Rarely seen malformations of the bladder

To the rarely encountered malformations of the bladder, urologists include the following pathologies: hypertrophy of the inter-ureteral ligament, redundancy of the mucous membrane of the urinary bladder, anomaly of the urinary duct, vesicouctal fistula, urinary duct cyst, incomplete navel fistula.

[1], [2], [3], [4], [5]

Forms

Hypertrophy of the inter-ureteral ligament

Hypertrophy of the inter-ureteral ligament is very rare in newborns and infants. Diagnosis is established with cystoscopy: they detect excessive development of a bundle of muscle fibers going along the upper boundary of the Lieto triangle between the two ureteral orifices. The main clinical symptom is difficulty, and sometimes frequent urination.

[6], [7], [8]

Redundancy of the mucous membrane of the urinary bladder triangle

In cystoscopy, a valve is found that hangs over the neck of the bladder, causing a violation of urination. The cystogram determines the filling defect at the exit from the bladder.

With a mildly pronounced excess of the mucous membrane, buoyage of the urethra is carried out against the background of antibacterial therapy, and when expressed, resection of excess tissue.

Among other extremely rare vestiges of the development of the bladder - an urinary bladder by the type of "hourglass," partial or complete septa of the bladder, located in the frontal or sagittal plane. Bladder agenesis, congenital bladder hypoplasia, etc. Very rarely occurs agenesis of the bladder, which is combined with other malformations. Therefore, this anomaly is incompatible with life. Stillborn babies are born or newborns die in the near future.

Abnormalities of the urinary duct

Normally, the upper anterior part of the bladder forms the apex (apex vesicae) well distinguishable with a filled bladder. Upper reaches up towards the navel in the middle umbilical ligament (ligamentum umbilicak medianum). Connecting the bladder with the navel. It is the obliterated urinary duct (urachus) and is located between the leaf of the peritoneum and the transverse fascia of the abdomen. The dimensions of the urinary duct vary (3-10 cm in length and 0.8-1 cm in diameter). It is represented by a muscular tube with three layers of tissues:

• epithelial canal, represented by a cubic or transitional epithelium;
• submucosal layer;
• surface smooth muscle layer, close in structure to the wall of the bladder.

[9], [10]

Embryological data

Allantoic is called the extra-embryonic cavity (further forming the bladder) inside the precursor of the allantoic stem, located on the front surface of the cloaca. Immersion of the bladder in the pelvis occurs in parallel with the lengthening of the urinary duct, the tubular structure of which extends from the fibrous allantoic duct to the anterior wall of the bladder. By the fifth month of pregnancy, the urinary duct gradually turns into an epithelial tube of small diameter, which is necessary to divert urine from the embryo to amniotic fluid. After the embryonic development of the fetus urachus gradually overgrows, and in those cases when, for one reason or another, the process of infection (obliteration) of the urinary duct is disrupted, various variants of its diseases develop.

[11], [12], [13], [14], [15], [16], [17], [18]

Bladder-navel fistula

Of all the variants of violation of the obliteration of the duct, the full urinary fistula is most often found. Diagnosis of this disease does not present any difficulties. Clinically, the urine goes away through the umbilical ring with a trickle or drops. Sometimes parents complain about periodically "wetting the navel" of their child.

In order to confirm the diagnosis, as a rule, in adults with suppuration of urinary cyst cysts, ultrasound, fistulography, fistula contrasting with indigocarbon solution, mictic cystourethrography, CT and sometimes a radioisotope study can be performed. Differential diagnosis should be performed with the healing of the umbilical stump, omphalitis, granuloma and non-involution of the yolk duct. Persistence of the urinary and intestinal fistula in one patient is extremely rare, but this variant of the anomaly should still be remembered. In children of the younger age group, often the urinary duct can close on its own in the first months of life, so sometimes these children are shown only observation. However, a long-lasting fistula in a number of cases provokes the development of cystitis and pyelonephritis.

[19], [20], [21], [22], [23], [24], [25]

Cyst of the urinary duct

The cyst of the urinary duct is formed in cases when its obliteration occurs in the proximal illegal areas. Most often it is located closer to the navel and less often - to the bladder. The contents of the cyst are stagnant urine with embarrassed epithelium or pus. Clinically, the cysts of the urinary duct proceed without any symptoms and are an accidental finding during ultrasound examination of the patient, but sometimes there are manifestations of acute purulent infection. Serious complications include peritonitis, which can develop when an abscess breaks into the abdominal cavity.

