What is the recommended treatment for a urachal cyst?

Treatment of Urachal Cyst

Complete surgical excision of the urachal cyst with bladder cuff resection is the definitive treatment to prevent recurrent infection and malignant transformation. 1

Treatment Algorithm Based on Clinical Presentation

Infected Urachal Cyst (Acute Presentation)

Two-stage approach is recommended when infection is extensive and severe:

• Stage 1: Initial incision and drainage with broad-spectrum antibiotics 2, 3, 4

  • This approach results in shorter hospital stays (mean 5.8 days vs 9.2 days) and fewer complications compared to single-stage excision in infected cases 4
  • Allows resolution of acute infection and inflammation before definitive surgery 3, 4

• Stage 2: Complete surgical excision after infection resolution (typically several weeks later) 2, 3, 4

  • Must include en-bloc resection of the entire urachal ligament with umbilicus 1
  • Bladder cuff excision is required 4
  • Laparoscopic approach is safe and allows rapid recovery 5, 3

Single-stage excision may be considered in select cases:

• When infection is mild or well-controlled with preoperative antibiotics 2
• However, this carries higher complication risk including enterocutaneous fistula formation (reported in single-stage cases) 4

Non-Infected Urachal Cyst in Adults

Radical surgical excision is indicated for all symptomatic or discovered urachal remnants in adults: 1, 5

• Surgical approach options:

  • Laparoscopic excision is the preferred minimally invasive technique 5, 3
  • Open surgical excision remains an alternative 2

• Extent of resection must include: 1

  • Complete urachal resection from bladder dome to umbilicus
  • En-bloc resection of urachal ligament with umbilicus
  • Bladder cuff excision

Rationale for excision even when asymptomatic: 2, 3

• Prevention of recurrent infection
• Prevention of malignant transformation (urachal carcinoma risk)
• Conventional chemotherapy for urothelial carcinoma is not effective for urachal carcinoma 1

Urachal Remnants in Infants and Young Children

Conservative management with observation is appropriate in specific circumstances: 6

• Candidates for non-operative management:

  • Patients younger than 6 months of age 6
  • Small urachal remnants without infection 6
  • 80% of remnants in patients <6 months resolve spontaneously 6

• Observation protocol: 6

  • Serial clinical examinations
  • Serial radiographic imaging to confirm resolution
  • Observation period up to 6 months of age

• Indications for surgical excision in pediatric patients: 6

  • Persistent symptoms beyond 6 months of age
  • Failure to resolve after 6 months of observation
  • Recurrent infections
  • Infected urachal cysts (9 of 12 cysts required excision, particularly those initially infected) 6

Diagnostic Workup Prior to Treatment

Imaging studies to confirm diagnosis and plan surgical approach: 2, 3, 4

• Ultrasound for initial detection 2, 3
• CT scan to define anatomy and assess for infection 2, 4
• MRI for detailed anatomic delineation 4
• Cystoscopy to evaluate bladder involvement 4

Critical Management Pitfalls to Avoid

Do not perform incomplete excision: 1

• Retained urachal remnants carry risk of malignant transformation
• Urachal carcinoma requires complete urachal resection and cannot be effectively treated with standard chemotherapy 1

Do not attempt single-stage excision in severely infected cases: 4

• Associated with longer hospitalization and higher complication rates
• Two-stage approach is safer when infection is extensive 4

Do not delay treatment in adults: 2, 3

• All urachal remnants discovered in adults should be excised
• Risk of malignancy increases with retained remnants 2, 3

Do not assume spontaneous resolution will occur after 6 months of age: 6

• Surgical excision is indicated if remnant persists beyond 6 months 6