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Year : 2005  |  Volume : 15  |  Issue : 3  |  Page : 357-360
Case report : Urachal pathologies


Department of Radio-diagnosis Gujarat Cancer and Research Institute, Asarwa, Ahmedabad - 380016, India

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Keywords: Urachal Cyst, Urachal Malignancy, USG, CT Scan

How to cite this article:
Soni H C, Patel S B, Shah S R, Patel H, Patel D. Case report : Urachal pathologies. Indian J Radiol Imaging 2005;15:357-60

How to cite this URL:
Soni H C, Patel S B, Shah S R, Patel H, Patel D. Case report : Urachal pathologies. Indian J Radiol Imaging [serial online] 2005 [cited 2019 Nov 12];15:357-60. Available from: http://www.ijri.org/text.asp?2005/15/3/357/29156

   Introduction Top


Urachus is extension of uro-genital sinus, seen in adult as fibromuscular. It gives rise to variety of pathologies. Most common Urachal cyst occurs due to non-fusion of urachus during later half of fetal life. There is also high incidence of spontaneous abortion and other obstretic complication. Urachal adenocarcinoma is a rare tumour from the urachus. It commonly invades dome of urinary bladder and Anterior abdominal wall. Most of the carcinoma are adenocarcinoma, rarely can give rise to Transitional cell carcinoma.

We report case of infected urachal cyst and urachal malignancy


   Case report Top


# 1

A 65 years old female patient presented with lower abdominal mass since 2 years, abdominal pain since 1 year and purulent discharge for last 8 days. On examination per abdomen, huge mass arising from pelvis reach up to 2 cm. above umbilicus. Circular infected 2 x 2 cm. ulcer noted over umbilicus with white discharge coming out through that.

USG examination was performed at our institute by 3.5 MHz convex and 6.5 MHz sector probe on RT 3200 Advantage II machine. USG revealed presence of huge collection with thick irregular wall noted, starting from umbilicus up to pelvis[Figure - 1]. Hypo-echoic band noted extending from lower end of lesion up to dome of Urinary Bladder[Figure - 2]. Thus it was diagnosed as infected urachal cyst. Transvaginal Sonography was performed which revealed Bicornuate Bicollis Uterus. Both uterine horns were widely apart. There was evidence of slit like collection in both endometrial cavities. There was no evidence of mass in either adnexal region. Free fluid was noted in Pouch of Douglas.

Infected urachal cyst was drained under General Anesthesia.

# 2

A 50 years old male patient with dull aching lower abdominal mass, pain and single episode of hematuria. Patient was initially adviced for CT scan Abdomen-Pelvis. NCCT showed presence of heterogenous density lesion with few specks of calcification, starting below umbilicus and extending up to dome of Urinary Bladder and involving it[Figure - 3]. CECT showed huge moderately enhancing mixed density mass involving the antero-superior wall of the bladder in the midline with large supra vesicle component in the space of Retzius. The fat plane between the mass lesion and the anterior abdominal wall is lost with invasion to anterior abdominal wall[Figure - 4]. There was no evidence of regional lymphadenopathy or metastasis. We kept diagnosis of urachal malignancy involving urinary bladder.

At surgery, partial cystectomy was done and the tumour with 5 cm. of surrounding normal bladder wall was removed along with the umbilical and infra umbilical part of the abdominal wall.

Histopathology revealed adenocarcinoma of urachal origin.

# 3

A 45 years male patient presented with pain in lower abdomen since 6 months with off and on episodes of hematuria. Patient was initially adviced CT scan Abdomen-pelvis. Contrast enhanced CT scan showed an inhomogenous enhancing mixed density mass with low density area just posterior to anterior abdominal wall in space of Retzius. Fat plane between mass and anterior abdominal wall is preserved [Figure - 5]. MPR shows anatomical location of lesion[Figure - 6]. There is no evidence of regional lymphadenopathy or distal metastasis. We kept diagnosis of primary urachal malignancy.

At surgery partial cystectomy was done and the tumour with 5 cm. of surrounding normal bladder wall was removed along with the umbilicus.

Histopathology revealed Transitional Cell Carcinoma of Urachus.

# 4

63 years old male patient presented with complains of swelling and pain in lower abdomen. Patient was initially advised CT Scan. CECT showed presence of heterogenous enhancing mass lesion just posterior to anterior abdominal wall involving it. There is no evidence of lymphadenopathy or distal metastasis. We put diagnosis of urachal malignant lesion. Patient was operated and histopathology revealed adenocarcinoma of Urachus.


   Discussion Top


The urachus is a musculofibrous band that is extension of the uro-genital sinus. This band extends from the Urinary bladder dome to umbilicus. In foetus, it is contiguous with the allantois. The urachus lies in the space of Reitzius, between transversalis fascia anteriorly and the peritoneum posteriorly. In 70% of adults a small lumen lined by transitional epithelium remains in urachus. There are four type of congenital urachal anomalies. There is a 2:1 predominance in males. Patent urachus 50%, urachal cyst 30%, urachal sinus 15%, urachal diverticulum 5%. The urachal cyst forms if the urachus closes at the umbilical and bladder ends but remains patent in between space which gets distended gradually by secretion of lining glands. The cyst is usually situated in the lower 1/3 of the urachus[1]. There is an increased incidence of adenocarcinoma. On USG, urachal cyst appears as cystic anechoic lesion with posterior enhancement. Thick irregular wall and presence of debris within cyst on USG suggests infected cyst. Remnant of lower part of urachus noted as hypoechoic band from lower end of cyst to dome of Urinary bladder. NCCT shows cystic lesion with peripheral contrast enhancement on post contrast study. Infected cysts shows thick irregular enhancing wall with high density content of cyst.

