1. Management of Urachal Anomolies Megan Lundeberg, MD R2 General Surgery Swedish Medical Center February 28, 2013

2. Case Presentation ME, an 11 year old girl who presented to the ED three weeks of waxing and waning abdominal pain. (First noted after a snowboard crash in which she bruised her hip).

3. ED Evaluation HPI Several days of constant, worsening infraumbilical abdominal pain. Nausea with some emesis Mild URI symptoms with low grade fevers. No urinary symptoms PMH, FH, SH: Unremarkable.

4. ED Evaluation Vitals: T 37.4 HR 118 BP 100/60 RR 22 100% Wt 43kg Physical Exam: Abdomen is round and soft. Tenderness in the immediately infraumbilical area of approximately 3 inches diameter. Some associated guarding. Otherwise non- tender. Labs: WBC 19 (83% polys), CRP 8. UA negative

5. ED Evaluation: Ultrasound

6. IR CT Guided Drain Placement

7. Clinical Course Diagnosed with urachal cyst remnant infection with plan for treatment with IV antibiotics. Due to failure to improve clinically with antibiotics alone, underwent IR guided drain placement. Final cultures grew MSSA. She was discharged home on HD#6 with oral augmentin.

8. Laparoscopic Excision of Urachal Cyst Remnant Returned one month later for elective excision. Findings: Intraabdominal adhesions with fine adhesions from the omentum to the body wall Inflammatory tissue in the area between the umbilicus and the top of the bladder, representing the remnant of the previously infected urachal cyst The bladder itself looked to be normal.

9. Clinical Question: Is surgical excision of urachal remnant disease necessary?

12. Retrospective chart review (2002-2008) comparing operative and non-operative treatment of symptomatic urachal anomalies All three of these children treated non-operatively recovered well and follow up ultrasound showed no evidence of residual cyst Non-infected cysts were treated operatively due to their potential for infection

13. Urachal anomalies with epithelium may have increased potential to undergo malignant transformation. Retrospective look at presentation compared to urachal pathology No correlation between presence of symptoms and presence or absence of epithelium

14. Retrospective comparison of ultrasound findings to urachal pathology and presentation (1990-2008)

15. Summary Urachal anomalies are rare. May present with symptoms or be found incidentally. Classic teaching and practice has advocated for surgical excision Beginning to investigate, observation of symptomatic and/or asymptomatic lesions, however remains controversial

16. Questions & Comments? References Lipskar AM, Glick RD, Rosen NG, Layliev J, Hong AR, Doglin SE, Soffer SZ. Nonoperative management of symptomatic urachal anomalies. Journal of Pediatric Surgery (2010) 45, 1016-1019. Copp HL, Wong IY, Krishnan C, Malhotra S, Kennedy WA. Clinical Presentation of Urachal Remnant Pathology: Implications for Treatment. The Journal of Urology (2009) 182, 1921-1924. Widni, EE, Hollwarth ME, Haxhija EQ. The impact of preoperative ultrasound on correct diagnosis of urachal remnants in children. Journal of Pediatric Surgery (2010) 45, 1433-1437.