Sometimes it is possible to independently drain the cyst through the navel or bladder, as well as the formation of a sinus (intermittent variant).

Of the symptoms of infection of the cyst, the most common pain in the abdomen, a rise in body temperature, a violation of the act of urination (painful, rapid, even if the general analysis of urine does not reveal pathological changes).

Sometimes palpation of the neoplasm in the anterior abdominal cavity is possible.

To additional diagnostic methods include CT and radioisotope study, which allows to clarify the diagnosis. Treatment of the cyst of the urinary duct depends on the symptoms and age of the patient. In the "cold" period, the cyst can be removed with laparoscopic or open surgical intervention. In an acute period with suppuration of the cyst of the urinary duct, an opening and draining of the abscess is performed. In young children with its asymptomatic course, observation is possible, with the attachment of inflammation, education is excised and drained. The final treatment is carried out after the inflammatory process subsides, it consists in complete excision of the cyst walls.

[26], [27], [28]

Incomplete navel fistula

An incomplete fistula of the navel is formed when there is a violation of the process of obliteration of the urinary duct in the umbilical segment. Clinical manifestations are possible at any age. Most often, patients are troubled by the puffy discharge in the region of the umbilical ring, accompanied by the dipping in this area of a permanent or intermittent nature, often with signs of omphalitis. In cases of violation of the outflow of gnoy-like contents, signs of intoxication are possible. Sometimes, in the area of the umbilical ring, the proliferation of granulations, which protrude above the surface of the skin, is noted.

In order to clarify the diagnosis, ultrasound, fistulography (after cupping the inflammatory process in the umbilical ring region) is necessary.

Treatment of the incomplete fistula of the navel is in the daily sanitizing baths with a solution of potassium permanganate, in processing the navel with a 1% solution of brilliant green, cauterizing the granulations with 2-10% silver nitrate solution. With ineffectiveness of conservative measures, the urinary duct is radically excised.

Treatment of the malformations of the bladder

Optimal surgical treatment of urinary duct anomalies is a laparoscopic method.

Stages of laparoscopic excision of the urinary duct (with fistula and cysts of the urinary duct)

• Open laparoscopy with the introduction of three trocars of small diameter (3 or 5.5 mm). Troakar No. 1 (for a laparoscope, 5 mm, 30 °) is usually inserted along the midline in the middle of the distance between the umbilical ring and the xiphoid process of the sternum. Trocars No. 2 and 3 (for working tools) are most often injected into the left and right celiac areas.
• Laparoscopic revision using optics with an angled end cut (30 ° or 45 °), visualization of the urinary duct throughout the entire length (from the umbilical ring to the bladder) or the area of its cystic enlargement.
• Excision of the urinary duct (usually begin with dissection of the umbilical ring). The urinary duct in this place is excreted circularly, cut off after careful bipolar coagulation. At the same time, additional surgical processing of the umbilical ring region is performed from the outside to completely remove the fistulous course.
• Isolation of the urinary duct to the site of its connection with the bladder by careful blunt dissection with unipolar or bipolar coagulation. Perform a dressing of the base of the urinary duct, most often with the help of endopellet. The tied urinary duct is cut off and removed through one of the trocar.
• Suturing an operating wound (intradermal sutures).

The duration of laparoscopic surgery usually does not exceed 20-30 minutes, patients can be discharged from the hospital 1-3 days after the operation.

Similar operations in children aged 1-17 years with fistulas and cysts of the urinary duct confirm the universality, simplicity and convenience of using endosurgical technologies in the treatment of this anomaly.

In those cases where laparoscopic excision of the urinary duct is not possible, an open operation is performed. Access depends on the level of impairment of obliteration. In children of the younger age group, the urinary duct is easily removed from the semilunar incision along the lower edge of the umbilical ring in connection with anatomical features and a high standing tip of the bladder. In children of the older age group and in adults, the lower-median laparotomy is performed and the entire urinary tract is excised. In those cases where the duct walls are intimately intertwined with surrounding tissues due to a previously transferred inflammatory process, excision is performed within a healthy tissue.