Management of urachal anomalies in children: insights from a retrospective cohort study.

Introduction: While large and symptomatic urachal anomalies (UAs) often lead to surgical excision, urachal malignancy is rare, rendering prophylactic excision unwarranted. We hypothesize that in the pediatric population, the presentation of an infected UA is the predominant etiology leading to surgical intervention.

Methods: We retrospectively identified patients with UA from July 2012 to December 2021 evaluated in our urology outpatient. Inclusion criteria included patients ≤18 years old and confirmation of UA on ultrasound (US). Exclusion criteria were patients diagnosed with clinical mimickers on US, excision by general pediatric surgery service, or excision done concomitantly as part of another urological procedure.

Results: We identified a total of 78 patients with UA. Of those, 35 (44.9%) underwent excision. The observation cohort was younger (5 months vs. 73 months, p=0.002), more likely to be asymptomatic (65.1% vs. 85.7%, p=0.038), and more likely to have UA characterized as a 'remnant' on US (72.1% vs. 48.6%, p=0.034). Univariate analysis showed that infected or symptomatic UA, or those characterized as hyperemic, cystic, or as a diverticulum on US were more likely to be excised. Multivariable analysis shows that patients with a 'urachal cyst' classification (p=0.008) and infectious presentation (p=0.046) were more likely to undergo surgical intervention. Excision was accomplished laparoscopically (80.0%) or robotically (11.4%). No excised UA was suspicious for malignancy.

Conclusion: We present a large pediatric cohort with UA and found that infectious symptoms at presentation and those classified as 'urachal cyst' based on US were more likely to prompt surgical excision as compared with other factors.