The fused caudal ends of two Mullerian ducts form the uterus, cervix and upper vagina whereas the unfused cranial cranial ends form the paried  Fallopian tube More Detailss. Fusion occurs in cephalic direction, and the median septum formed by the medial walls of the Mullerian ducts resorbs, leaving a single uterine cavity. Failure of fusion of the Mullerian ducts may be complete or partial. When partial it forms bicornis unicollis uterus and when complete it forms bicornis bicollis uterus. Urinary tract developmental anomalies are usually associated with genital tract anomalies.

In some patients, the epithelium of urachus can undergo metaplasia to become glandular epithelium. This may results in to malignancy usually Mucinous adenocarcinoma[2],[4]. Most (90%) of urachal carcinoma are juxta vesical, specifically supra-vesical, antero-supoerior to the bladder or in mid line.

The pathogenesis of urachal carcinoma is poorly understood. Adenocarcinoma is believed to arise from malignant transformation of columnar metaplasia in as many as 84% of patients. However in 3%, it arises from metaplastic conversion of transitional cell epithelium to glandular epithelium. About 70% of urachal carcinoma is mucin producing adenocarcinoma and 15% are non-mucin producing adenocarcinoma. Incidence of Transitional cell carcinoma arising from remnant of transitional epithelium is low. 75% of urachal neoplasm in patient less then 29 years of age are sarcomas. Rarely squamous cell carcinoma can also occur.

Malignant lesions of urachus are usually located Supravesically, in midline, anterior80%, in space of Retzius, which is bounded by transversalis fascia ventrally and peritoneum dorsally.


   Staging Top


I - Cancer limited to the urachus.

II - Invasion limited to the urachus.

IIIA- Local invasion of bladder.

IIIB - Invasion of abdominal wall.

IIIC - Invasion of peritoneum.

IIID - Invasion of other visera

IVA - Metastases to local lymph nodes.

IVB - Distant metastases.

Mortality is based on the stage of presentation. Early detection is important in preventing death because urachal cancer that are found early have good prognosis. However in 50% of patients the disease is fatal. The 5 years survival rate is less then 16%[2]. The poor prognosis is the result of late presentation of patient, tendency of early local invasion and distal metastasis.

Plain radiographic findings usually are normal, although a few urachal carcinomas can be calcified enough to be depicted on plain radiographs.

Plain and contrast enhanced study of abdomen and pelvis is helpful in diagnosis and staging of lesion. CT scan shows hypodense lesion with heterogenous contrast enhancing mass just posterior to anterior abdominal wall in space of Retzius. The lesion has tendency to involve dome of Urinary bladder and anterior abdominal wall. It also shows presence of calcification which is often dotted, stippled or curvilinear[3],[5]. Multiplanner reconstruction

of lesion helps in better explanation of extent to surgeon. MRI has got advantages of multi-planner capacity, better soft tissue contrast and lack of radiation exposure. MRI appearance of urachal carcinoma depends on the composition of the tumor. Most of tumors have extremely high signal intensity on T2 weighted images because of their mucoid composition.

Treatment of localized bladder dome urachal cancer includes surgery to remove the cancer and the bladder, in whole or in part. This removal may be accompanied by en block resection of the umbilicus and bilateral pelvic lymphadenopathy[5]. Many advocate the use of radiation therapy because the most common area of recurrence is at or near the bladder dome. The use of chemotherapy in treating urachal cancer remains experimental.

 
   References Top

1.Gerald W, Friedland, Pieter A devries, Matilde Nino- Murcia-congenital Anomalies of Urachus & bladder in clinical urography-2nd edition Philadelphia- W B saunders Howard M Pollack 2000 pg. No 829-831.  Back to cited text no. 1    
2.Wolfgang Dahnert- Radiolgy Review Manual- 4th ed.- 1999- pg. 814- Philadelphia- Lipppincott- Raven, William & Wilkins.  Back to cited text no. 2    
3.Brick SH, Freidman AC, Pollack HM, et al: Urachal carcinoma CT findings. Radiology 1988 Nov, 169 (2): pg. 377-81.  Back to cited text no. 3    
4.Narumi Y, Sato T, Kuriyama K, et al: vesical dome tumours: significances Of extravesical extension on CT. Radiology 1988 Nov; pg. 383-385  Back to cited text no. 4    
5.Sheldon CA, Clayman RV, Gonzalez R, et al: Malignant urachal lesions. J Urol 11984 Jan, 131 (1): pg. 1-8  Back to cited text no. 5    

Top
Correspondence Address:
H C Soni
Department of Radio-diagnosis, Gujarat Cancer & Research Institute, Asarwa, Ahmedabad - 380016
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-3026.29156

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    Figures

[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6]

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    Introduction
    Case report
    Discussion
    Staging
    References
    Article Figures

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