Case Report Crossed Testicular Ectopia Muhammad Akram Malik, Zahid Iqbal, Khalid Mahmood Chaudri, Naveed Ashraf Malik, and Azhar Javed Ahmed Crossed testicular ectopia/transverse testicular ectopia is an extremely rare anomaly, in which both gonads migrate toward the same hemiscrotum. About 100 cases of transverse testicular ectopia have been reported in published studies. We report a case of transverse testicular ectopia in an 8-year-old boy who presented with right inguinal hernia and nonpalpable left testis. On exploration, both testes were present in the right inguinal region. Bilateral orchiopexy was performed by crossing the left testis in the preperitoneal space. The diagnosis could not be made preoperatively in most of reported cases. Magnetic resonance imaging, magnetic resonance venography, and laparoscopy are useful for diagnosis and management. UROLOGY 71: 984.e5–984.e6, 2008. © 2008 Elsevier Inc.
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rossed testicular ectopia, also called transverse testicular ectopia (TTE), testicular pseudoduplication, unilateral double testis, and transverse aberrant testicular mal-descent, is an uncommon anatomic abnormality in which both gonads migrate toward the same hemiscrotom.1 In 1886, Von Cenhossek described the first case of TTE, and, in 1895, Martin et al.2 described the syndrome of TTE with persistent müllerian ducts. About 100 cases of TTE have been reported in published studies.3,4 Usually hernia is associated with an ectopic testis. In most reported cases, a correct diagnosis was not made preoperatively.5,6
CASE REPORT We recently encountered an 8-year-old boy who had crossed testicular ectopia. He presented with pain in the right inguinal region. The physical examination revealed an undeveloped left empty scrotum, with a nonpalpable testis in the left inguinal area. The right scrotum was partially developed, with palpable testes at the superficial inguinal ring. Inflamed tender swelling was present in the right inguinal region, with normal bowel sounds. Immediate exploration was undertaken after a diagnosis of a right irreducible hernia. At exploration, a hernia sac and a second testis at the level of the deep inguinal ring were present (Figs. 1 and 2). Both testes had separate processes vaginalis and a separate blood supply. Herniotomy was performed, and orchiopexy was done on both sides by crossing the left testis in the preperitoneal space. The presence of müllerian ductal structures was ruled out by ultrasonography and computed tomography postoperatively. From the Department of Urology and Renal Transplantation, Allied Hospital, Faisalabad, Pakistan Reprint requests: Muhammad Akram Malik, F.C.P.S. (Surgery), F.C.P.S. (Urology), 80-C, PMC Staff Colony, Allied Hospital, Faisalabad, Pakistan. E-mail:
[email protected] Submitted: February 17, 2007, accepted (with revisions): November 14, 2007
© 2008 Elsevier Inc. All Rights Reserved
Figure 1. Two testes separately visible. They were joined by a common/single vas, and their blood supply was separate.
His postoperative recovery was uneventful. Karyotyping confirmed a male gender 46XY. The renal ultrasound findings were normal.
COMMENT TTE is an extremely rare anomaly. The ectopic testis can lie in the hemiscrotom, in the inguinal canal, or at the deep inguinal ring. An inguinal hernia is invariably present on the side to which the ectopic testis has migrated. According to the presence of various associated anomalies, TTE has been classified into three types: (a) associated with inguinal hernia alone (40% to 50%), (b) associated with persistent or rudimentary müllerian duct structures (30%), and (c) associated with other anomalies without müllerian remnants (inguinal hernia, hypospadias, pseudohermaphroditism, and scrotal abnormalities) (20%).7 The mean age at presentation is 4 years. In most cases, the correct diagnosis has not been made preoperatively, and the condition was 0090-4295/08/$34.00 984.e5 doi:10.1016/j.urology.2007.11.088
CONCLUSIONS A conservative approach to this rare syndrome in the form of herniotomy and orchiopexy without risking the vas deferens is recommended. Long-term follow-up is needed for the assessment of fertility in these patients. References
Figure 2. Both testis were placed in separate hemiscrotums, keeping their blood supply intact. They were crossed preperitoneally in the suprapubic region.
revealed during herniotomy. Recently, magnetic resonance imaging and magnetic resonance venography have been suggested for preoperative location of impalpable testes.8 Laparoscopy is useful for both diagnosis and treatment of TTE and associated anomalies.9 Management includes transceptal orchiopexy or extraperitoneal transposition of the testis, a search for müllerian remnants and other anomalies, and long-term postoperative follow-up. As with all dysgenetic testis, infertility and progression to malignancy are relatively frequent with TTE.10,11
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1. Barrack S: Crossed testicular ectopia with fused bilateral duplication of the vasa deferential: an unusual finding in cryptorchidism. East Afr Med J 71: 398 – 400, 1994. 2. Martin EL, Bennett AH, and Cromie WJ: Persistent müllerian duct syndrome with transverse testicular ectopia and spermatogenesis. J Urol 147: 1615–1617, 1992. 3. Vaos G, and Zavras N: Irreducible inguinal hernia due to crossed testicular ectopia in an infant. Hernia 8: 397–398, 2004. 4. Al-Bassam AA: Persistent müllerian duct syndrome associated with transverse testicular ectopia. Ann Saudi Med 17: 226 –227, 1997. 5. Mehmood MT, Ahmad J, and Ather MS: Transverse testicular ectopia and persistent müllerian duct syndrome: a rare association. J Coll Physicians Surg Pak 12: 320 –321, 2002. 6. Kella N, Rathi PK, Memon S, et al: Persistent müllerian duct syndrome with transverse testicular ectopia. J Coll Physicians Surg Pak 15: 119 –120, 2005. 7. Gauderer MW, Grisoni ER, Stellato TA, et al: Transverse testicular ectopia. J Pediatr Surg 17: 43– 47, 1982. 8. Lam WW, Le SD, Chan KL, et al: Transverse testicular ectopia detected by MR imaging and MR venography. Pediatr Radiol 32: 126 –129, 2002. 9. Gornall PG, and Pender DJ: Crossed testicular ectopia detected by laparoscopy. Br J Urol 59: 283, 1987. 10. Fujita J: Transverse testicular ectopia. Urology 16: 400 – 402, 1980. 11. Melman A, Leiter E, Perez JM, et al: The influence of neonatal orchiopexy upon the testis in persistent müllerian duct syndrome. J Urol 125: 856 – 858, 1981.
UROLOGY 71 (5), 2008
