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Crossed Testicular Ectopia

I. Basca¹,², A. Nica², L. Niculescu², M. Andriescu², C. Datu¹,²

¹Chair of Pediatric Surgery Department, “Carol Davila” University, Bucharest, Romania

² “Grigore Alexandrescu” Children Emergency Hospital, Bucharest, Romania

 

Correspondence:

Ion Basca, MD,PhD

Pediatric Surgery Department, “Grigore Alexandrescu” Children Emergency Hospital

“Carol Davila” Medicine and Pharmacy University

Blv. Iancu de Hunedoara 30-32, Sector 1, Bucharest, Romania

E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

Abstract

Crossed testicular ectopia is an extremely rare anomaly, in which both testes migrate toward the same hemiscrotum through the same inguinal canal. We report a case of crossed testicular ectopia in a 6-year-old boy operated for hypospadias and left cryptorchidism. Previously he underwent a surgical exploration of the right inguinal canal which established the diagnosis of right testicular agenesia. On exploration, both testes were present in the left inguinal canal together with a voluminous inguinal hernia. Bilateral orchiopexy was performed by crossing the right testis transseptal to the right hemiscrotum. The mechanisms and diagnosis of this rare anomaly are discussed.

Key words: crossed testicular ectopia, bilateral cryptochidism

  

Introduction

Normally the testes are located in the scrotum at birth. Ectopic testes have been reported in different sites, including: suprapubic, femoral area, perineal area, the base of the penis [1].

Crossed ectopia is one of the rarest types of testicular ectopia. It is an uncommon anomaly of testicular migration characterized by the descent of bought testicles through the same inguinal canal, toward the same hemiscrotum. The ectopic testis can be found in the opposite hemiscrotum [2], in the opposite inguinal canal [3], or at the opposite deep inguinal ring [4]. The vascular supply to the ectopic testis originates from the same side as the testis [5]. Crossed testicular ectopia is diagnosed in most cases during surgery [6].

We present here a case of a 6 year old boy with crossed testicular ectopia and hypospadias.

Case report

A 6 year old boy with surgically corrected penile hypospadias and right testicular agenesis was admitted to our department for surgical cure of left cryptorchidism.

At the age of 1 year and 9 months a Snodgrass type urethroplasty was performed for penile hypospadias. At the age of 2 years and 5 months, after 6000 UI hCG over the course of 6 weeks, we performed a second intervention for closing of the urethral fistula and surgical exploration of the right inguinal canal. Neither the right testis nor the right spermatic cord could be found in the right inguinal canal and the patient was considered to have right testicular agenesis.

At the age of 3 years and 6 months a third surgical intervention was performed for closing of a mediopenile urethral fistula. At the present admission, at the age of 6, the patient had an impalpable right testis and a hypoplastic right hemiscrotum. The left testis could be palpated at the deep inguinal ring. A surgical intervention for left orchidopexy was performed.

During surgery, a normal sized left testis with a voluminous hernia sac was found at the level of deep inguinal ring. Near the left testis we found another testis (the right testis with crossed testicular ectopia), slightly hypoplastic. All anatomical elements of both testicles are present and normal (vas deferens, epididymis, vascular supply) (Fig. 1). After herniorrhaphy was performed a transverse incision was made in the scrotum and two subdartous pouches were made, one for each hemiscrotum. The left testis was placed in the left hemiscrotum, and the right testis was placed transseptal in the right hemiscrotum. The postoperative recovery was uneventful.

crossed testic

Figure 1. Intraoperative view showing both testes in the same side. Continue arrows point to the left testis with epididymis and left spermatic cord. Dashed arrows point to the right testis (hypoplasic) with its corresponding right spermatic cord
Discussion

First description of crossed testicular ectopia was made by Lenhossek in 1886 [7]. He presented the case of a 35 years old man, at whose autopsy both testicles were found in the left hemiscrotum. In 1895 Jordan Max presented the case of an 8 years old boy with hypospadias operated for left inguinal hernia, and during surgery he found in the hernia sac the right testis [8]. In 1907 Halstead describe another case [9].

Although more that one hundred cases of crossed testicular ectopia can be found reported in the literature, to our knowledge this is the first case reported in the Romanian literature.

