|Year : 2016 | Volume
| Issue : 4 | Page : 191-194
Transverse testicular ectopia: What surgeons must know; Insights in embryology and management
Advait Prakash1, Suraj Jain2, Manoj Kela2, Chandrajeet Yadav3, Rajat Lohiya2, Tanmay Maheshwari2
1 Department of Pediatric Surgery, Sri Aurobindo Institute of Medical Sciences and Post Graduate Institute, Indore, Madhya Pradesh, India
2 Department of General Surgery, Sri Aurobindo Institute of Medical Sciences and Post Graduate Institute, Indore, Madhya Pradesh, India
3 Department of Radiology, Sri Aurobindo Institute of Medical Sciences and Post Graduate Institute, Indore, Madhya Pradesh, India
|Date of Web Publication||8-Dec-2017|
Dr. Advait Prakash
Department of Pediatric Surgery, Sri Aurobindo Institute of Medical Sciences & Post Graduate Institute, Indore, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
Transverse testicular ectopia (TTE) is a rare congenital anomaly, in which both gonads migrate toward the same hemiscrotum. It is usually associated with other abnormalities such as persistent Müllerian duct syndrome (PMDS), true hermaphroditism, inguinal hernia, hypospadias, pseudo-hermaphroditism, and scrotal anomalies. Most of the reported cases are in children with very few reported cases in adults. We report a case of 30-year-male, who presented with right reducible inguinal hernia and left undescended testis. Diagnosis was confirmed preoperatively by ultrasound followed by diagnostic laparoscopy and open inguinal exploration for orchiopexy. Bilateral transseptal orchiopexy and hernioplasty were performed. He had an uneventful recovery. Due to lack of awareness most of these cases are diagnosed accidentally intraoperatively. Preoperative diagnosis can be achieved by proper knowledge and imaging techniques (ultrasonography and magnetic resonance imaging). Surgeons who frequently repair inguinal hernias should be aware of disease and appropriate surgical management options available to them when this condition is unexpectedly identified during inguinal exploration. The embryology, clinical features and management algorithm are discussed herewith with review of pertinent literature.
Keywords: Crossed testicular ectopia, cryptorchidism, transverse testicular ectopia, undescended testis
|How to cite this article:|
Prakash A, Jain S, Kela M, Yadav C, Lohiya R, Maheshwari T. Transverse testicular ectopia: What surgeons must know; Insights in embryology and management. Arch Int Surg 2016;6:191-4
|How to cite this URL:|
Prakash A, Jain S, Kela M, Yadav C, Lohiya R, Maheshwari T. Transverse testicular ectopia: What surgeons must know; Insights in embryology and management. Arch Int Surg [serial online] 2016 [cited 2018 Sep 24];6:191-4. Available from: http://www.archintsurg.org/text.asp?2016/6/4/191/220322
| Introduction|| |
Testicular ectopia is an anomaly of testicular descent characterized by localization of the testis out of its normal migration pathway towards the scrotum. There are five known types of testicular ectopia: superficial inguinal (interstitial), femoral (crural), perineal, pubopenile, and crossed (transverse).
The transverse testicular ectopia (TTE), also known as crossed testicular ectopia, is a rare anomaly where the ectopic testis is found in the opposite groin or hemiscrotum, beside the other testis. It has also been termed as unilateral double testis, testicular pseudoduplication or transverse aberrant testis. TTE presents characteristically as an ipsilateral inguinal hernia with both testes in hernia sac and contralateral undescended testis, the diagnosis can be completely ascertained only during surgical exploration. It may be suspected clinically when an empty unilateral scrotal sac is present in association with an inguinal hernia on the contralateral side. The inguinal hernia is usually present on the side to which the ectopic testis has migrated.
