Hernia uterus inguinale: a proposed algorithm using the laparoscopic approach

Management of the patients with persistent Müllerian duct syndrome: Is the ultimate goal testicular descent?

OBJECTIVE

Persistent Müllerian duct syndrome (PMDS) is a rare congenital disease characterized by the presence of rudimentary Müllerian structures within an intra-abdominal or hernial sac in a virilized male, often presenting as undescended testes. In this study, we aim to present a series of the PMDS patients who were managed by orchiopexy without removal of Müllerian remnants (MR).

MATERIAL AND METHODS

Between May 2010 and June 2017, we treated six cases diagnosed as PMDS in our department. Laparoscopy and gonadal biopsy were performed in all patients, and vessel ligation was done in four patients for the first session of Stephen-Fowler orchiopexy. After initial diagnosis, genetic analyses and endocrine investigations were performed. Demographic and clinical features of the patients, operative methods and follow-up data were analyzed retrospectively.

RESULTS

Mean age of the patients was 5.5 years. Three boys had undergone inguinal surgery due to hernia or undescended testis, while others were diagnosed during laparoscopic investigation of nonpalpable testis. As a definitive operation, testes and MR were completely removed in an adult patient, and the remaining patients were treated with laparoscopic or open orchiopexy with or without utero-cervical splitting and the MRs were left in situ. Two testes atrophied during follow-up period.

CONCLUSION

The goal of the approach in PMDS patients is to preserve testes, as well as carry them to their natural location. Leaving the MR in place is a suitable option for blood circulation of the testes but the long-term results are still unknown.

Laparoscopic management of Müllerian duct remnants in the paediatric age: Evidence and outcome analysis

Background:

This study performed a literature analysis to determine outcomes of laparoscopic management in Müllerian duct remnants (MDRs).

Patients and Methods:

Literature was searched for terms ‘Müllerian’ ‘duct’ ‘remnants’ and ‘laparoscopy'. Primary end points were age at surgery, laparoscopic technique, intraoperative complications and postoperative morbidity.

Results:

The search revealed 10 articles (2003–2014) and included 23 patients with mean age of 1.5 years (0.5–18) at surgery. All patients were 46XY, n = 1 normal male karyotype with two cell lines. Explorative laparoscopy was performed in n = 2 and surgical management in n = 21. The 5-port technique was used in n = 10, 3-port in n = 9 and robot-assisted laparoscopic approach in n = 1 (n = 1 technique not described). Complete MDRs removal in n = 9, complete dissection and MDRs neck ligation with endoscopic loops in n = 11 and n = 1 uterus and cervix were split in the midline. After MDRs removal, there were n = 2 bilateral orchidopexy, n = 3 unilateral orchidopexy, n = 1 Fowler–Stephens stage-I and n = 1 orchiectomy. Mean operative time was 193 min (120–334), and there were no intraoperative complications. Mean follow-up was 20.5 months (3–54) and morbidity included 1 prostatic diverticula. There were 13 associations with hypospadias, of which 3 had mixed gonads and 3 bilateral cryptorchidism. Other associations were unilateral cryptorchidism and incarcerated inguinal hernia n = 1, right renal agenesis and left hydronephrosis n = 1 and n = 2 with transverse testicular ectopy.

Conclusion:

This MDRs analysis suggests that the laparoscopic approach is an effective and safe method of treatment as no intraoperative complication has reported, and there is low morbidity in the long-term follow-up.

Persistent müllerian duct syndrome: How to deal with the müllerian duct remnants - a review

Persistent müllerian duct syndrome (PMDS) is usually a surprise finding either during orchidopexy or during routine inguinal hernia repair in male patients. Often, the surgeon would face a dilemma about what is to be done with the remnants of müllerian duct, i.e. the fallopian tubes, uterus and proximal vagina. Till recently, it was advised to retain these structures whenever it was felt that the complete excision of these structures may jeopardise the blood supply and integrity of the vas deferens. Recent reports of malignancy in these retained structures would justify more aggressive approach. In our patients with PMDS, we have removed the mucosa of the retained müllerian structures, without compromising the integrity and vascularity of the vas deferens, thus reducing the chances of malignancy.