0022-534 7/92/1483-0886$03.00 /0 Vol. 148, 886-888, September 1992 Printed in U.S.A.

THE JOURNAL OF UROLOGY

Copyright© 1992 by AMERICAN UROLOGICAL ASSOCIATION, INC.

CROSSED ECTOPIA OF LEFT VAS DEFERENS, LEAVING IPSILATERAL SEMINAL VESICLE IN NORMAL POSITION MORIHIRO WATANABE, JUNJI HIRANO, KAZUO NUMASAWA

AND

TERUHIRO NAKADA

From the Department of Urology, Yamagata University School of Medicine, Yamagata, and Mitaka-Kitakuchi Hospital, Tokyo, Japan

ABSTRACT

A 19-year-old man with crossed ectopia of the vas deferens was investigated with special reference to right hydronephrosis and renal dysfunction. There was no vesicoureteral reflux. The left kidney was hypoplastic or dysplastic and the left ureter emptied into the left seminal vesicle. The right malrotated hydronephrotic kidney was in the lumbar position. The right lower ureter communicated with either the right seminal vesicle or the ampullary portion of the left vas deferens and drained into the bladder at the normal site. The end of the right vas deferens was dilated. The left vas deferens crossed the midline and opened into the right seminal vesicle, leaving the ipsilateral seminal vesicle in the normal position. A search of the literature failed to reveal any similar anomalies. KEY WORDS:

choristoma, vas deferens

Anomalies of the vas deferens, alone and in association with other urogenital structures, are varied. To date, congenital absence, duplication and ectopia of this structure have been reported. Among these conditions, the ectopic vas deferens is rare and we found fewer than 30 cases in the literature. The majority of cases of ectopic vas deferens are attributed to a persistent mesonephric dµct, in which the vas deferens drains off the ipsilateral urinary tract from the renal pelvis to the urethra. 1 We present an uncommon case of crossed ectopia of the vas deferens that was separate from the ipsilateral seminal vesicle and associated with other urogenital anomalies, such as ectopic ureter and maldescended kidney (fig. 1). CASE REPORT

K. M., a 19-year-old Japanese man, was referred for the investigation of renal dysfunction. He underwent an operation to ascertain the presence of the kidneys at the age of 3 years. At that operation the left collecting system was not detected and the right kidney was at the lumbar level. There had been no medical history suggesting urinary tract infection. On inspection, both testes, epididymides and vasa deferentia were normal, and rectal examination revealed a well developed prostate. Blood urea nitrogen was 33 mg./dl.(normal 8 to 20) and serum creatinine was 2.5 mg./dl. (normal 0.6 to 1.2). A voiding cystogram showed a normal bladder and urethra. There was no vesicoureteral reflux. An excretory urogram demonstrated a malrotated lumbar kidney with a deformed and dilated collecting system. The left kidney was not visualized. Cystoscopy revealed that the right ureteral orifice was normal in position and form, while the left orifice was not visualized. A right retrograde pyelogram visualized not only the right collecting system but the bilateral deformed seminal vesicles and left ureter as well (fig. 2, A). The blind ending left ureter drained into the left seminal vesicle. On a right seminal vesiculogram the end of the right vas deferens was dilated and deviated laterally. The right seminal vesicle was not visualized (fig. 2, B). A left seminal vesiculogram, front (fig. 3, A) and right anterior oblique (fig. 3, B) views, revealed that tha- left vas deferens crossed the midline and opened at the right seminal vesicle. Each seminal vesicle fused to form the common ejaculatory duct. Computerized tomography showed that from the front to the back the right seminal vesicle, and ampullas of the left and right vasa deferentia were aligned tandemly in that order (fig. 4). Semen analysis revealed azoospermia. Accepted for publication February 14, 1992.

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FIG. 1. Posterior view of urogenital system in our patient. RK, right kidney. RU, right ureter. LU, left ureter. B, bladder. RA, ampulla of right vas deferens. LA, ampulla of left vas deferens. RS, right seminal vesicle. LS, left seminal vesicle.

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These radiographic findings suggested that the right ureter communicated with either the right seminal vesicle or the ampullary portion of the left vas deferens. We interpreted that the contrast medium, injected into the right ureteral orifice, effluxed also to the right seminal vesicle and through the common ejaculatory duct to reach the left seminal vesicle and left ureter. Semen might be diluted with urine. After an indwelling Double-J* ureteral stent was placed the right hydronephrosis improved. We believe that the right hydronephrosis was partly due to stenosis of the right ureteral orifice. Subsequently, right ureteroneocystostomy and partial left ureterectomy were performed. At operation we confirmed that the left lower ureter drained into the left seminal vesicle, and the left vas deferens crossed the midline and coursed to the right seminal vesicle. The right seminal vesicle was behind the right ureter and adjacent to the left seminal vesicle. The right ureter was spatulated as distal as possible and then anastomosed to the right lateral bladder wall. The left ureter was removed. Histological study of the resected specimen demonstrated ureteral tissue. Convalescence was uneventful. Postoperatively, an excretory urogram revealed a persistently dilated collecting system. The serum urea and creatinine levels were evaluated slightly. Semen analysis was almost identical with the preoperative value. Post-

FIG. 2. A, right retrograde pyelogram demonstrates malrotated right kidney with dilated collecting system, as well as left ureter and bilateral seminal vesicles. B, right seminal vesiculogram shows dilated end of right vas deferens. Right seminal vesicle is not shown. Double-J stent is in right ureter .

