Laparoscopic excision of urachal cyst found at preoperative examination for ovarian dermoid cyst
© Springer-Verlag Berlin/Heidelberg 2005
Published: 13 December 2005
A 30-year-old, gravida 1 para 1 married woman was referred to our hospital because of an ovarian dermoid cyst found during a regular check-up. Transabdominal ultrasonography and abdominal magnetic resonance imaging showed the presence of a cystic tumor in the preperitoneal space of the abdominal wall below the umbilicus, in addition to an ovarian dermoid cyst in the pelvic cavity. Under a diagnosis of urachal cyst, laparoscopic excision was performed using LigaSure Atlas at the same time as ovarian cystectomy.
The urachus is an embryonic tubal structure that connects the bladder top to the umbilicus (Fig. 1a), and it is formed in the early period of fetal development . The lumen of the normal urachus usually becomes obliterated or completely collapsed. However, incomplete obliteration of the urachal lumen can result in several anomalies (Fig. 1b–e) . Urachal cyst is a remnant tubal structure of the urachus formed between the bladder and the umbilicus (Fig. 1c) and is a relatively rare disorder that occurs in approximately 1/5,000 births [2, 3]. Urachal cyst is usually found at the time of infection or malignant transformation ; however, an asymptomatic urachal cyst is sometimes noted at a regular check-up .
The operating time for excision of the urachal cyst and ovarian cystectomy was 45 min, and the estimated blood loss was less than 20 ml. There were no intraoperative or postoperative complications. The patient was discharged 3 days after surgery. Six months later, she spontaneously became pregnant, and the pregnancy course was uneventful.
The urachus is a vestigial structure arising from the anterior bladder wall and extending cranially to the umbilicus within the extraperitoneal fat between the peritoneum and transversalis fascia . The urachus consists of a three-layered structure of transitional cell epithelium, connective tissue, and an outer smooth muscle layer. Derived from involution of the allantois, which begins at 4-5 months of gestation, it becomes a fibrous cord, called the median umbilical ligament, by birth. The umbilicovesical fascia surrounds the urachus and extends laterally to envelop the two obliterated umbilical arteries, called medial umbilical ligaments .
Urachal cyst develops if the urachus closes at both the umbilical and bladder ends but remains patent between these two endpoints (Fig. 1c) . It occurs primarily in the lower one-third of the urachus, while a cyst in the upper one-third, as shown in the present report, is less frequent . Urachal cyst is usually small but varies considerably in size. It becomes symptomatic when enlarged due to either infection or malignant transformation. However, it can also be found as an incidental mass during routine examination by image diagnostic procedures such as ultrasonography, computed tomography, and MRI . In the present case, images obtained by MRI were more useful than findings from transabdominal sonography because the tumor’s location in the preperitoneal space of the abdominal wall was especially evident on the MRI sagittal sectional view. Identification of a cord-like structure between the cyst and bladder top on the sagittal sectional view of MRI is also helpful for diagnosing urachal cyst.
Traditionally, excision of urachal cyst is performed by laparotomy with a transverse or midline infraumbilical incision . However, as laparoscopic instrumentation and technical skills improve, laparoscopy has increasingly been performed as an alternative to traditional open surgery to treat urachal cyst . Because urachal anomalies are rare and most such cases are treated by urologists  after symptoms become manifest, gynecologists may encounter urachal anomalies on limited occasions . As in the present case, if the urachal cyst is located near the umbilicus, preoperative diagnosis is not difficult after detection of the tumor, and treatment by a urologist may be a choice. However, if the urachal cyst is located near the bladder, it is sometimes difficult to differentiate from an ovarian cyst and may require treatment by a gynecologist after the correct diagnosis is made by laparoscopic observation . Also, if urachal cyst is incidentally found, as in the present case, during the routine examination for a gynecological disorder, a gynecological laparoscopist can positively participate in treatment because the procedure used in gynecological laparoscopic surgery can be applied to excise a urachal cyst, although a urologist’s assistance could be helpful for understanding the urachal structure and avoiding bladder injury.
Location of the first trocar insertion in this case was primarily important after identifying the urachal cyst because if the trocar were inserted at the usual position around the umbilicus, the urachal cyst could be injured, making the surgical procedures more difficult. At excision of the urachal cyst, LigaSure Atlas was useful for coagulating and cutting the tissue with minimal blood loss within a short period.
Although urachal cyst is a rare disorder, preoperative evaluation for the presence of such disorders other than gynecological disease should be carefully done to avoid unexpected complications.
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