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CASE REPORT Table of Contents   
Year : 2014  |  Volume : 11  |  Issue : 3  |  Page : 269-272
Crossed testicular ectopia: Report of six cases


1 Şişli Etfal Education and Research Hospital, Departments of Pediatric Surgery, Istanbul, Turkey
2 Department of Pediatric Surgery, Yüzüncü Yıl University, Faculty of Medicine, Van, Turkey
3 Private Veni Vidi Hospital, Department of Pediatric Surgery, Ankara, Turkey

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Date of Web Publication22-Jul-2014
 

   Abstract 

Crossed testicular ectopia or transverse testicular ectopia is an extremely rare anomaly characterised by migration of one testis towards the opposite inguinal canal, usually associated with unilateral inguinal hernia. This report describes six cases of crossed ectopic testes, one of the largest series, and with unusual clinical histories.

Keywords: Crossed testicular ectopia, transverse testicular ectopia, undescended Testis

How to cite this article:
Akin M, Erginel B, Bilici S, Gedik &, Yıldız A, Karadağ &A, Sever N, Dokucu A&. Crossed testicular ectopia: Report of six cases. Afr J Paediatr Surg 2014;11:269-72

How to cite this URL:
Akin M, Erginel B, Bilici S, Gedik &, Yıldız A, Karadağ &A, Sever N, Dokucu A&. Crossed testicular ectopia: Report of six cases. Afr J Paediatr Surg [serial online] 2014 [cited 2019 Oct 17];11:269-72. Available from: http://www.afrjpaedsurg.org/text.asp?2014/11/3/269/137341

   Introduction Top


Crossed testicular ectopia or transverse testicular ectopia (TTE) is an extremely rare anomaly characterised by migration of one testis towards the opposite inguinal canal, usually associated with inguinal hernia. In most reported cases, the accurate diagnosis was not made before surgery. Treatment modalities include laparoscopic and surgical procedures. Unlike the undescended testis, which occurs in approximately 1% of male children, it has been noted that fewer than 100 cases have been reported in the world literature. [1] The typical presentation of crossed testicular ectopia is ipsilateral inguinal hernia and contralateral undescended testis. [2] In this manuscript, we report six cases to highlight the diagnosis of crossed ectopic testis in undescended testis cases with unusual clinical findings.


   Case Reports Top


Case 1

A 5-year-old boy was admitted to our clinic with bilateral undescended testes and right inguinal hernia. On physical examination, both testes were palpated in the right groin region and ultrasound (US) supported this finding. Transverse incision of the right inguinal region visualized both testes at the level of the external inguinal ring [Figure 1]. After the hernia sac was prepared and tied, both testes were brought down sequentially into the ipsilateral and contralateral hemiscrotums with transseptal incision [Figure 2].
Figure 1: Intraoperative appearance of Case 1. Right and left testes with funicular elements emerging from the right inguinal region

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Figure 2: Intraoperative appearance of Case 1. Scrotum after transseptal orchiopexy

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Case 2

A 6-year-old boy presented with bilateral undescended testes and left inguinal hernia. On physical examination, the left testis could be palpated at the inguinal region, but the right testis was impalpable and was not visualised by US. At surgery, a transverse incision of the left inguinal region was performed, and the left testis was found at the level of the external inguinal ring. During the preparation of the hernia sac, the right testis was also found in the sac. Similarly, both testes were brought down to both hemiscrotums with transseptal incision [Figure 3].
Figure 3: Intraoperative appearance of Case 2. Right and left testes with funicular elements emerging from the left inguinal region

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Case 3

An 8-year-old boy presented with a left impalpable testis and right inguinal bulging. On physical examination, the right testis was palpated in the swollen right inguinal region. The left testis was neither palpated nor visualised by US. At surgery, transverse incision of the right inguinal was made. The right testis was found at the level of the external inguinal ring, and the left testis was found in the hernia sac. In addition, the ductus deferens of the testes was fused proximally. After the sac was prepared and tied, the same surgical technique was successfully performed [Figure 4].
Figure 4: Intraoperative appearance of Case 3. Fused ductus deferens

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Case 4

A 2-year-old boy was admitted to the clinic with bilateral non-palpable testes and a previously repaired left inguinal hernia. On physical examination, both testes were non-palpable, the scrotum was hypoplastic and there was a left inguinal transverse inguinal scar. The bilateral testes were visualised in the right inguinal canal entrance on US. During laparoscopy, both testes were visualised near the internal inguinal canal entrance in the abdomen. At operation, the right transverse incision was made and both testes were found. There was no cord abnormality or remaining Mullerian structures. Multiple cystic appearance was present on the surface of the testes and hence a testis biopsy was performed. After the hernia sac was tied, bilateral transseptal orchidopexy was done. Histological examination revealed testis tissue.

