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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 30  |  Issue : 6  |  Page : 281-283

A rare case of prolapsed and everted bladder through a widely patent urachus with an absent omphalocele


1 Department of Surgery, Urology Unit, Hospital Universiti Sains Malaysia, Kelantan, Malaysia
2 Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia

Date of Submission15-Apr-2019
Date of Decision06-Jun-2019
Date of Acceptance26-Jun-2019
Date of Web Publication23-Dec-2019

Correspondence Address:
Dr. Ahmad Naoras Bitar
Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang 11700
Malaysia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/UROS.UROS_24_19

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  Abstract 


A prolapsed and everted bladder through a widely patent urachus with an absent omphalocele is considered as an extremely rare and unique case, which requires emergency treatment and surgical intervention. A newly born baby was born at term and then referred from a district hospital for a mass at the umbilical region. She was referred as a case of gastroschisis, but she was eventually found to have a rare patent urachus with bladder eversion and prolapse onto the abdominal wall. The prolapsed bladder was repaired without any complications, and an umbilicoplasty was performed successfully. The infant recovered uneventfully and without any difficulty in voiding. A significant reduction in bladder dome inflammation as well as in mucosal necrosis can be obtained by performing the repair procedure as soon as possible.

Keywords: Everted bladder, gastroschisis, omphalocele, patent urachus, prolapse


How to cite this article:
Hamzah AA, Khan AH, Bitar AN. A rare case of prolapsed and everted bladder through a widely patent urachus with an absent omphalocele. Urol Sci 2019;30:281-3

How to cite this URL:
Hamzah AA, Khan AH, Bitar AN. A rare case of prolapsed and everted bladder through a widely patent urachus with an absent omphalocele. Urol Sci [serial online] 2019 [cited 2020 Jul 15];30:281-3. Available from: http://www.e-urol-sci.com/text.asp?2019/30/6/281/273874




  Introduction Top


Umbilical anomalies in a neonate include abdominal wall defects, omphalomesenteric duct remnants, and urachal remnants. A prompt distinction among various anomalies is imperative because their association with other congenital abnormalities, need for further workup, and surgical correction, differs.

Four major variants are described in most series: urachal sinus, urachal cyst, urachal diverticulum, and patent urachus.[1] Ultrasound has emerged as the study of choice in delineating these anomalies, both during the fetal period and during childhood.[2],[3]

The objective of this write-up is to report a case of bladder prolapse and eversion through a patent urachus which is rarely seen in even in pediatric surgical practice. This entity, which has been rarely reported,[4] has distinct fetal and neonatal characteristics. The embryology and malformations of the urachus were discussed, and the rare case reports of similar anomalies were reviewed in this report.


  Case Report Top


A female infant weighing 3800 g was delivered at term via spontaneous vaginal delivery with Apgar scores of 8 and 9 at 1 and 5 min, respectively. There were no intrapartum complications, and on delivery of the baby, she was noted to have mass at the umbilical region. She was then referred to a tertiary care setting for gastroschisis.

An informed consent was obtained from the patient's mother (35 years old woman). who was on diet control for her gestational diabetes mellitus. This was her fifth pregnancy, and all her previous pregnancies were uneventful and all her previous children are healthy.

Clinically, she was pink, active, and not dysmorphic. There was a red mucosal mass protruding from the umbilical area [Figure 1]a, [Figure 1]b, [Figure 1]c]. It was measured 5 cm × 5 cm × 4 cm and had a central cavity. Otherwise, her abdomen was soft and not distended. Her external genitalia, lower abdominal wall, and pelvis were normal by clinical examination, with no evidence of bifid clitoris or split symphysis which can be present with bladder exstrophy or its variants. Other systemic examinations were unremarkable.
Figure 1: (a-c) A mass (prolapsed bladder) protruding infraumbilically

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The mass was covered with a saline-soaked gauze and protected by a plastic wrap, while further investigations and diagnostic tests were obtained. Then, she was scheduled for surgical repair. The neonate also received intravenous antibiotics.

She underwent surgery on day 1 of life. A wide “stoma” of the everted bladder mucosa was seen at the bladder dome. Urine was noted draining from the everted and prolapsed bladder mucosa. The abdominal wall was dissected away from the bladder wall, allowing the everted bladder to be invaginated. Then, the bladder was everted inside out and attached to itself.