Associated abnormalities may include persistent Müllerian duct syndrome (PMDS), true hermaphroditism, inguinal hernia, hypospadias, pseudohermaphroditism, defects of abdominal wall, and scrotal anomalies. The lack of awareness leads to delay in diagnosis and accidental detection during surgery for inguinal hernia. We report a case of TTE diagnosed preoperatively due to prompt surgical suspicion and confirmed by exploration and treated by a combined laparoscopic and open approach. A review of pertinent literature and an algorithm for management of such cases is also provided herewith.
| Case Report|| |
A 30-year-old male, labourer by occupation, presented to us with the complaints of swelling in right inguinoscrotal region noticed since 2 years. The swelling was painless, gradually increasing in size, and more prominent on coughing and straining. He did not have chronic cough, constipation, or urinary complaints. On examination, there was a large reducible right indirect inguinal hernia and absent testes on left side. General and systemic examination was unremarkable. On local genital examination, the right hemiscrotum was well developed and was having large reducible inguinoscrotal swelling, i.e., hernia but left hemiscrotum was poorly developed and empty. A small globular swelling was palpable in right inguinal region which had testicular sensations.
Routine hemogram was within normal limits. Ultrasonography (USG) confirmed the presence of a large right inguinal hernia with omentum as the content. USG also revealed that both the testes were on right side with one demonstrated in the right inguinal canal and the other one near the right deep inguinal ring (DIR) [Figure 1]. Left hemiscrotum was empty and no Müllerian structures were seen on abdominal ultrasound. Patient was planned for diagnostic laparoscopy and orchidopexy. Diagnostic laparoscopy confirmed the findings of USG. The right DIR was open and omentum was seen herniating through it. The right vas deferens and vessels were seen entering the right DIR. The left DIR was closed and left vas deferens was visualized crossing the midline entering the right DIR along with left cord structures. The long vas and vessels of left testis were mobilized laparoscopically [Figure 2]a and [Figure 2]b. Open inguinal exploration was then planned to perform bilateral orchiopexy and hernia repair. Open inguinal exploration showed that both testes had a common meso-orchium proximally and were separated by a distance of 4 cm [Figure 3]. Both the testes with their respective cords were separated from hernia sac which was closed and herniotomy was accomplished. A transseptal orchidopexy was performed and the lower right testis was placed in the ipsilateral right subdartos pouch while the left testis was placed in left subdartos pouch by transseptal approach. Subsequently, hernioplasty was performed with a prolene mesh. He had an uneventful recovery and on follow-up had no complications. Both the testes were normal to feel with no vascular compromise on Doppler study. He is on a regular follow-up with no complications till date.
|Figure 1: (a) Ultrasonography findings depicting hernia with omentum; (b) Ultrasonography findings depicting both testes in right hemiscrotum|
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|Figure 2: (a) Diagnostic laparoscopy showing left testis near right DIR. (b) Findings after mobilization of left vas and vessels|
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| Discussion|| |
Transverse testicular ectopia (TTE) which is a rare form of testicular ectopia was first reported by von Lenhossek in 1886 and about 100 cases have been reported in the literature since then. Several theories regarding the embryogenesis of TTE have been postulated viz. adhesion and fusion of developing Wolffian canals, aberrant gubernaculum, testicular adhesions, defective formation of the internal inguinal ring, and traction on a testis by persistent Müllerian structures. Berg proposed the possibility of the development of both testes from the same genital ridge. Gupta and Das postulated that due to early adherence and fusion of the developing Wolffian ducts, the descent of one testis has caused the second one to follow.
PMDS may result from the failure of synthesis or release of mullerian inhibiting sustance, defect in the timing of the release of MIS or due to the failure of end organs to respond to MIS. It has been postulated that the mechanical effect of the persistent Müllerian duct structures prevents the testicular descent or leads to both testicles descending toward the same hemiscrotum, producing TTE. An inguinal hernia is invariably present on the side to which the ectopic testis has migrated.
On the basis of the presence of various associated anomalies, TTE has been classified into three types: Type 1: accompanied only by hernia (40–50%), Type 2: accompanied by persistent or rudimentary Müllerian duct structures (30%), and Type 3: associated with disorders other than PMDS (inguinal hernia, hypospadias, disorders of sexual differentiation, and scrotal abnormalities) (20%). According to this classification, our case was Type 1 TTE.
