Background <p>Urachal anomalies are rare entities in the adult population with significant malignant potential. This study aims to comprehensively describe clinical and paraclinical characteristics, as well as to analyze and evaluate prognostic factors for urachal carcinoma, thereby facilitating early diagnosis and effective management.</p> Methods <p>We conducted a retrospective study on patients diagnosed with urachal anomalies from 2017 to 2025. Data regarding clinical characteristics, imaging findings, treatment modalities, and clinical outcomes were collected for both benign and malignant cases. Additionally, survival outcomes were specifically analyzed for patients with urachal carcinoma.</p> Results <p>A total of 112 patients were included, comprising 8.9% cases of urachal carcinoma, while infection was the predominant presentation (72.3%). Surgical management differed significantly by pathology, with urachal excision and partial cystectomy performed in 80.0% of malignant cases versus 23.9% of benign cases. Multivariate logistic regression identified hematuria (Odds Ratio (OR) 14.1; 95% Confidence Interval (CI) 1.3–153.6; <i>p</i> = 0.03) and calcification (OR 13.5; 95% CI 1.7–109.2; <i>p</i> = 0.01) as significant independent predictors of malignancy. Histologically, adenocarcinoma was the major subtype (80%), with most tumors being Sheldon stage IIIA or IV. Overall survival (OS) showed a steep decline, recorded at 90.0%, 60.0%, and 15.0% at 1, 3, and 5 years, respectively.</p> Conclusions <p>Gross hematuria and calcification serve as critical, independent predictors of urachal malignancy. Given the aggressive nature and poor overall prognosis (5-year OS of only 15.0%), the presence of these indicators necessitates an aggressive diagnostic workup and prompt radical surgical intervention (en-bloc urachal excision with partial cystectomy) to optimize long-term patient outcomes.</p>