Management of Urachal Cyst
Primary Recommendation
Complete surgical excision of the urachal cyst with en-bloc resection of the entire urachal ligament, umbilicus, and bladder cuff is the definitive treatment for all symptomatic or discovered urachal remnants in adults. 1
Treatment Algorithm
For Adults with Urachal Cysts
Perform complete surgical excision that includes the entire urachal ligament from umbilicus to bladder dome with a bladder cuff to prevent recurrent infection and malignant transformation 1
Laparoscopic approach is preferred over open surgery, offering reduced morbidity, faster recovery (typically within 2 weeks), shorter hospital stays (mean 2.75 days), and superior cosmetic outcomes while maintaining complete excision 2, 3
Single-incision laparoscopic surgery represents an even less invasive option for appropriate candidates, using the umbilicus port for specimen removal 4
For Infants and Young Children (< 6 Months)
Observation with serial imaging and clinical examination is appropriate, as 80% of urachal remnants in patients younger than 6 months resolve spontaneously 5
Surgical excision is indicated if the remnant persists beyond 6 months of age, becomes infected, or causes persistent symptoms 5
For Infected Urachal Cysts
Proceed directly to surgical excision rather than attempting conservative management, as infected cysts rarely resolve and carry higher risk of complications 5, 3
The National Comprehensive Cancer Network emphasizes that infected cysts require complete excision to prevent recurrence 1
Critical Management Pitfalls
Incomplete Excision
Never perform partial excision or simple drainage, as retained urachal remnants carry significant risk of malignant transformation into urachal carcinoma 1
Urachal carcinoma is resistant to conventional chemotherapy used for urothelial carcinoma, making complete initial surgical excision paramount 1
Bladder Cuff Omission
Always include a bladder cuff in the resection to ensure complete removal of all urachal tissue at the bladder dome attachment site 1, 2
Patients requiring bladder cuff resection should expect longer catheterization (mean 11 days) and hospital stays (mean 14.4 days) 3
Technical Considerations
Laparoscopic Technique
Use 2-4 ports (typically two 10mm and one to two 5mm ports) for adequate visualization and instrument manipulation 2, 3
Divide the urachus and medial umbilical ligaments at the umbilicus cephalad to the cyst, then separate the specimen from the bladder dome 2
Remove the specimen intact through the umbilical port to allow complete pathological evaluation 2, 3
Mean operative time ranges from 150-210 minutes, which is acceptable given the reduced postoperative morbidity 2