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International Journal of Urology (2015) 22, 330–331
Urological Notes
Transverse testis ectopia: diagnostic and management algorithm Rosito Jr Bascuna M.D.,1,3 Ji Yong Ha M.D.,2 Yong Seung Lee M.D.,1 Hye Young Lee M.D.,1 Young Jae Im M.D.1 and Sang Won Han M.D., Ph.D.1
Abbreviations & Acronyms AMH = anti-Müllerian hormone PMDS = persistent Müllerian duct syndrome TTE = transverse testis ectopia 1
Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul, 2Department of Urology, Keimyung University School of Medicine, Daegu, Republic of Korea, and 3Section of Urology, Department of Surgery, Bicol Medical Center, Naga City, the Philippines [email protected] DOI: 10.1111/iju.12705
330
TTE shows abnormal descent of both testes through the same inguinal canal.1 Less than 100 cases have been reported and its rarity presents a surgical dilemma. With institutional review board approval, we reviewed six TTE cases, with a median age of 8 months at presentation, managed surgically in our institution from January 2006 to June 2013. Clinical presentation, intraoperative findings, operative technique and follow-up duration of 5 months to 7 years were assessed. Four patients (66%) presented with two palpable testes in one inguinoscrotal region. Of the patients whom we had no suspicion of TTE, we carried out inguinal incision on the testis with inguinal hernia and contralateral cryptorchidism, and on discovering TTE, we extended the incision medially for scrotal exploration. The other patient with bilateral cryptorchidism and hypospadias underwent diagnostic laparoscopy, showing an ectopic left testis crossing over the midline to the right inguinal region. We encountered rudimentary Müllerian duct structures in two cases, but did not carry out a biopsy to avoid potential vascular damage. Five patients underwent transabdominal orchiopexy, while one had transseptal orchiopexy. On follow up, all testes were normal-sized and palpable in the hemiscrotum, except for one atrophied testis. TTE etiology is unknown, but the most accepted theory comes from Lockwood, who noted the testis is pulled toward the distal insertions of the gubernacula: scrotal, abdominal wall, femoral, perineal, contralateral hemiscrotal and pubopenile.1 TTE is classified as: type I (40–50%) with inguinal hernia alone; type II (30%) with PMDS; and type III (20%) with hypospadias, inguinal hernia, scrotal abnormalities and pseudohermaphroditism.2 The mechanism involving between TTE and PMDS is not fully elucidated. Deficiencies in the synthesis or release of AMH or defects in its receptor functions are suspected causes but some patients with PMDS, however, express normal amount of AMH.3 In our experience, diagnostic laparoscopy was beneficial to confirm the diagnosis of TTE, check for presence of PMDS, map out the anatomy, assess the cord structures and vascular supply, and plan the definitive surgical management. The most common laparoscopic 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, such as a uterus, round ligament and fallopian tubes.4 The surgical goals are fertility preservation and placement of the testis in the hemiscrotum for surveillance for potential malignant development.5 Based on our experience and literature review, we propose a diagnostic and management algorithm of TTE (Fig. 1). 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 remnant Müllerian structures. Depending on the surgeon’s expertise and preference, one might apply open or laparoscopic technique. 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 (Fig. S1).5 A transseptal window is made, through which the ectopic testis is passed and is fixed to the correct hemiscrotum. The spermatic cord, however, still crosses the midline and goes through the contralateral inguinal canal. 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.6 Transabdominal orchiopexy should be carried out 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.7 Before orchidopexy, distend the bladder and check if there will be mechanical
© 2015 The Japanese Urological Association
Urological Notes
Fig. 1
Diagnostic and management algorithm of transverse testis ectopia.
obstruction of the transposed structures. If PMDS are seen, we do not recommend biopsy because of the potential risk to the vascular supply. Two testes in one inguinoscrotal region give a clinical diagnosis of TTE. It must be considered in the differential diagnosis of patients with non-palpable 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.
Conflict of interest None declared.
References 1 Heyns CF, Hutson JM. Historical review of theories on testicular descent. J. Urol. 1995; 153: 754–67.
© 2015 The Japanese Urological Association
2 Gauderer MW, Grisoni ER, Stellato TA, Ponsky JL, Izant RJ Jr. Transverse testicular ectopia. J. Pediatr. Surg. 1982; 17: 43–7. 3 Giri SK, Berney D, O’Driscoll J, Drumm J, Flood HD, Gupta RK. Choriocarcinoma with teratoma arising from an intra-abdominal testis in patient with persistent Mullerian duct syndrome. Lancet Oncol. 2004; 5: 451–2. 4 Fairfax CA, Skoog SJ. The laparoscopic diagnosis of transverse testicular ectopia. J. Urol. 1995; 153: 477–8. 5 Hughes DT, Croitoru DP. Case report: Crossed testicular ectopia. J. Pediatr. Surg. 2007; 42: 1620–2. 6 Divarci E, Ulman I, Avanoglu A. Transverse testicular ectopia treated by transseptal contralateral transposition: case report. Eur. J. Pediatr. Surg. 2011; 21: 191–2. 7 Karnak I, Tanyel FC, Akçören Z, Hiçsönmez A. Transverse testicular ectopia with persistent mullerian duct syndrome. J. Pediatr. Surg. 1997; 32: 1362–4.
Supporting information Additional supporting information may be found in the online version of this article at the publisher’s web-site: Fig. S1 Management schema of transverse testis ectopia using transseptal orchiopexy.
