WeBSurg, the e-surgical reference of Laparoscopic surgery

WebSurg is a free virtual surgical university, accessible worldwide through the Internet. Our goal is to provide surgeons, scientific societies and the medical industry with the first online continuing medical education in laparoscopic surgery and information on the latest developments in laparoscopic surgery, including NOTES and robotics.

Browse the WORLD
Virtual University
English ▼

WeBSurg, the e-surgical reference of Laparoscopic surgery

Clinical Case

TUMOR OF THE URACHUS


M Smith, MD, Hôpitaux Universitaires de Strasbourg, Strasbourg, France

1. Summary


This case gives the radiologic imaging and diagnosis of a urachal tumor. This pathology is extremely rare (with only 500 cases published in the literature). The initial surgical treatment consists of a large resection of the tumor, the bladder and the umbilicus, to assure a cure for the patient. The resection can be performed by laparoscopy.

2. Keywords


Emergency, cancer, parietal wall

3. Patient


56-year-old male

4. Past medical history


- renal colic;
- otherwise uneventful.

5. History of present illness


Patient presented with pain in the left lower quadrant and hematuria consistent with renal colic. An ultrasound is performed which confirmed the presence of a kidney stone but also revealed a mass at the bladder dome. For treatment of the stone, extra-corporeal lithotripsy is attempted but without success. The stone is extracted by cystoscopy. At time of cystoscopy the bladder walls are normal.

6. CT scan


6 cm mass, liquid and homogeneous
Figure
Figure 6.a
Figure
Figure 6.b
Figure
Figure 6.c
Figure
Figure 6.d
Figure
Figure 6.e

7. Treatment


It was decided to take the patient for exploratory laparoscopy. At the time of surgery, a tumor was found on the anterior superior dome of the bladder. A partial bladder resection was performed as well as an umbilectomy with removal of the urachal tract.

8. Postoperative period


Postoperatively pathology confirmed an adenocarcinoma of the urachus. The patient was given adjuvant chemotherapy.

9. Discussion


Urachal cancers are uncommon malignancies with a location that often permits considerable local extension before they are discovered. The most common histological type is adenocarcinoma, which may produce mucus which helps to confirm the diagnosis. The presence of stippled calcification in a midline abdominal wall mass is almost pathognomonic for urachal carcinoma. The most common clinical presentation is hematuria with pain on micturition and/or the presence of a suprapubic mass. Many lesions are visible endoscopically and, thus, the diagnosis can be made preoperatively from a biopsy. As in this case, a partial cystectomy may be considered as a surgical option. However, because of a high rate of local failure, most authors recommend an en bloc cystectomy with umbilectomy and pelvic lymphadenectomy unless the tumor is known to be a sarcoma or early stage (I) carcinoma. If these patients are undertreated and there is a local recurrence then the patient usually is not salvageable. The most common site of recurrence is local (51%), followed by lymph nodes, lung, and intraperitoneal metastases. Because of the difficulty in identifying the origin of a bladder adenocarcinoma, any tumor on the dome or anterior wall should be approached initially as if it were a urachal tumor. Chemoradiation is generally ineffective in these patients but may be offered.

10. References


  1. D'Addessi A, Racioppi M, Fanasca A, La Rocca LM, Alcini E. Adenocarcinoma of the urachus: radical or conservative surgery? A report of a case and a review of the literature. Eur J Surg Oncol 1998;24:131-3.
  2. Sheldon CA, Clayman RV, Gonzalez R, Williams RD, Fraley EE. Malignant urachal lesions. J Urol 1984;131:1-8.