Robotic-Assisted Excision of a Urachal Diverticulum

Abstract

Study objective: To demonstrate a combined robotic-assisted laparoscopic technique with concomitant cystoscopy use for excision of a urachal diverticulum to ensure complete resection of diverticulum and bladder cuff.

Design: Step-by-step demonstration and explanation of the procedure using video illustration. Institutional Review Board/Ethics Committee ruled that approval was not required for this case report; however, patient consent was obtained (Canadian Task Force Classification III).

Setting: Vesicourachal diverticula account for approximately 3% to 5% of congenital urachal anomalies. Although usually asymptomatic, the diverticulum may be associated with an increased risk of urinary tract infections, intraurachal stone formation, and an increased prevalence of carcinoma after puberty. When diverticula become symptomatic or infected, surgical management is warranted.

Patient: A 68-year-old gravida 0 woman was evaluated with cystoscopy for recurrent culture-proven urinary tract infections. A suspected vesicourachal diverticulum was identified on cystoscopy, and the diagnosis was confirmed on computed tomography. She was counseled on management options and elected to undergo robotic-assisted excision of the urachal remnant with concomitant cystoscopy.

Intervention: After identifying the diverticulum both laparoscopically and on cystoscopy, the anterior peritoneum was incised to dissect the diverticulum off the anterior abdominal wall. The dissection was carried down to the level of the bladder dome, necessitating entry into the retropubic space of Retzius. A partial cystectomy was performed to ensure complete resection of the diverticulum. The bladder was repaired in 2 layers. Concurrent laparoscopy and cystoscopy allowed for assurance of watertight closure by retrograde filling of the bladder and observing laparoscopically. Although entered, the space of Retzius is an avascular potential space between the pubic symphysis and the bladder and does not necessitate closure. Surgery was performed successfully without intraoperative or postoperative complications. On final pathology, a benign urachal diverticulum was completely excised. The patient's presenting symptoms resolved postoperatively.

Conclusion: Robotic-assisted excision of a vesicourachal diverticulum with concomitant use of cystoscopy is a safe, effective, and efficient technique for successful, minimally invasive, management of symptomatic urachal diverticula.

Keywords: Urachal diverticulum; robotic Surgery; urachal remnant.