The mean age of presentation for TTE is 4 years. The patient generally presents with an inguinal hernia on one side and a contralateral or rarely a bilateral cryptorchidism. Due to lack of awareness the condition is usually missed and the diagnosis is made during surgical exploration. The diagnosis of TTE can be made preoperatively, as in our case, by thorough clinical examination supported by USG by an experienced sonologist. Other imaging modalities like computerized tomography, magnetic resonance imaging, or magnetic resonance venography have also proved useful in preoperative diagnosis.
In recent times, diagnostic laparoscopy has become extremely useful to confirm the diagnosis of TTE, check for presence of PMDS, map out the anatomy, assess the cord structures, evaluate vascular supply, and plan the definitive surgical management. During laparoscopy the most common findings include crossing over the midline and to the contralateral internal ring of the vessels and vas of the ectopic testis, and the presence of rudimentary Müllerian structures like uterus, round ligament, and fallopian tubes.
Patients with TTE are at increased risk of malignant transformation. In fact, the overall incidence of malignant transformation of gonads is about 18%., Previously, there have been reports of embryonal carcinoma, seminoma, yolk sac tumour, and teratoma. Walsh et al. concluded that testicular cancer was nearly six times more likely to develop in cases with cryptorchidism whose operations were delayed until after age 10–11 years. Wood et al. showed that risk of malignancy in undescended testicles decreased if their orchidopexy performed before ages 10–12 years.,
The surgical goals in treatment of TTE are fertility preservation and placement of the testis in the hemiscrotum for surveillance for potential malignant development. Once diagnosis is confirmed by incidental intraoperative findings on inguinal exploration, and/or diagnostic laparoscopy, one must assess the vas deferens, its vascular supply and proximal attachments, such as persistent Müllerian structures. In 2–97% of patients with TTE, disorders of the upper and lower urinary tract system have been reported. If two gonads become visible during exploration of one inguinal side, complete abdominal exploration must be performed. Intraoperative abdominal evaluation via laparotomy or diagnostic laparoscopy allows for detection of Müllerian structures and other genitourinary congenital abnormalities. A biopsy should be taken from tissue remnants between cord structures or abdomen. There is no report of malignancy arising from the retained Müllerian structures, and the absence of MIS does not appear to increase the relative risk of testicular malignancy. Hysterectomy is, hence, not recommended routinely in patients who have obvious uterus and fallopian tubes. Extensive dissection of vas deferens and excision of persistent Müllerian duct structures should be avoided in order to prevent the injury.
Depending on the intraabdominal findings various surgical techniques can be used. Transseptal orchiopexy is recommended if there is adequate length of the vas deferens to allow the ectopic testis to be placed tension-free to the correct scrotum. A transseptal window is made, through which the ectopic testis is passed and is fixed to the correct hemiscrotum. Another option is to proceed with transseptal “contralateral” orchiopexy, wherein the orthotopic testis with more than sufficient vas deferens length can cross transseptally, and the ectopic testis with inadequate length undergoes transseptal fixation.
Transabdominal orchiopexy should be performed if there is inadequate length of the vascular supply to the vas deferens despite dissection of the proximal attachments up the level of the internal inguinal ring. In this procedure, the spermatic cords and testes are not very proximal to each other, offering decreased risk of bilateral damage in cases of scrotal trauma, orchitis, or epididymitis. If PMDS is seen, biopsy is not recommended because of the potential risk to the vascular supply. In the rare case with fused vas deferens, a transseptal orchiopexy is recommended.
Two testes in one inguinoscrotal region give a clinical diagnosis of TTE. TTE must be considered in the differential diagnosis of patients with nonpalpable testis and contralateral inguinal hernia. Diagnostic laparoscopy provides detailed anatomy, identifies associated anomalies, and plans the operative approach. Preservation of vascular supply and placement of testes in their hemiscrotum are essential. One must be prepared to manage TTE, especially if the diagnosis was made intraoperatively.
This case is reported with a view that surgeons who frequently repair inguinal hernias should be aware of the appropriate surgical management options when this condition is unexpectedly identified during inguinal exploration. Patients of TTE should be treated adequately and safely and should be followed up for long term considering the increased risk of malignancy in such patients.
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[Figure 1], [Figure 2], [Figure 3]