more commonly described after an attempted umbilical artery cannulation [7]. Urachal remnants are believed to result from incomplete obliteration of the allantois, which connects the yolk sac to the cloaca in the embryo. The bladder forms from the ventral aspect of the cloaca and descends into the lower abdomen by the fifth month of gestation. The urachus is an epithelialized, tubular, and fibromuscular cord between the umbilicus and the dome of the bladder that gradually narrows and becomes a fibrous band (the median umbilical ligament) by late gestation. The clinical presentation depends on which portion of the urachus remains patent [2,3]. Persistence of the entire urachus results in a congenital patent urachus, which usually presents in infancy with drainage of urine from the umbilicus (Fig. 2). A large patent urachus is sometimes referred to as a vesicoumbilical fistula and is probably caused by incomplete descent of the bladder. Persistence of the umbilical portion of the tract results in a urachal sinus, which can present with intermittent serous drainage from the umbilicus or recurrent infection, often with granulation
Fig. 2 Four commonly seen variants of urachal remnants: A, urachal sinus; B, urachal cyst; C, bladder diverticulum; D, patent urachus.
724
Fig. 3 Illustration of the cross-section of the umbilicus in a newborn with patent urachus. The urachus could be mistaken for a vein but is usually situated in the caudal portion of the cord, where it is more commonly injured during attempts to cannulate one of the umbilical arteries.
tissue at the umbilicus. Persistence of the mid portion of the urachal tract results in a urachal cyst, which is often asymptomatic but can become infected. A urachal diverticulum results from persistence of the portion of the urachus adjacent to the dome of the bladder; it is usually asymptomatic but can accompany other urachal remnants. Symptoms from a urachal diverticulum can develop in adulthood owing to infection, calculus, or carcinoma. Umbilical drainage, recurrent infection, or persistent granulation tissue should raise suspicion for a urachal remnant. The differential diagnosis also includes an omphalomesenteric duct remnant. Although VCUG has been used more frequently in the past, ultrasound is now the preferred diagnostic study for patients suspected of having a urachal remnant. It is noninvasive and accurate. A VCUG was chosen as the initial test for our patient because of the clinical concern about urinary extravasation. In some cases, a sinogram can be useful in confirming the presence of a urachal sinus or when an omphalomesenteric duct remnant is suspected. Injury of a urachal remnant is more commonly associated with attempted umbilical artery catheterization, presumably because of its proximity to the inferior aspect of the umbilicus (Fig. 3). The urachus can also be injured during umbilical arterial catheterization by surgical cut down and during laparoscopy [8]. The bladder in neonates is intraabdominal and can be close to the umbilicus when distended, placing it at risk for injury, especially during
P. Mattei umbilical artery cut down. Urinary ascites can also result from perforation of the bladder during urethral catheterization [9,10] or from manual decompression of the bladder [11], particularly in premature newborn infants. The initial treatment of perforation with urinary ascites involves placement of a Foley catheter to minimize urinary extravasation and to prevent additional injury to the bladder during manipulation of the urachus. Intravenous antibiotics are usually given, and serum electrolytes should be monitored. Any complication of a urachal remnant is best treated surgically. The operation should include excision of the remnant with meticulous closure of the defect in the bladder wall in 2 or more layers. The approach is generally via a small lower midline or transverse abdominal incision, although laparoscopic approaches have been described. With the more traditional open approach, the operation is largely extraperitoneal, which should minimize postoperative ileus and potential intraabdominal complications.
References [1] Moller JC, Reiss I, Schaible T. Vascular access in neonates and infants—indications, routes, techniques and devices, complications. Intensive Care World 1995;12(2):48 - 53. [2] McCollum MO, MacNeily AE, Blair GK. Surgical implications of urachal remnants: presentation and management. J Pediatr Surg 2003; 38(5):798 - 803. [3] Yu JS, Kim KW, Lee HJ, et al. Urachal remnant diseases: spectrum of CT and US findings. Radiographics 2001;21:451 - 61. [4] Dmochowski RR, Crandell SS, Corriere Jr JN. Bladder injury and uroascites from umbilical artery catheterization. Pediatrics 1986;77(3): 421 - 2. [5] Mata JA, Livne PM, Gibbons MD. Urinary ascites: complication of umbilical artery catheterization. Urology 1987;30(4):375 - 7. [6] Omene JA, Odita JC, Diakparomre MA. The risks of umbilical vessel catheterization in a neonatal intensive care unit. Afr J Med Sci 1979; 8(3-4):115 - 23. [7] Kaufman JM, Pai S, Austin TL, et al. Neonatal bladder injury occurring after umbilical artery catheterization by cutdown. JAMA 1983;250(21):2968 - 70. [8] McLucas B, March C. Urachal sinus perforation during laparoscopy. J Reprod Med 1990;35(5):573 - 4. [9] O’Brien WJ, Ryckman FC. Catheter-induced urinary bladder rupture presenting with pneumoperitoneum. J Pediatr Surg 1994;29(10): 1397 - 8. [10] Raupp P. Urethral catheterization in neonates—how far is too far? J Perinat Med 2002;30:440 - 1. [11] Salama H, AlJuFairi M, Rejjal A, et al. Urinary bladder perforation in a very low birth weight infant. J Perinat Med 2002;30:188 - 91.