V36 - Management of Colo-Urachal Fistula with Robotic Resection and Repair

CME Eligible

Purpose/Background: Urachal remnants in adults are rare, and secondary complications such as infection or fistulization to adjacent organs are even more unusual. Fistula formation between a urachal cyst and the sigmoid colon represents an exceptional presentation, with few cases described in the literature. Minimally invasive approaches, including robot-assisted surgery, offer the potential for precise dissection and safe management of these complex pathologies.

Methods/Interventions: A 53-year-old male with a 10-year history of umbilical hernia presented with spontaneous drainage from the umbilicus during exertion. He is otherwise healthy, with no prior surgical history. CT imaging demonstrated a urachal cyst complicated by abscess formation and a fistulous connection to the sigmoid colon. The patient was treated initially with antibiotics and, after multidisciplinary discussion between urology and general surgery, was scheduled for definitive robotic resection.

On robotic exploration, the abscess cavity was found adherent to the anterior abdominal wall, with the sigmoid colon situated posteriorly. The abscess was carefully dissected free from the abdominal wall, and the bladder was mobilized by entering the space of Retzius. The abscess was peeled off the bladder, and a small bladder defect was repaired in two layers. The urachal cyst remnant remained firmly attached to the sigmoid colon, necessitating sigmoidectomy with intracorporeal end-to-end anastomosis. A leak test was performed intraoperatively and was initially positive, the anastomosis was resected and redone, subsequent leak test was negative.

Results/Outcomes: The patient's recovery was complicated by an incarcerated port-site hernia requiring reoperation for fascial closure, a contained bladder leak requiring prolonged Foley catheter drainage, and Clostridioides difficile colitis. All complications were successfully managed, and the patient ultimately recovered well.

Conclusion/Discussion: This case represents an unusual manifestation of urachal disease with colo-urachal fistula. It underscores the importance of considering urachal pathology in adults presenting with atypical umbilical drainage and highlights the utility of a robotic approach in managing complex disease processes involving both the bladder and colon.

Colo-urachal fistula
Sagittal CT image demonstrating urachal cyst and abscess with fistula to the sigmoid colon
Umbilical drainage
The image demonstrates the quality of the drainage that was coming from the patient's umbilicus.