|Year : 2021 | Volume
| Issue : 2 | Page : 80-82
Crossed testicular ectopia: A report of two cases
Puja Ganguly1, Pankaj Halder2, Partha Chakraborty2, Kartik Chandra Mandal3
1 Department of General Surgery, R. G. Kar Medical College, Kolkata, West Bengal, India
2 Department of Pediatric Surgery, R. G. Kar Medical College, Kolkata, West Bengal, India
3 Department of Pediatric Surgery, Dr. B.C. Roy Postgraduate Institute of Pediatric Sciences, Kolkata, West Bengal, India
|Date of Submission||19-Feb-2021|
|Date of Acceptance||20-Aug-2021|
|Date of Web Publication||27-Nov-2021|
Saroda Palli, Panchanon Tala, Baruipur, Kolkata - 700 144, West Bengal
Source of Support: None, Conflict of Interest: None
The term “crossed testicular ectopia” (CTE) means the deviation from the normal path of descent resulting in unilaterality of both testes. The condition is mostly detected incidentally during repair of inguinal hernia or laparoscopic evaluation of impalpable undescended testis. Preoperative identification of this anomaly is feasible during the clinicoradiological evaluation of the genito-urinary abnormalities. Orchiopexy (transeptal/extraperitoneal transposition/laparoscopy-assisted) is the mode of surgical management. We present here two cases of CTE where laparoscopy-assisted trans-inguinal orchiopexy was done.
Keywords: Descend, ectopia, genito-urinary, laparoscopy, orchiopexy, pediatric, testis
|How to cite this article:|
Ganguly P, Halder P, Chakraborty P, Mandal KC. Crossed testicular ectopia: A report of two cases. J Med Soc 2021;35:80-2
| Introduction|| |
Crossed testicular ectopia (CTE) or transverse testicular ectopia is multifactorial. It often associated with other congenital anomalies and depending on these associated anomalies, Hussein suggested a classification;
- Type 1: Associated with contralateral inguinal hernia
- Type 2: Accompanied with persistent Mullerian structures
- Type 3: Associated with hypospadias, bifid scrotum, pseudohermaphroditism, renal anomalies, and seminal vesicle cysts.
It is a rare condition and the diagnosis preliminary depends on the clinician's high level of suspicion. However, a satisfactory outcome is observed after surgery. We report two cases of CTE, their presentations and management.
| Case Reports|| |
A 5-year-old child was brought to us for empty tight hemiscrotum since birth. Local examination revealed well-developed scrotal sac with an empty right hemiscrotum with the absence of right testis (RT). We could not find the RT in the right hemiscrotum or other ectopic sites. Ultrasonography (USG) did not find the RT in the abdomen or in the right inguinal canal (IC) also. Considering the clinical findings and available investigation, we diagnosed the case as right-sided impalpable undescended testis (UDT) and went for a diagnostic laparoscopy (DL). During DL, we found both the testicular vessels and vas entering into the left deep inguinal ring (DIR). On exploration, we found both the testes and their contents in the left IC [Figure 1]. We gently separated the vas and vessels of each testis. Laparoscopically, we identified the RT by tracing the right testicular vas and vessels through the abdomen. Next, we pull up the RT in the abdomen from the left IC and brought down it to the right hemiscrotum (sub-dartos pouch) through its normal pathway of descends, traversing the right DIR and IC and superficial inguinal ring (SIR). All incisional wounds and laparoscopic port wounds were closed accordingly. The postoperative period was uneventful.
|Figure 1: Intraoperative pictures of laparoscopy-assisted transinguinal orchiopexy in a 5-year-old boy with crossed testicular ectopia of the right testis|
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A 10-year-old boy was admitted with the absence of RT since birth and was being treated previously in the form of chordee correction and Thiersch Duppley urethroplasty for associated penoscrotal hypospadias. There was no residual chordee and the urethral meatus was in the mid glans level. His right hemiscrotum was empty and underdeveloped. The left hemiscrotum had two testicular structures which were later confirmed by USG. Left inguinal exploration revealed the two testes along with their vas and vasculatures [Figure 2]. We identified the RT by tracing the blood vessels and vas similar to the previous case and performed laparoscopy-assisted right orchiopexy. The postoperative period was uneventful, and the patient was doing well in 6 months' follow-up.