. FIG. 3.. A, ant~rior view of lef~ seminal vesicujogram. _Left vas deferens ~rosses _midline and opens in right seminal vesicle (RS). Ureter and ng~t semmal vesicle als? are depicted. Both semn~al vesicl~s fuse ~o for~ smgle eJaculatory duc_t. B, right anterior oblique view of left seminal vesiculogram. Ends of bilateral vas deferens and nght semmal vesicle align from back to front m that order. RU right ureter LU left ureter RA, ampulla of right vas deferens. LA, ampulla of left vas deferens. LS, left seminal vesicle. ' · ' ·

BLD

FIG. 4. Computerized tomography of pelvic cavity. Double-J ureteral stent is between bladder and right seminal vesicle or ampulla of left vas deferens. Scan also confirms interrelationships in urogenital system demonstrated by previous study. * Medical Engineering Corp., New York, New York.

FIG. 5. Deformed lateral view of genitourinary system in our patient shows bladder (BLD), urethra ( U), prostate (P), right (RS) and left (LS) seminal vesicles, left ureter (LU) and verumontanum (VR).

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operative cystourethroscopy revealed a fistula at the 7 o'clock position in the mid prostatic urethra. DISCUSSION

The overall interrelationships of the urogenital systems are complicated and difficult to understand in our patient. From the radiological and operative findings, we interpreted the structure of the genitourinary system as shown in figure 1. This case is remarkable for 5 reasons: 1) the left ureter drains exclusively into the left seminal vesicle, 2) the right and left seminal vesicles fuse to form a single ejaculatory duct, 3) the prostatic urethra has a fistula, 4) the left vas deferens crossed the midline and opened into the contralateral seminal vesicle, and 5) on the left side the openings of the vas deferens and seminal vesicle are separate. If the ureteral bud arises from a more cephalad position during intrauterine life, the ureteral orifice may be at the seminal vesicle, such as the left ureter in our patient. Fusion of both seminal tracts is an uncommon anomaly. Radiologically, each seminal vesicle seems to form a common ejaculatory duct in our patient (fig. 5). If this is true, the mesonephric duct may unite at 6 to 8 weeks of gestation because the ejaculatory duct differentiates from the mesonephric duct. Beall and Ware reported a similar case of an intercommunicating vas deferens with no demonstration of seminal vesicles. 2 We consider fistula in the prostatic urethra to be the opening for the ejaculatory duct and not the left ureter (fig. 5). The position of the ejaculatory duct on the left seminal vesiculogram (fig. 3, B) seems to be identical with the fistula. We have no explanation for the

crossed ectopia of the left vas deferens. In the literature ectopic opening sites of the vas deferens consist of the contralateral seminal vesicle,3 inguinal region,4 anterior urethra 5 or anterior seminal vesicle. 6 In any case, the ectopia is associated with the ipsilateral seminal vesicle. It is noteworthy that the left vas deferens and seminal vesicle in our patient were separate. To our knowledge, such a case has not been reported previously. The ontogeny of our case is to be settled. As noted previously, one should not rule out the possibility that this anomaly represents displacement by a mass rather than genuine ectopia. 7 REFERENCES 1. Schwarz, R. and Stephens, F. D.: The persisting mesonephric duct:

high junction of vas deferens and ureter. J. Urol., 120: 592, 1978.

2. Beall, M. E. and Ware, R. E: Intercommunicating vas deferens. J. Urol., 116: 126, 1976. 3. Mellin, H.-E., Kjaer, T. B. and Madsen, P. 0.: Crossed ectopia of seminal vesicles, renal aplasia and ectopic ureter. J. Urol., 115: 765, 1976. 4. Shinogara, Y., Yamamoto, N. and Sakatoku, J.: Congenital ectopic seminal vesicle: report of a case. Nishinippon J. Urol., 45: 1245, 1983. 5. Boreau, J.: Images of the Seminal Tracts. Radiological and Clinical Comparisons. New York: S. Karger, p. 116, 1974. 6. Vaidyanathan, S., Rao, M. S., Rao, K. M. K., Rajendran, L. J. and Subudhi, C. L.: Anterior transposition of seminal vesicles with ectopy of their common ejaculatory duct. J. Urol., 120: 768, 1978. 7. Tanagho, E. A.: Editorial comment. J. Urol., 115: 766, 1976.

Crossed ectopia of left vas deferens, leaving ipsilateral seminal vesicle in normal position.

A 19-year-old man with crossed ectopia of the vas deferens was investigated with special reference to right hydronephrosis and renal dysfunction. Ther...
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