Case 5

A 3-year-old boy was admitted to the clinic with a left impalpable testis and a right hydrocele. On physical examination, the left testis was not palpable and there was an inguinal undescended testis with hydrocele. US confirmed the physical examination findings. During laparoscopy, the left testis was visualized close to the internal ring. The spermatic cord and vessels were stayed from the right internal orifice to the left, and connection anomalies between the testes and these structures were noted. Remaining Mullerian anomalies were not established, and a biopsy was not taken from the testes because visual inspection revealed completely normal testicular appearance in both testes. After the hernia sac was tied, a bilateral transseptal orchidopexy was done.

Case 6

A 3year-old boy was referred to the clinic with ambiguous genitalia and bilateral undescended testes. At the rightinguinal transverse incision, twotestes were found on the ipsilateral side, each having its own fused ductus deferens. exploration was performed laparoscopically and neither the left testis nor the left cord structure was found in the abdomen Transseptal orchidopexy was performed.

The medical records of all patients with the diagnosis of TTE were analysed with respect to age, side of TTE, mode of presentation, localisation of testes on physical examination, associated anomaly, localisation of testes on USG and at laparoscopy; and the operation performed are listed in [Table 1].
Table 1: The medical records of all patients with the diagnosis of TTE were analysed with respect to age, side of TTE, mode of presentation, localisation of testes on physical examination, associated anomaly, localisation of testes on USG and at laparoscopy; and the operation performed

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   Discussion Top


The migration of the testes to an ectopic site, such as caudal to external ring, suprapubic, femoral, perineal and penile, has been reported. Crossed testicular ectopia is a rare anomaly of testicular migration wherein a testis descends into the opposite hemiscrotum. Typical clinical history is an inguinal hernia with contralateral undescended testis. Mean age at presentation is 4 years. [3] The patients in this study were much older than the usual presentation age with a mean of 5.2 years. This could be due to the low socioeconomic status of the region, which may have resulted in delayed awareness of the condition and delayed admission to the hospital.

The diagnosis of crossed testicular ectopia is often made intraoperatively during inguinal hernia repair. Only one out of six cases in this study was pre-operatively diagnosed TTE by ultrasonography (USG). The diagnostic clinical criteria consist of two testes located in the same hemiscrotum or inguinal canal with an empty contralateral hemiscrotum; however, as demonstrated by this present series, there are many different presentation modes.

Gauderer et al. [4] described a classification system for crossed testicular ectopia based on the presence of associated abnormalities: Type 1, the most common type (40-50%), is associated with inguinal hernia alone; Type 2 (30%) is associated with persistent or rudimentary Mullerian duct structures; and Type 3 (20%) is associated with other genitourinary abnormalities without Mullerian remnants. Mullerian duct remnants, duplication of ductus deferens and other anomalies have also been reported. Cases 1, 2, 4 and 5 can be classified as Type 1 and Cases 3 and 6 as Type 3, due to the presences of fused ductus deferentes. None of the cases was Type 2; therefore, contrary to current belief, Type 2 may account for less than the suggested 30% of all crossed ectopic testes.

Recently, USG, laparoscopy, and magnetic resonance imaging (MRI) have been used for the diagnosis of this condition. [5],[6],[7] However, none of the patients in this series underwent MRI. The aim of the treatment is fixation of the testes into the scrotum and exploration for ductus deferens anomalies, Mullerian remnants and subsequent malignancy. In one study, yolk sack tumour had developed on a patient who presented with transverse ectopic testes. [8] Transseptal orchiopexy was performed in all the patients in this present study, which is usually the preferred surgical option for fixing the testes into the scrotum. Laparoscopy may be beneficial whether Mullerian remnants and ductus deferens anomalies are present and may allow evaluation of contralateral hernia. Laparoscopic guide can be helpful, while performing the transseptal orchidopexy. [9] During exploration, two cases demonstrated ductus deferens anomaly, but this did not complicate the surgery. Mullerian duct remnants were not observed. However, laparoscopy was performed on three of the six patients, which might explain why Mullerian remnants were not detected.

