Misdiagnosis and mistreatment of transverse testicular ectopia-two case report and review of literature

RATIONALE

Transverse testicular ectopia (TTE) is a rare congenital malformation with a high rate of misdiagnosis and mistreatment before operation, which cannot be diagnosed even during operation due to lack of knowledge.

PATIENT CONCERNS

Two patients with ectopic testes who were misdiagnosed as right inguinal hernia for the first time and underwent surgery. The "ovary" and "testicle" like structures was seen in the right inguinal region during the first operation. After being transferred to our hospital for laparoscopic surgery, it was found that the left spermatic cord and testis were transversely transverted to the right, the left testis was fixed at the right inner ring, and agglomerated soft tissue could be seen in the right inguinal canal, which was suspected to be Muller tube.

DIAGNOSES

Based on preoperative images and intraoperative findings, both cases were diagnosed with Transverse testicular ectopia (TTE). The postoperative pathology report for the second patient revealed the presence of an in situ spermatogenic cell tumor in the ectopic testis.

INTERVENTIONS

Preperitoneal tension-free repair of right inguinal hernia and resection of left cryptorchidism were performed on the 2 patients.

OUTCOMES

Postoperative pathology of the first patient confirmed that the resected specimens contained tubal-like and uterine-like structures. The postoperative pathology of the second patient showed that the resected tissue consists of immature testis, epididymis, uterus and seminal vesicle glands, in which an in situ spermatogenic tumor could be seen in the testicular tissue. Postoperative diagnosis: left transversal testicular ectopia and right indirect inguinal hernia.

LESSONS

The clinical misdiagnosis and mistreatment rate of TTE is very high. Once the patients with cryptorchidism complicated with inguinal hernia are found in clinic, the possibility of the disease must be considered. For the patients whose cryptorchidism does not descend into the ipsilateral scrotum and it is difficult to diagnose, laparoscopy can be used for both diagnosis and treatment. If a patient has both inguinal hernia and cryptorchidism, it is crucial to rule out a diagnosis of TTE to prevent misdiagnosis and inappropriate treatment.

A rare case report of bilateral recurrent inguinal hernia due to persistent Müllerian duct syndrome treated by transabdominal preperitoneal repair

INTRODUCTION

Persistent Müllerian duct syndrome (PMDS) is a rare disease occurring in men with an otherwise completely normal phenotype, in which female internal sex organs are present, including a uterus, fallopian tubes, cervix, and vagina. We report a case of bilateral recurrent inguinal hernia due to PMDS treated by transabdominal preperitoneal repair (TAPP).

PATIENT CONCERNS

A 72-year-old male presented with a complaint of swelling on both sides of the groin. The patient had undergone bilateral inguinal hernia suture repair 50 years ago.

DIAGNOSIS

Bilateral recurrent inguinal hernia INTERVENTIONS:: TAPP was performed. There was a fibrous structure linking the left and right hernia orifice and a muscular structure in the hernia sac on the left. We noticed that the muscular structure was a vagina and fibrous structure was the salpinx, and we diagnosed the patient with PMDS. Supravaginal hysterectomy and right salpingectomy were performed. After that a preperitoneal mesh repair was performed for bilateral inguinal hernia.

OUTCOMES

Histologically, the diagnosis was confirmed as PMDS. The patient had an uneventful recovery.

CONCLUSION

This case is the first case of bilateral recurrent inguinal hernia due to PMDS managed by TAPP.

Transverse testicular ectopia associated with persistent Müllerian duct syndrome treated by transseptal orchiopexy: A case report

RATIONALE

Persistent Müllerian duct syndrome (PMDS) is rare form of male pseudohermaphroditism characterized by the presence of uterus and fallopian tubes with normal external genitalia and secondary sexual characteristics. Transverse testicular ectopia (TTE) is also a rare form of testicular ectopia that may be associated with PMDS.

PATIENT CONCERNS

We present a 2-year-old boy who presented with bilateral non-palpable testes with left inguinal mass.

DIAGNOSIS

TTE with PMDS.

INTERVENTIONS

On exploration, both testes were present in the left inguinal region. Uterus and fallopian tubes were located between the testes. A hysterectomy was perfomed with resection of the underdeveloped fallopian tubes. Bilateral orchiopexy was performed by placing both gonads into subdartos pouches in each scrotum with transseptal approach.

OUTCOMES

Both testes were palpable in both the scrotum at 1-year postoperative follow-up and we are planning a regular follow-up.

LESSONS

In case of TTE with PMDS, optimal surgical approach with orchiopexy and excision of Müllerian duct should be needed. A long-term postoperative follow-up is necessary for assessment of malignant transformation and infertility.

Persistence of müllerian duct structures in a genetic male with distal monosomy 10q

Persistent müllerian duct syndrome (PMD) with antimüllerian hormone (AMH) deficiency is usually associated with mutations or deletions of the AMH gene, although many cases have no identified gene association. We report on a genetic male with PMD and AMH deficiency associated with distal monosomy 10q. A term 3,230 g infant was born to a healthy 27-year-old. Fetal ultrasound had shown possible genital ambiguity. Postnatal exam showed a 0.5 cm phallus with basal meatus, normal scrotum with no palpable gonads, no vaginal orifice, and a rectal fistula with an imperforate anus. Voiding cystourethrogram with ultrasound, cystoscopy, and laparoscopy showed normal bladder, urethral orifice, distal vagina, cervix, and bilateral abdominal testis. At 24 hours of life, testosterone was within normal range with low AMH level. Chromosome microarray analysis showed 46, XY, del10(10q25.3q26.13) involving an 8.2 MB interstitial deletion. Whole exome sequencing identified a NOTCH2 variant (1p11.2). AMH sequencing revealed no abnormalities. Following multidisciplinary team and parent discussion, male gender was assigned. Testosterone treatment resulted in penile length of 1.5 cm. Bilateral orchiopexy and posterior sagittal anorectoplasty were performed at 11 months of age; rudimentary müllerian structures were identified. This observation suggests an association of 10qter elements with male differentiation including AMH expression and is similar to a patient with 46, XY, del(10q26.1) in which AMH levels were not reported. Regional candidate genes include FGFR2 (10q26.13). The possible contribution of a NOTCH2 variant cannot be excluded.

Transverse testicular ectopia: a rare presentation with persistent Müllerian duct syndrome

Undescended testes can be found in the inguinal channel or in the abdomen. Rarely, undescended testes can present with transverse testicular ectopia (TTE) and very rarely, with residual Müllerian duct (MD) structures. This latter presentation is called persistent MD syndrome (PMDS). PMDS is mostly discovered during surgery for inguinal hernia or cryptorchidism. TTE is a rare congenital anomaly in which both testes descend through a single inguinal canal. Patients with TTE present with symptoms of unilateral cryptorchidism and contralateral inguinal hernia. Herein, we report two TTE cases: one associated with PMDS and the other having only cross ectopia. For patients with inguinal hernia and cryptorchidism associated with TTE, PMDS should be kept in mind and radiologic evaluation with ultrasonography or magnetic resonance imaging of the genitourinary system and karyotyping are recommended. Radiologic evaluation can be helpful in the diagnosis of TTE; however, it cannot diagnose the malignancy itself. Laparoscopy is very useful for both diagnosis and treatment of TTE.