|Figure 2: Per-operative pictures showing laparoscopy-assisted identification of right testicular vas and vessels followed by transinguinal (right) placement of testis in the right hemiscrotum in a 10-year-old boy|
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| Discussion|| |
Ectopic testis (ET) is aberrantly located in the superficial inguinal pouch/prepenile area/perineum/femoral canal or in the contralateral hemiscrotum/CTE. The incidence of testicular ectopia is 5%–10%. Holsted reported the first case of ET and Lenhossek described the first case of CTE in 1886.
According to the widely accepted hypothesis, it occurs due to the mechanical effect of the persistent Mullerian duct. Berg et al. said the possibility of the development of both testes from the same genital ridge. Gupta and Das proposed the early adherence and fusion of the developing Wolffian ducts. Other postulations are aberrant gubernaculum, abnormal position of genito-femoral nerve, and defective formation of the DIR.
Usually, this condition is diagnosed intraoperatively during surgery for hernia or DL for an impalpable UDT. Few cases may be detected preoperatively either during the clinical evaluation of urogenital anomalies or during US screening of a UDT. From our study, we suggest the screening USG to the opposite IC and scrotum. An adult patient with CTE may present with infertility and subsequent investigations (USG or magnetic resonance imaging) reveal the CTE. One of our cases was diagnosed intraoperatively during DL for impalpable UDT while another case was diagnosed preoperatively during clinical examination for UDT with penoscrotal hypospadias.
The aim of the treatment of CTE is to place the testes in their own position and management of associated congenital anomalies (if any). The management strategy depends on the type of CTE, findings on exploration, and associated anomalies. Bascuna et al. described a management algorithm for the CTE. Herniotomy and orchiopexy for type I CTE. Complete/segmental resection of Mullerian remnants and orchiopexy for type II CTE and for type III CTE, management of associated anomalies in addition to an orchiopexy.
The options for orchiopexy include trans-septal (through a trans-septal incision), extra-peritoneal (by a suprapubic subcutaneous tunnel through the respective SIR), and laparoscopy-assisted (intraperitoneally through its respective DIR, IC, and SIR). The trans-septal orchiopexy or Ombredanne-Miller technique is the most popular and simple technique. However, without tracing the vas and vessels from the above, site determination (identification of true ectopic one) is practically difficult.
A similar problem is encountered in extra-peritoneal orchiopexy and it is not always feasible because of the inadequate length of the vessels and vas. Laparoscopy-assisted orchiopexy is more physiological and the length of the vas and vessels will never be a problem as they are brought through the respective DIR, IC, and SIR. Moreover, it may allow the evaluation of the contralateral hernia. It may also be beneficial for better delineation of any Mullerian remnants, and ductus deferens anomalies. However, we did not detect any such anomalies in our cases. The incidence of malignant transformation of CTE is 18%, similar to the rate in UDT in otherwise normal cases. Embryonal carcinoma, seminoma, yolk sac tumor, and teratoma in CTE are common. However, an increased risk of adenocarcinoma, squamous cell carcinoma, and papillary cystadenocarcinoma are seen in type II CTE with Mullerian remnants.
| Conclusion|| |
The lack of awareness leads to delay in the diagnosis and incidental discovery of CTE during the surgery. However, the management strategy should be individualized considering the length of the vessels and vas, the availability of the laparoscopic facility, and the surgeon's experiences. Laparoscopy-assisted orchiopexy is more physiological and should be attempted whenever possible.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
The authors would like to thank Prof. Supriya Basu: (MS, M.Ch). Head of the Department, Department of Urology, R. G. Kar Medical College and Hospital, Kolkata, India.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]