|Year : 2013 | Volume
| Issue : 3 | Page : 310-312
Transverse testicular ectopia: Pre-operative diagnosis and management
Shreeprasad Patankar1, Shilpa Patankar2
1 Department of Pediatric Surgery, Bharati Vidyapeeth Medical College and Hospital, Pune, Maharashtra, India
2 Department of General Surgery, Bharati Vidyapeeth Medical College and Hospital, Pune, Maharashtra, India
|Date of Web Publication||5-Jul-2013|
35/1, Padmadarshan Coop Socy, 62/B, Parvati, Off Satara Road, BH Rawat Brothers, Pune - 411 009, Maharashtra
Source of Support: None, Conflict of Interest: None
Transverse testicular ectopia (TTE) is an extremely rare variety of undescended testis where both the testes migrate to one side. Common presentation is non-palpable testis on one side and inguinal hernia on opposite side. Pre-operative clinical diagnosis may not be always possible and usually TTE is diagnosed during surgery for inguinal hernia. High-index of suspicion, investigations like ultrasonography and laparoscopy would help in pre-operative diagnosis and management.
Keywords: Transverse testicular ectopia, trans-septal orchiopexy, undescended testis
|How to cite this article:|
Patankar S, Patankar S. Transverse testicular ectopia: Pre-operative diagnosis and management. Med J DY Patil Univ 2013;6:310-2
| Introduction|| |
Transverse testicular ectopia (TTE) is an extremely rare variety of undescended testis. Common presentation is non-palpable testis on one side and inguinal hernia on opposite side. Pre-operative clinical diagnosis may not be always possible and usually, TTE is diagnosed during surgery for inguinal hernia. High-index of suspicion, investigations like USG and laparoscopy would help in pre-operative diagnosis and management. Associated condition like persistent Mullerian structures should also be kept in mind and treated accordingly. Prompt diagnosis, mobilization of testis and trans-septal orchiopexy is the standard treatment. We describe here a case of TTE diagnosed clinically, and operated successfully.
| Case Report|| |
An 18-month-old male baby presented with non-palpable right undescended testis and left congenital hernia. The baby was born full-term normal delivery with no significant past medical history. Examination of scrotum showed a well-developed scrotal sac with normal pigmentation and rugosity. Right testis was not palpable. Left testis was palpable in left half of scrotum slightly at higher position. A reducible congenital hernia was noted on left side. An ovoid firm structure was palpable in left inguinal region just lateral to left pubic tubercle when hernia contents were reduced [Figure 1]. Penis was well-formed and normal. General and other systemic examination was normal and the hemogram, renal function tests, and bleeding profile were normal. USG of inguino-scrotal region showed an echogenic, oval structure suggestive of testis lateral to left pubic tubercle in inguinal region. Left testis was located in left hemi-scrotum. A probable diagnosis of TTE was made and left inguino-scrotal exploration was planned.
|Figure 1: Ectopic testis located in left inguinal region marked with star. Left testis present in left scrotal sac|
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Under general and caudal epidural anesthesia left inguinal crease incision was taken. A processus vaginalis sac was found extending right up to left hemi-scrotum. Sac was opened midway to find both the testes, along their vas and vessels. Both testes were of size 15 mm × 20 mm and were firm in consistency. There was no vaso-epididymal anomaly. The vas and vessels of two testes were enclosed in separate soft-tissue sheaths distal to superficial inguinal ring. However, they fused together in a common soft-tissue sheath in region of inguinal canal and entered deep ring together [Figure 2]. The deep ring was enlarged slightly to allow examination of pelvic cavity. There was no evidence of any remnants of Mullerian structures. The hernia sac was dissected carefully from the sheath containing vas and vessels and high-ligation was carried out at deep ring. Left testis now could comfortably reach base of left hemi-scrotum now. The right testis, which was found in left superficial inguinal pouch could reach right hemi-scrotum and was placed there via a window created in scrotal septum. Both the testes were pexed in respective halves of scrotum and inguinal incision was closed [Figure 3]. Baby tolerated surgery well and was discharged next day and he is doing fine on follow-up.
|Figure 3: Both testes in corresponding scrotal sacs after transseptal orchiopexy|
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| Discussion|| |
TTE is the rarest of the varieties of undescended testis, few hundred cases reported in literature so far. In this condition, both the gonads descend towards same side and the ectopic testis may be located in the pelvis, at internal ring or in contra lateral inguinal canal. ,, Both the testes share common processus vaginalis sac, hence inguinal hernia on the side to which ectopic testis migrates is the most common presentation.
Based on presence of associated anomalies three types of TTE are described. (1) Type I: Associated with inguinal hernia (40-50%). (2) Type II: Associated with persistent or rudimentary Mullerian Duct structures (PMDS) (30%). (3) Type III: Anomalies other than PMDS such as hypospadias, pseudohermaphroditism, and scrotal anomalies (20%). ,, The baby described here belongs to type I TTE and various theories explain embryogenesis of TTE. Adherence of the developing testes and Wolffian ducts explains embryogenesis of TTE better since the vessels of the crossed ectopic testis travels to the side of origin once it enters the pelvis. Mullerian inhibiting substance has role in both regression of Mullerian structures and descent of testis. Hence, association of TTE and persisting Mullerian structures can be explained. Mechanical effect of the PMDS may prevent normal testicular descent or may push both the testes towards the same hemi-scrotum, producing TTE. ,
The most common mode of presentation is association of inguinal hernia and contra-lateral non-palpable undescended testis. Majority of times TTE is encountered during surgery for hernia. There are case reports of babies presenting with obstructed hernias and TTE found during surgery. , One should remember this association of hernia and contra lateral non-palpable undescended testis and investigate to locate the undescended testis.
The baby described here is a unique case where a pre-operative diagnosis of TTE was carried out. There are reports mentioning use of Magnetic resonance imaging (MRI) and MR angiogram helping in pre-operative diagnosis.  However, need of general anesthesia for MRI study in children would be a deterrent. Laproscopy would be of advantage being diagnostic and therapeutic both and it would confirm the diagnosis, would document migration of testis towards opposite deep inguinal ring and confirm origin of vessels from original side. Laproscopy helps in diagnosing associated PMDS and it would help in dissection of testicular vessels during mobilization of testis for orchiopexy. ,,,, Whenever, TTE is encountered during herniotomy a complete abdominal and pelvic exploration is mandatory. Trans-inguinal laproscopy or enlarging the incision at deep inguinal ring to mini-laprotomy will give good exposure of pelvis to look for PMDS. Once PMDS is ruled out, herniotomy is carried out testis is mobilized and pexed. Trans-septal orchiopexy is surgery of choice.
Treatment of TTE consists of detection of other congenital anomalies, herniotomy, and orchiopexy to preserve fertility and allow monitoring for development of malignancy. There are cases with TTE diagnosed late childhood or adulthood. Orchidectomy should be advised in such cases.
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[Figure 1], [Figure 2], [Figure 3]