Persistent Müllerian duct syndrome with transverse testicular ectopia

Transverse testicular ectopia associated with persistent Mullerian duct syndrome in infertile male: two case reports and literature review

Transverse testicular ectopia (TTE) associated with persistent Mullerian duct syndrome (PMDS) is a rare form of male pseudohermaphroditism usually unexpectedly found at surgery for cryptorchidism or inguinal hernia in children. Its etiology and prevalence are unclear, although defects in the gene that encodes anti-Mullerian hormone (AMH) or AMH receptor has been generally considered as the major cause. Adult cases of TTE associated with PMDS are even more peculiar, as the adult patients usually present more complex medical history, require more comprehensive medical examination and management. Two adult men with normal karyotype were referred to the urology outpatient clinic for infertility and cryptorchidism. Semen analysis showed both patients were azoospermic. Ultrasound and computed tomography (CT) found both testes were located at the same side of abdominal cavity or pelvic cavity, which was confirmed during the laparoscopic exploration. A tubular structure adhering to the spermatic cord was also found in both cases. Laparoscopic-assisted transabdominal orchiopexy was performed and the tubular mass was removed. Pathological examination confirmed the existence of Mullerian duct, which showed positive immunostaining of the uterus marker genes. The principles of treatment include the restoration of testes, the preservation of fertility, and the prevention of malignancy. Much attention should be payed to avoid damage of fertile testes and vas deferens in the surgery. Long-term postoperative follow-up is necessary for assessment of malignant transformation and infertility.

[Persistent Müllerian ducts syndrome: one case of late hypofertility]

We report the case of a 35-year-old patient with a syndrome of persistent Müllerian ducts (PMDS) of the female type (group A). The diagnosis was made in adulthood during an infertility workup. Clinical examination revealed an empty scrotum, a normal penis and bilateral inguinal cystic masses. The spermogram found azoospermia. Imaging using MRI and tomotensidometry found the presence of an uterus, two fallopian tubes and two inguinal positions of polycystic testes. A surgical management was performed for surgical testicular biopsy. Histological examination then found a cystic formation of multi-celled mesothelial origin, with atrophic testis Sertoli cell involution and without sperm. PMDS is a rare form of pseudo-internal hermaphroditism characterized by the presence in a man of the uterus, fallopian tubes and upper vagina with external male genitalia and virilized characters. About 200 cases are reported in the literature. The diagnosis is often made in children intraoperatively during a cure of testicular ectopia. The karyotype is 46 XY type. The pathogenesis is related to a deficiency of anti-Müllerian hormone (AMH) or tissue resistance to its action by receptor abnormalities. The regression of the Müllerian duct derivatives can give three types of PMDS : masculine type, feminine type and a transverse type. Surgical treatment is difficult but necessary because of the risk of infertility and ectopic testicular degeneration.

Transverse testicular ectopia: a three-case report and review of the literature

OBJECTIVES

To describe the embryologic, clinical, and therapeutic features of transverse testicular ectopia (TTE) and to review the literature on similar cases.

METHODS

Three cases of TTE were discovered accidentally during surgery for inguinal hernia and undescended testes; a persistent Müllerian duct syndrome (PMDS) was associated in 1 case. We also performed a literature search for other reports of TTE.

RESULTS

A conservative surgical approach was chosen: transseptal orchiopexy was preferred in 2 cases and the Müllerian remnant was preserved in the first case.

CONCLUSIONS

TTE is a rare anomaly that usually presents as a unilateral cryptorchidism and a contralateral descendent testis with an associated hernia. In suspected cases, laparoscopy and ultrasonographic evaluation may be helpful in diagnosing this condition before surgery. Surgery, transseptal orchiopexy, is highly recommended to manage TTE especially when vasa deferentia are fused. In case of PMDS, the authors preferred preserving Müllerian remnants because of the risk of vas deferens and testicular blood supply damage. Recently, laparoscopy is useful for both diagnosing and management of TTE and associated anomalies.

Persistent mullerian duct syndrome and transverse testicular ectopia: embryology, presentation, and management

BACKGROUND

The finding of persistent mullerian duct syndrome (PMDS) with transverse testicular ectopia (TTE) is rare. We present nonidentical triplets with PMDS with TTE.

CASES

Triplet A presented with a right inguinal hernia and left nonpalpable testis at 4 months of age. Ultrasound demonstrated 1 testis in the right hemiscrotum. Laparoscopy revealed both testes in the right inguinal canal with a thick midline structure. Triplet B presented at 6 months of age in the exact manner with similar intraoperative findings as triplet A. No additional mullerian structures were identified in triplets A and B. Both underwent laparoscopic left orchiopexy and open right inguinal herniorraphy/orchiopexy. A portion of vas was noted in the path specimen of triplet B. Triplet C presented at 7 months of age with a nonpalpable left testis. Laparoscopy demonstrated bilateral fallopian tubes and a midline uterine remnant. Open bilateral orchiopexy was performed, and bilateral biopsies confirmed testes. All 3 were 46-X,Y.

CONCLUSION

Persistent mullerian duct syndrome with TTE may be encountered when performing laparoscopy for patients with nonpalpable testis. The persistent mullerian remnants vary among individuals and alter the normal anatomy, thus may complicate diagnosis and surgical management.

PERSISTENT Müllerian duct syndrome associated with transverse testicular ectopia: report of two cases

Persistent Mullerian duct syndrome (PMDS) with transverse testicular ectopia (TTS) is a very rare pathological association, often discovered during repair for inguinal hernia or cryptorchidism. We present 2 cases with PMDS associated with TTS and discuss the diagnosis and management. A hysterectomy was performed, with resection of the underdeveloped fallopian tubes. Both gonads wereplaced into subdartos pouches in each scrotum by the transseptal approach. The diagnosis of PMDS was confirmed postoperatively by genetic and hormonal investigations. Chromosome analysis revealed 46,XY. Pathological findings demonstrated the immature testes and the immature uterus.

Syndrome de persistance du canal müllérien avec ectopie testiculaire transverse : une association rare

Persistent mullerian duct syndrome with transverse testicular ectopia is a very rare pathological association, often fortuitously discovered in boys during repair for inguinal hernia or cryptorchidism. The authors present the case of an 15 year old adolescent with cryptorchidism, in whom ultrasonography of the right iliac fossa showed 2 testicles and a uterus. Surgical exploration confirmed the diagnosis.