The ureteral orifices were identified; then, the everted part of the bladder dome was resected and it was sutured in two layers using absorbable sutures. To decompress the bladder, a Foley catheter was used and left. To repair the umbilical defect, an umbilicoplasty was performed, and then, it was closed using purse-string technique. A viable smooth muscle with hemorrhagic necrosis was detected in the inner mucosal lining containing islands of transitional epithelium.

Postoperatively on the 9th day, a voiding cystourethrogram was obtained. The bladder capacity was fine, no vesicoureteral reflux was detected, and the patient's bladder was emptying properly. The baby was discharged on the 11th day of her life and scheduled for follow-ups, and almost 8 months later, the baby was completely asymptomatic and her ultrasound presented a normal bladder.


  Discussion Top


In the 5th month of pregnancy, the urachus starts to obliterate its lumen, while it is descending into the pelvis. The urachus plays as artetic fibrous cord that connects the bladder dome to the umbilicus passing through the Retzius space, at this stage, it is called as the median umbilical ligament.[3],[5] The incomplete closure of this vesicoallantoic channel usually is the main cause of the urachal remnants.

The urachal anomalies' types are interconnected with parts of the urachus persist after birth. Urachal sinus is caused by patent allantic or umbilical end which leads to drainage and cellulitis. Patent vesical end leads to a bladder diverticulum. Urachal cysts are caused by obliteration of the umbilical and vesical ends at the same time along with patent middle portion, which is manifested by preperitoneal abscesses.[6] Finally, urinary drainage from the umbilicus is caused by completely persistence urachus, which may also occur even without any bladder obstruction.

Typically, urachal sinuses and umbilical urinary drainage were present in this case. In fact, even though this condition is rare and unique, they are the most common features of prolapsed and everted bladder through patent urachus.[3] The most important and unique finding of this anomaly was the “disappearing omphaloceles.” Cystic mass was also detected at the base of the cord separate from the umbilical vessels. Yeats and Pinch[7] diagnosed a less severe similar case and they were able to repair the bladder without resection, whereas in Thambi Dorai's[8] case report, the patient had an omphalocele minor.

Unfortunately, in the present case, the bladder dome was extremely inflamed, prolapsed, and strongly adherent to itself which made simple reduction and closure without resection not a possible option. After all, it was the right decision and the outcomes of this operation were extremely successful. In our case, the urgently performed repair operation prevented the bladder from developing more edematous and complicating the situation.


  Conclusion Top


We reported a rare case of prolapsed and everted bladder through a widely patent urachus, which is rare and unique to neonates. Patent urachus with bladder prolapse can be predicted by a skilled perinatologist in fetal ultrasound sessions. A significant reduction in bladder dome inflammation as well as in mucosal necrosis can be obtained by performing the repair procedure as soon as possible. Large cysts and lack of descent can indicate wide urachal remnant, which can lead to prolapse.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Choi YJ, Kim JM, Ahn SY, Oh JT, Han SW, Lee JS. Urachal anomalies in children: A single center experience. Yonsei Med J 2006;47:782-6.  Back to cited text no. 1
    
2.
Vavilova S, Krishnan J, Jiwane A, Shand AW. Patent urachus with bladder prolapse. J Pediatr Surg Case Rep 2017;24:17-20.  Back to cited text no. 2
    
3.
Lugo B, McNulty J, Emil S. Bladder prolapse through a patent urachus: Fetal and neonatal features. J Pediatr Surg 2006;41:e5-7.  Back to cited text no. 3
    
4.
Gleason JM, Bowlin PR, Bagli DJ, Lorenzo AJ, Hassouna T, Koyle MA, et al. A comprehensive review of pediatric urachal anomalies and predictive analysis for adult urachal adenocarcinoma. J Urol 2015;193:632-6.  Back to cited text no. 4
    
5.
McCollum MO, Macneily AE, Blair GK. Surgical implications of urachal remnants: Presentation and management. J Pediatr Surg 2003;38:798-803.  Back to cited text no. 5
    
6.
MacNeily AE, Koleilat N, Kiruluta HG, Homsy YL. Urachal abscesses: Protean manifestations, their recognition, and management. Urology 1992;40:530-5.  Back to cited text no. 6
    
7.
Yeats M, Pinch L. Patent urachus with bladder eversion. J Pediatr Surg 2003;38:E12-3.  Back to cited text no. 7
    
8.
Thambi Dorai CR. Umbilical evagination of the bladder with omphalocele minor. Pediatr Surg Int 2000;16:128-9.  Back to cited text no. 8
    


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