Urachal adenocarcinoma: Case report, literature review, and therapeutic algorithm proposal

Urachal adenocarcinoma is an extremely rare malignancy, accounting for less than 1% of all bladder tumors. Diagnosis is often delayed due to nonspecific symptoms and low clinical suspicion. We report the case of a 52-year-old male with no relevant medical history who presented with lower urinary tract symptoms. Cystoscopy revealed a cystic lesion at the bladder dome. Transurethral resection confirmed mucinous urachal adenocarcinoma. CT imaging showed no locoregional or distant spread, and tumor markers were within normal limits. The patient underwent laparoscopic partial cystectomy with en bloc excision of the urachus and umbilicus plus bilateral pelvic lymphadenectomy. Final pathology confirmed a Sheldon stage IIIA mucinous cystadenocarcinoma. At 25 months of follow-up, the patient remains free of disease recurrence. Given its low prevalence and aggressive nature, accurate diagnosis and appropriate surgical management are critical. While surgery remains the cornerstone in localized disease, the role of systemic therapy remains unclear. Immunotherapy and targeted therapies are emerging as promising options in advanced stages. This case illustrates the diagnostic challenges and emphasizes the importance of surgical planning and long-term surveillance in the absence of standardized treatment guidelines. Midline bladder lesions should prompt suspicion of urachal adenocarcinoma. Complete surgical excision is essential, with lymphadenectomy and systemic therapy considered on a case-by-case basis. Long-term follow-up is necessary due to the high risk of recurrence.