In the literature, the usual presentation of crossed testicular ectopia is ipsilateral inguinal hernia and contralateral undescended testis, whereas in this series, four out of the six patients admitted with bilateral undescended testes. [10] To the best of our knowledge, no more than 10 cases in the literature describe the two cases with cross-testicular ectopia and fused vas deferentes in this series. [11] Yıldız et al. in their study have reported a six-case series with TTE, which is the largest series showing this rare pathology up to our knowledge. [12]


   Conclusion Top


The six-cases reported in this series had unusual clinical histories for crossed testicular ectopia, such as bilateral undescended testes with palpable or non-palpable testes, inguinal swelling instead of hernia and unsatisfactory impalpable testes treatment. However, the same surgical technique was performed on all cases, and impalpable testes were found in the hernia sacs of all patients. The main aim of the surgical therapy was the fixation of the testes, searching for Mullerian duct remnants and long-term follow-up for malignancy. [13] The fusion of ductus deferentes was determined in two cases, but accompanying Mullerian duct anomalies were not present in either patient. Surgical management might also be performed with laparoscopically assisted transseptal orchidopexy. It is recommended that the diagnosis of crossed ectopic testes should not be overlooked in undescended testis cases with unusual clinical findings.

 
   References Top

1.Park Y, Lee G. An unusual presentation of crossed testicular ectopia as an incarcerated inguinal hernia. World J Mens Health 2013;31:265-7.  Back to cited text no. 1
    
2.Yanaral F, Yildirim ME. Testicular fusion in a patient with crossed testicular ectopia: A rare entity. Urol Int 2013;90:123-4.  Back to cited text no. 2
    
3.Malik MA, Iqbal Z, Chaudri KM, Malik NA, Ahmed AJ. Crossed testicular ectopia. Urology 2008;71:984.e5-6.  Back to cited text no. 3
    
4.Gauderer MW, Grisoni ER, Stellato TA, Ponsky JL, Izant RJ Jr. Transverse testicular ectopia. J Pediatr Surg 1982;17:43-7.  Back to cited text no. 4
[PUBMED]    
5.Chen KC, Chu CC, Chou TY. Transverse testicular ectopia: Preoperative diagnosis by ultrasonography. Pediatr Surg Int 2000;16:77-9.  Back to cited text no. 5
    
6.Dean GE, Shah SK. Laparoscopically assisted correction of transverse testicular ectopia. J Urol 2002;167:1817.  Back to cited text no. 6
    
7.Lam WW, Le SD, Chan KL, Chan FL, Tam PK. Transverse testicular ectopia detected by MR imaging and MR venography. Pediatr Radiol 2002;32:126-9.  Back to cited text no. 7
    
8.Zhu YP, Zhang SL, Ye DW, Shi GH, Xiao WJ. Yolk sac tumor in a patient with transverse testicular ectopia. World J Surg Oncol 2011;9:91.  Back to cited text no. 8
    
9.Takahashi M, Kurokawa Y, Nakanishi R, Nakatsuji H, Izaki H, Oka N, et al. Laparoscopic findings of transverse testicular ectopia. Urology 2008;71:547.e3-5.  Back to cited text no. 9
    
10.Hughes DT, Croitoru DP. Case report: Crossed testicular ectopia. J Pediatr Surg 2007;42:1620-2.  Back to cited text no. 10
    
11.Naji H, Peristeris A, Stenman J, Svensson JF, Wester T. Transverse testicular ectopia: Three additional cases and a review of the literature. Pediatr Surg Int 2012;28:703-6.  Back to cited text no. 11
    
12.Yıldız A, Yiğiter M, Oral A, Bakan V. Transverse testicular ectopia. Pediatr Int 2014;56:102-5.  Back to cited text no. 12
    
13.Oludiran OO, Sakpa CL. Crossed ectopic testis: A case report and review of the literature. Pediatr Surg Int 2005;21:672-3.  Back to cited text no. 13
    

Top
Correspondence Address:
Dr. Başak Erginel
Yildirim Oguz Goker Sokak, 5 Gazeteciler Sitesi, C-1 Blok, No. 36, Akatlar, Besiktas, Istanbul
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0189-6725.137341

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1]

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Current Urology Reports. 2015; 16(7)
[Pubmed] | [DOI]



 

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