Surgical Management of Urachal Cysts
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
Indications for Surgery
- All symptomatic urachal cysts require complete surgical excision to prevent recurrent infection and malignant transformation 1
- Surgery is indicated even for asymptomatic discovered urachal remnants in adults, as retained urachal tissue carries risk of malignant degeneration 1, 2
- Incomplete excision should be avoided as it leaves residual tissue at risk for malignancy 1
Surgical Technique
Standard Approach Components
The procedure must include en-bloc resection of:
- The entire urachal ligament from umbilicus to bladder 1
- The umbilicus itself 3, 1
- A bladder cuff at the dome 1, 4
- The medial umbilical ligaments 2
Laparoscopic vs. Open Approach
Laparoscopic excision is the preferred method as it provides equivalent oncologic outcomes with significantly reduced morbidity compared to traditional open excision 2, 4, 5
Laparoscopic technique details:
- Utilizes 2-4 ports (typically two 10mm and one to two 5mm ports) 2, 4
- Transperitoneal dissection of the urachal remnant 4
- Division of urachus and medial umbilical ligaments at the umbilicus 2
- Separation from bladder dome with or without bladder cuff 2
- Intact specimen removal, typically through the umbilical port 4, 5
Operative outcomes with laparoscopic approach:
- Mean operative time: 150-210 minutes 2, 4
- Hospital stay: 1-4 days (mean 2.75 days without bladder cuff; longer with bladder cuff resection at 14.6 days) 2, 4
- Return to normal activity within 2 weeks 2
- No intraoperative or postoperative complications reported in multiple series 2, 4, 5
Critical Management Considerations
When Bladder Cuff Resection is Performed
- Foley catheterization required for approximately 11 days postoperatively 4
- Hospital admission extended to mean of 14.4 days 4
- No voiding difficulty reported at long-term follow-up (mean 46.3 months) 4
Pathologic Evaluation
- All excised specimens must undergo pathologic evaluation to rule out malignancy 2, 4
- Most cases are benign infected urachal cysts, but urachal adenocarcinoma can occur 4
Common Pitfalls to Avoid
Incomplete excision is the primary pitfall - any retained urachal tissue carries malignant transformation risk and may lead to symptom recurrence 1, 2
Do not perform simple drainage or partial excision - wide surgical excision of all anomalous tissue is mandatory 4, 6
Ensure bladder cuff inclusion - the bladder attachment site must be excised to achieve complete removal 1, 2
Special Consideration for Malignancy
If urachal carcinoma is identified (rather than benign cyst), conventional chemotherapy for urothelial carcinoma is not effective, and complete surgical resection becomes even more critical 3, 1