Appropriate category

Case 89

2. Umbilical-urachal sinus

【Progress】
They all underwent successful surgical treatment of resection of abscess and closure of the umbilical urachal sinus

【Discussion】
Urachal duct is situated in the retropubic space which is the extra-peritoneal space between pubic synthesis and urinary bladder. The retropubic space connect to the pre-peritoneal space, behind the transverse muscle fascia and in front of peritoneum. Urachal abnormality is categorized into four types: patent urachus (urachal fistula), umbilical-urachal sinus (urachal sinus), vesicourachal diverticulum (urachal diverticulum), and urachal cyst (Fig. 7) (1-3). Patent urachus is a communicating duct between urinary bladder and umbilicus, remaining in state of fetus (before birth). Umbilical sinus is one-sided communication with umbilicus. Vesico-urachal diverticulum is one-sided communication with urinary bladder. Urachal cyst is a closed space, not communicating with umbilicus and urinary bladder. In our cases, all of them had the abscess communicating with umbilicus, which implies that heir lesions came from umbilical-urachal sinus. Urachal abnormality occurs in 2 % of the adult population (1, 2) (1000/50000 population of our city, Hannan shi).

In fetus, urachal space becomes narrow and extended associated with urinary bladder descending to the pelvis by the 4 th or 5th month of gestation. In the late fetus life and early past natal life, urachal tube normally close and shrinkages and remains as a fibrous band or a microscopically opening without function (4, 5). But it might reopen when acquired urachal remnant diseases occur such as infection or neoplasm. Our cases experienced abscess formation from the remnant of umbilical-urachal sinus.
The clinical importance is not only urachal abscess but also urachal cancer originated from vesicourachal diverticulum. Urachal carcinoma predominantly manifest as adenocarcinoma (approximately 90% of the cases) although it rarely happens in less than 0.5% of all urinary bladder cancers (6-8). However, conversely, 34 % of bladder adenocarcinoma come from urachal origin (6-8). Unfortunately, we do not have cases with urachal neoplasm treated by surgical treatment in our hospital for these ten years. This is simply because we did not have urologists and patients with urachal neoplasm would have been introduced to the other hospital.

【Summary】
We presented six patients with urachal abscess originated from umbilical urachal sinus treated by surgical procedure. It is borne in mind that urachal abnormality is categorized into 4 types: patent urachus (urachal fistula), umbilical-urachal sinus (urachal sinus), vesicourachal diverticulum (urachal diverticulum), and urachal cyst. Although not included in our cases, urachal cancer occur from vesico-urachal diverticulum and manifest as adenocarcinoma which occupies 34 % of bladder adenocarcinoma.

【References】
1.Schubert GE, Pavkovic MB, Bethke-Bedurftig BA. Tubular urachal remnants in adult bladders. J Urol 1983; 127:40-42.
2.Berman SM, Tolia BM, Laor E, Reid RE, Schweizerhof SP, Freed SZ. Urachal remnants in adults. Urology 1988; 31:17-21.
3.Blichert-Toft M, Koch F, Nielsen OV. Anatomic variants of the urachus related to clinical appearance and surgical treatment of urachal lesions. Surg Gynecol Obstet 1973; 137:51-54. Medline
4.MacNeily AE, Koleilat N, Kiruluta HG, Homsy YL. Urachal abscesses: protean manifestations, their recognition, and management. Urology 1992; 40:530-535. Crossref, Medline
5.DiSantis DJ, Siegel MJ, Katz ME. Simplified approach to umbilical remnant abnormalities. RadioGraphics 1991; 11:59-66. Link
6.Sheldon CA, Clayman RV, Gonzalez R, Williams RD, Fraley EE. Malignant urachal lesions. J Urol 1984; 131:1-8. Medline
7.Ravi R, Shrivastava BR, Chandrasekhar GM, Prahlad S, Balasubramanian KV, Mallikarjuna VS. Adenocarcinoma of the urachus. J Surg Oncol 1992; 50:201-203. Crossref, Medline
8.Beck AD, Gaudin JH, Bonham DG. Carcinoma of the urachus. Br J Urol 1970; 42:555-562. Crossref, Medline

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2018.1.24