The etiology of this anomaly is still unknown. Lenhossek (1886) [8] was the first to suggest that this type of testicular ectopia is caused by an abnormal gubernaculum testis. Lockwood (1888) developed this theory, describing the 5 parts of the gubernaculum and their points of insertion: the bottom of the scrotum, the front of the pubis, the perineum, Scarpa’s triangle in the thigh the region of the inguinal ligament just medial to the anterior superior iliac spine [10,11]. Berg (1905) suggested that both testicles arose from the same genital ridge [12]. Gray and Skandalakis thought that, since in most cases, the each testis has his own deferent duct, the crossing over occurred during testicular descent, each testis arising from the ipsilateral genital ridge [13].

Kimura [14] stated that true crossed testicular ectopia is only if there are two distinct deferent ducts, a common duct suggesting the development of the testis from one genital ridge. Gupta and Das [15] postulated that adherence and fusion of the developing Wolffian ducts takes place early and that descent of one testis causes the other one to follow it toward the same hemiscrotum. Josso (1977) develops the theory of anatomical anomalies, which includes: abnormal gubernaculums testis, obstruction of the inguinal canal, adherences between the testis and the nearby structures [16]. Another theory says that in the cases which present persistent Mullerian duct syndrome,the crossed ectopia is caused by the traction exercised on the testis by the Mullerian duct.

Many patients with crossed testicular ectopia present also some other genitourinary anomalies [17,18]. Depending on these associations, some experts have proposed the following classification of crossed testicular ectopia [19]: type 1, accompanied only by inguinal hernia (40-50%); type 2, accompanied by persistent Mullerian duct syndrome (30%); type 3, associated with genitourinary anomalies, other than persistent Mullerian duct, (13-20%): hypospadias, pseudohermaphroditism, seminal vesicle cyst, scrotal abnormalities, common deferent duct, horseshoe kidney. According to this classification, the case presented here was a type 3 crossed testicular ectopia, the patient presenting also inguinal hernia and hypospadias.

Crossed testicular ectopia should be suspected in patients presenting with inguinal hernia on one side and cryptorchidism on the other side. Most cases reported in the literature the accurate diagnosis was made during surgery for inguinal hernia.

The diagnosis can be made preoperatively using ultrasounds [2], MRI [20], CT, arteriography, venography [21]. The use of imagistic techniques is still controversial. The ultrasound is the first method of choice to localize the absent testis. The computer tomography is not frequently used because of the radiation. The MRI seems to be the most valuable in cases where ultrasounds could not find the testis [20], the only problem is the high price.

The diagnosis of crossed testicular ectopia should be followed by more tests to exclude other genitourinary anomalies. It is important to exclude an associated persistent Mullerian duct syndrome, the two being frequently found together.

The difference between crossed testicular ectopia and testicular duplication should be made. In case of duplication both testicles aroused from the same genital ridge and they have a common deferent duct and blood supply [20]. A differential diagnosis should be made with: hydrocele, spermatocele, tumor of the testis, spleenogonadal fusion [22].

There have been reported cases of malignant transformation (embryonic carcinoma, seminomas, choriocarcinoma, teratoma) of the ectopic testis. The risk of malignant transformation is of 5%, and can happen bilateral. Because of this risk the patient should followed up for a long period of time. The testicular biopsy and hormonal and genetic assessment are not routinely used. They should be performed only when persistent Mullerian duct syndrome is suspected [3].

The therapy for crossed testicular ectopia is surgical treatment. In most case a transseptal orchidopexy, the Ombredanne technique is performed [23]. This was the technique used in the presented case. Another technique brings the ectopic testis in his hemiscrotum using a suprapubic subcutaneous tunnel [24]. In 2002 Dean and Shah [25] reported a case successfully treated by laparoscopic approach.

Conclusions

Crossed testicular ectopia is a rare condition and should be suspected in patients presenting with inguinal hernia on one side and cryptorchidism on the other side. In most cases the accurate diagnosis was made during surgery for inguinal hernia. An imagistic assessment, i.e. ultrasounds, should be performed in all children presenting with unilateral non-palpable undescended testis. If the undescended testis is not found during inguinal surgery a contralateral inguinal surgical exploration might be considered. In the case of bilateral undescended testes with only one palpable testis we suggest performing the first orchidopexy on the palpable testis side. The testicular biopsy and hormonal assessment are not routinely used.

 

 

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