What is the recommended treatment for a patient with a vesicourachal diverticulum?

Vesicourachal Diverticulum: Recommended Treatment

Surgical excision is the definitive treatment for symptomatic vesicourachal diverticulum, particularly when associated with recurrent urinary tract infections, and should include complete resection of the diverticulum with partial cystectomy of the bladder dome to ensure removal of all urachal tissue. 1, 2, 3

Diagnostic Confirmation

Before proceeding with treatment, confirm the diagnosis through:

• CT urography (CTU) as the gold standard imaging modality, which provides detailed anatomic depiction of the bladder and can identify the diverticulum extending from the bladder dome toward the umbilicus 4, 5, 3
• Cystoscopy to visualize the diverticulum opening at the bladder dome and assess for concurrent pathology 1, 2
• MRI as an alternative imaging option with excellent soft-tissue contrast for evaluating the structure and complexity of the diverticulum 4, 5

Treatment Algorithm

For Infected/Symptomatic Vesicourachal Diverticulum

Initial Management:

• Initiate intravenous antibiotics with gram-negative and anaerobic coverage (e.g., ciprofloxacin plus metronidazole or amoxicillin-clavulanate) for 4-7 days 2, 3
• Consider temporary drainage via JJ stent placement through the bladder during cystoscopy as an alternative to percutaneous drainage, allowing internal drainage of the infected diverticulum 2

Definitive Surgical Management:

• Perform complete surgical excision of the urachal remnant after infection resolution 1, 2, 3
• Include partial cystectomy of the bladder dome to ensure complete removal of all urachal tissue and prevent recurrence 1
• Repair the bladder in two layers to ensure watertight closure 1

Surgical Approach Options

Robotic-Assisted Laparoscopic Technique (Preferred):

• Offers minimally invasive approach with excellent visualization 1
• Use concurrent cystoscopy during laparoscopy to identify the diverticulum from both perspectives and confirm complete resection 1
• Dissect the diverticulum off the anterior abdominal wall after incising the anterior peritoneum 1
• Carry dissection to the bladder dome level, entering the retropubic space of Retzius as needed 1
• Verify watertight closure by retrograde bladder filling under laparoscopic observation 1

Laparoscopic Extravesical Approach:

• Transperitoneal approach is preferred 6
• Mean operative time approximately 265 minutes with minimal blood loss (<100 mL) 6
• Leave urethral catheter for 7 days for primary diverticula, 11-14 days for secondary diverticula 6

Open Surgical Excision:

• Reserved for complex cases or when minimally invasive approaches are not feasible 2

Special Considerations

When Vesicoureteral Reflux is Present

If the vesicourachal diverticulum is located near a ureteral orifice and causing vesicoureteral reflux:

• Perform ureteral reimplantation after diverticulum excision and bladder wall repair 7
• This approach successfully eradicates reflux in patients with diverticulum-associated reflux 7

Postoperative Management

• Remove urethral catheter on day 7 for uncomplicated primary diverticula 6
• Perform gravity-fill cystogram prior to catheter removal to confirm no extravasation 6
• If leakage is detected, continue catheterization for an additional 2 weeks 6
• Expected hospital stay: 3-4 days 6

Clinical Context and Rationale

Vesicourachal diverticula represent only 3-5% of congenital urachal anomalies but carry significant risks when symptomatic 1, 2, 3. The primary indications for surgical intervention include:

• Recurrent urinary tract infections (most common presentation) 1, 3
• Risk of intraurachal stone formation 1
• Increased prevalence of carcinoma after puberty 1
• Persistent symptoms despite medical management 2

Conservative management with antibiotics alone is insufficient for definitive treatment, as the structural abnormality persists and serves as a nidus for recurrent infection 2, 3.

Common Pitfalls to Avoid

• Incomplete resection of the diverticulum without including the bladder cuff can lead to recurrence 1
• Failing to perform cystoscopy during laparoscopic excision may result in incomplete visualization and inadequate resection 1
• Premature catheter removal before confirming watertight closure can lead to urinary extravasation 6
• Treating with antibiotics alone without addressing the structural abnormality will not prevent recurrent infections 2, 3
• Misdiagnosing as simple recurrent cystitis without imaging in patients with recurrent UTIs, missing the underlying structural cause 3