Conservative management of a urachal remnant perforation during laparoscopic ovarian cystectomy
© Springer-Verlag 2009
Received: 27 April 2009
Accepted: 13 May 2009
Published: 13 June 2009
Complications associated with persistent urachal remnant disease have been well documented in neonates and more recently in adults. These include laparoscopic perforation. The case has previously been made for conservative management of small symptomatic urachal remnants in young infants and also for conservative management of iatrogenic cystotomies in the absence of overt sepsis using assisted bladder drainage and prophylactic antibiotics. However, to our knowledge, there has been no recent case of successful conservative management of laparoscopically perforated urachal remnant in an adult. This case describes the incidental perforation of a suspected urachal remnant in an adult female which resulted in an infected anterior abdominal wall collection. The patient was treated with assisted bladder drainage and intravenous antibiotics. Evidence of healing was demonstrated 4 weeks later using a cystogram.
A 29-year-old female with no previous medical or surgical history presented with dysmennorrhoea and hirsutism. Ultrasound demonstrated a 6-cm cyst on her right ovary, with appearances suggestive of a dermoid. She was referred to secondary care for right-sided abdominal pain and admitted for laparascopic ovarian cystectomy. A 6–7-cm right-sided dermoid cyst was removed via the suprapubic port with copious washout. The procedure was otherwise uneventful.
Post-operatively, she was unable to pass urine and required catheterisation. The next day, she developed a right-sided, erythematous and oedematous rash involving the right labia majora. This was initially thought to be an allergic chemical peritonitis from the washout fluid which was treated with chlorpheniramine and steroids. She then became pyrexial and was treated with co-amoxiclav for urinary tract infection and cellulitis. She experienced delayed return of voiding until day 5 post-operatively when she was discharged on oral antibiotics with some improvement in her rash.
She then presented 2 days later with abdominal pain and distension with vomiting. Examination revealed a grossly distended abdomen with features of tense ascites and a persistent rash. A clear fluid exudate was noted at the umbilical port scar. Laboratory analysis was consistent with a sample of urine. She was recatheterised due to ongoing voiding difficulties.
The patient was discharged 6 days after readmission once her umbilical discharge had ceased with a urinary catheter in situ. A cystogram performed 4 weeks later confirmed no residual leak. The catheter was removed, and the patient experienced no further voiding difficulties.
This case highlights a rare but manageable complication of laparoscopic surgery. Clinical clues as to the likely diagnosis in this case were the patient's persistent difficulties passing urine post-operatively, the distribution of the rash and, finally, discharge from the umbilicus. Differentials included chemical peritonitis and cellulitis.
The urachus is formed during embryological development from the remnant of the vesico-urethral portion of the urogenital sinus. In the neonate, it becomes the median umbilical ligament, a fibrous cord connecting the apex of the bladder to the umbilicus, lying in the deep surface of the anterior abdominal wall. It is bordered anteriorly by the transversalis fascia and posteriorly by the peritoneum [2, 3].
Many congenital anomalies involving the urachus are known, including urachal sinus, urachal cysts and patent urachus. Patent urachal remnant in the neonate may present with urination from the umbilicus or umbilical discharge if there is a sinus or cyst . Management of symptomatic urachal abnormalities is usually surgical involving laparoscopic radical excision of the patent urachus . However, conservative management has been advocated in patients of less than 6 months of age with small urachal remnants using assisted bladder drainage .
Cases of persistent urachal remnant and associated complications have been well documented in neonates, but cases found in adult life are rare. Most cases documented have advocated laparoscopic radical excision of the patent urachus [6, 7]. The authors have found two documented cases of perforation of a previously undiagnosed urachal remnant in an adult at laparoscopy in English language papers. In one of these cases, the patient presented 2 days after a diagnostic laparoscopy with serous umbilical discharge. A cystogram confirmed communication between bladder and umbilicus. Treatment was with prophylactic oral antibiotics and catheterisation. Normal bladder function returned after 2 weeks . In the second, also following a diagnostic laparoscopy, the patient developed generalised peritonitis within 24 h of the procedure, and the remnant was excised at emergency laparotomy . In this case, clinical presentation differed due to the unusual complication of an anterior abdominal wall collection causing a rash, for which intravenous antibiotics seemed to be effective.
Although most cases of iatrogenic bladder injury at laparoscopy are managed surgically, conservative management has been advocated in comparable situations. Angle et al.  described two cases of incidental cystotomy during primary trocar insertion at laparoscopy. These were both treated successfully with Foley catheterisation. Alperin et al.  described a series of post-hysterectomy cystotomies diagnosed post-operatively which also were successfully managed with assisted bladder drainage. They recommended that such injuries may be treated conservatively in the absence of infectious morbidity with radiological confirmation of healing.
In this case, as the perforation was uncomplicated and there was no evidence of infected urachal tissue, urologists advocated a conservative approach. We hope this case report will be a useful addition to the literature on this rare complication of laparoscopic surgery.
Conflict of interest
There is no actual or potential conflict of interest in relation to this article.
- Yu JS, Kim KW, Lee HJ, Lee YJ, Yoon CS, Kim MJ (2001) Urachal remnant diseases: spectrum of CT and US findings. Radiographics 21(2):451–461PubMedGoogle Scholar
- Moore KL (2003) The developing human. Clinically oriented embryology. Saunders, PhiladelphiaGoogle Scholar
- Snell RS (2000) Clinical Anatomy for Medical students. Lippincott Williams & Wilkins, New YorkGoogle Scholar
- Khurana S, Borzi PA (2002) Laparoscopic management of complicated urachal disease in children. J Urol 168(4 Pt 1):1526–1528PubMedGoogle Scholar
- Galati V, Donovan B, Ramji F, Campbell J, Kropp BP, Frimberger D (2008) Management of urachal remnants in early childhood. J Urol 180(4 Suppl):1824–1826; discussion 1827PubMedView ArticleGoogle Scholar
- Pust A, Ovenbeck R, Erbersdobler A, Dieckmann KP (2007) Laparoscopic management of patent urachus in an adult man. Urol Int 79(2):184–186PubMedView ArticleGoogle Scholar
- Linos D, Mitropoulos F, Patoulis J, Psomas M, Parasyris V (1997) Laparoscopic removal of urachal sinus. J Laparoendosc Adv Surg Tech A 7(2):135–138PubMedView ArticleGoogle Scholar
- McLucas B, March C (1990) Urachal sinus perforation during laparoscopy. A case report. J Reprod Med 35(5):573–574PubMedGoogle Scholar
- Yong EL, Prabhakaran K, Lee YS, Ratnam SS (1989) Peritonitis following diagnostic laparoscopy due to injury to a vesicourachal diverticulum. Case report. Br J Obstet Gynaecol 96(3):365–368PubMedGoogle Scholar
- Angle HS, Young SB (1995) Conservative management of incidental cystotomy at laparoscopy. A report of two cases. J Reprod Med 40(11):809–812PubMedGoogle Scholar
- Alperin M, Mantia-Smaldone G, Sagan ER (2008) Conservative management of post-operatively diagnosed cystotomy. Urology 73(5):1163e17–1163e19Google Scholar