331
Copyright of International Journal of Urology is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
International Journal of Urology (2015) 22, 330–331
Urological Notes
Transverse testis ectopia: diagnostic and management algorithm Rosito Jr Bascuna M.D.,1,3 Ji Yong Ha M.D.,2 Yong Seung Lee M.D.,1 Hye Young Lee M.D.,1 Young Jae Im M.D.1 and Sang Won Han M.D., Ph.D.1
Abbreviations & Acronyms AMH = anti-Müllerian hormone PMDS = persistent Müllerian duct syndrome TTE = transverse testis ectopia 1
Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul, 2Department of Urology, Keimyung University School of Medicine, Daegu, Republic of Korea, and 3Section of Urology, Department of Surgery, Bicol Medical Center, Naga City, the Philippines [email protected] DOI: 10.1111/iju.12705
330
TTE shows abnormal descent of both testes through the same inguinal canal.1 Less than 100 cases have been reported and its rarity presents a surgical dilemma. With institutional review board approval, we reviewed six TTE cases, with a median age of 8 months at presentation, managed surgically in our institution from January 2006 to June 2013. Clinical presentation, intraoperative findings, operative technique and follow-up duration of 5 months to 7 years were assessed. Four patients (66%) presented with two palpable testes in one inguinoscrotal region. Of the patients whom we had no suspicion of TTE, we carried out inguinal incision on the testis with inguinal hernia and contralateral cryptorchidism, and on discovering TTE, we extended the incision medially for scrotal exploration. The other patient with bilateral cryptorchidism and hypospadias underwent diagnostic laparoscopy, showing an ectopic left testis crossing over the midline to the right inguinal region. We encountered rudimentary Müllerian duct structures in two cases, but did not carry out a biopsy to avoid potential vascular damage. Five patients underwent transabdominal orchiopexy, while one had transseptal orchiopexy. On follow up, all testes were normal-sized and palpable in the hemiscrotum, except for one atrophied testis. TTE etiology is unknown, but the most accepted theory comes from Lockwood, who noted the testis is pulled toward the distal insertions of the gubernacula: scrotal, abdominal wall, femoral, perineal, contralateral hemiscrotal and pubopenile.1 TTE is classified as: type I (40–50%) with inguinal hernia alone; type II (30%) with PMDS; and type III (20%) with hypospadias, inguinal hernia, scrotal abnormalities and pseudohermaphroditism.2 The mechanism involving between TTE and PMDS is not fully elucidated. Deficiencies in the synthesis or release of AMH or defects in its receptor functions are suspected causes but some patients with PMDS, however, express normal amount of AMH.3 In our experience, diagnostic laparoscopy was beneficial to confirm the diagnosis of TTE, check for presence of PMDS, map out the anatomy, assess the cord structures and vascular supply, and plan the definitive surgical management. The most common laparoscopic 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, such as a uterus, round ligament and fallopian tubes.4 The surgical goals are fertility preservation and placement of the testis in the hemiscrotum for surveillance for potential malignant development.5 Based on our experience and literature review, we propose a diagnostic and management algorithm of TTE (Fig. 1). 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 remnant Müllerian structures. Depending on the surgeon’s expertise and preference, one might apply open or laparoscopic technique. 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 (Fig. S1).5 A transseptal window is made, through which the ectopic testis is passed and is fixed to the correct hemiscrotum. The spermatic cord, however, still crosses the midline and goes through the contralateral inguinal canal. 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.6 Transabdominal orchiopexy should be carried out 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.7 Before orchidopexy, distend the bladder and check if there will be mechanical
© 2015 The Japanese Urological Association
Urological Notes
Fig. 1
Diagnostic and management algorithm of transverse testis ectopia.
obstruction of the transposed structures. If PMDS are seen, we do not recommend biopsy because of the potential risk to the vascular supply. Two testes in one inguinoscrotal region give a clinical diagnosis of TTE. It must be considered in the differential diagnosis of patients with non-palpable 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.
Conflict of interest None declared.
References 1 Heyns CF, Hutson JM. Historical review of theories on testicular descent. J. Urol. 1995; 153: 754–67.
© 2015 The Japanese Urological Association
2 Gauderer MW, Grisoni ER, Stellato TA, Ponsky JL, Izant RJ Jr. Transverse testicular ectopia. J. Pediatr. Surg. 1982; 17: 43–7. 3 Giri SK, Berney D, O’Driscoll J, Drumm J, Flood HD, Gupta RK. Choriocarcinoma with teratoma arising from an intra-abdominal testis in patient with persistent Mullerian duct syndrome. Lancet Oncol. 2004; 5: 451–2. 4 Fairfax CA, Skoog SJ. The laparoscopic diagnosis of transverse testicular ectopia. J. Urol. 1995; 153: 477–8. 5 Hughes DT, Croitoru DP. Case report: Crossed testicular ectopia. J. Pediatr. Surg. 2007; 42: 1620–2. 6 Divarci E, Ulman I, Avanoglu A. Transverse testicular ectopia treated by transseptal contralateral transposition: case report. Eur. J. Pediatr. Surg. 2011; 21: 191–2. 7 Karnak I, Tanyel FC, Akçören Z, Hiçsönmez A. Transverse testicular ectopia with persistent mullerian duct syndrome. J. Pediatr. Surg. 1997; 32: 1362–4.
Supporting information Additional supporting information may be found in the online version of this article at the publisher’s web-site: Fig. S1 Management schema of transverse testis ectopia using transseptal orchiopexy.
331
Copyright of International Journal of Urology is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
