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Presentation of fused vas deferens
CASE REPORT
PRESENTATION OF FUSED VAS DEFERENS JOB K. CHACKO, PETER D. FURNESS III,
AND
GERALD C. MINGIN
ABSTRACT Transverse testicular ectopia is a rare condition that usually presents as a unilateral nonpalpable testis and a contralateral descended testis with an associated hernia. Currently, with the use of diagnostic laparoscopy, transverse testicular ectopia is found before groin exploration. We reviewed 2 cases that were referred to our institution. Both patients had a common vas deferens with proximal fusion. To our knowledge, a fused vas deferens has only been reported three other times in published reports. Our second case is unique in that this is the first time a common vas deferens has been reported outside of transverse testicular ectopia. UROLOGY 67: 1085.e17–1085.e18, 2006. © 2006 Elsevier Inc.
T
ransverse testicular ectopia is an uncommon occurrence in pediatric urology. Transverse testicular ectopia associated with a common vas deferens is exceedingly rare. We report our experience with 2 cases of a common vas deferens. CASE REPORT
CASE 1 A 20-month-old boy was referred to the Children’s Hospital (Denver, Colo) after bilateral groin exploration for nonpalpable testes. Intraoperatively, two testes were found in the right inguinal canal. The testes were left in situ, and the incisions were closed. Physical examination revealed normal external genitalia. Diagnostic laparoscopy revealed closed internal rings bilaterally with a vas deferens crossing from the left side to join the vas deferens on the right. At open exploration, each testis was dissected free. Both appeared of equal size, with each having a normal epididymis and separate vas deferens that were fused proximally (Fig. 1). Medial and cephalad retroperitoneal dissection provided adequate length for the cord structures to allow them to be passed over the right pubic tubercle into the right hemiscrotum. The testes (biopsy proven) were brought down, and the right testis was placed in a subdartos pouch. The left testis was brought through the scrotal septum and placed From the Children’s Hospital of Denver, Denver, Colorado Address for correspondence: Job K. Chacko, M.D., Department of Urology, University of Colorado Health Sciences Center, 4200 East 9th Avenue, Room 5415, Denver, CO 80262. E-mail: job.chacko@ uchsc.edu Submitted: June 20, 2005, accepted (with revisions): November 30, 2005 © 2006 ELSEVIER INC. ALL RIGHTS RESERVED
into a subdartos pouch on the left side. Postoperative follow-up revealed both testes in a good position in the scrotum. CASE 2 A 6-month-old phenotypic male was referred for bilateral undescended testes. Chromosomal analysis revealed a 46XY karyotype. On physical examination, the child had a normal-appearing phallus without hypospadias or chordee. The anti-mullerian hormone level was slightly elevated at 73 ng/mL (normal 15.5 to 48.7). Diagnostic laparoscopy revealed two intra-abdominal gonads approximately 2 to 3 cm from their respective internal inguinal rings (Fig. 2). Each testis was connected by a common vas deferens that emanated from the left retrovesical space (off midline) that initially appeared mullerian in nature. A well-defined cap suggestive of ovarian tissue was observed. The diagnosis of hermaphrodite was considered; however, bilateral polar biopsies revealed normal testicular tissue. A first-stage laparoscopic bilateral Fowler-Stevens orchiopexy was performed. Six months later, a second-stage laparoscopic Fowler-Stevens orchiopexy was undertaken, with the left testis brought over to the right side. Both testes were placed into the right scrotum. COMMENT Transverse testicular ectopia is an uncommon entity that has been well described in published studies.1– 4 In almost all cases, two testes are present on one side, with each testis having its own blood supply, epididymis, and vas deferens. The finding of a common vas deferens in transverse testicular 0090-4295/06/$32.00 doi:10.1016/j.urology.2005.11.056 1085.e17
TABLE I. Previous reports of common vas deferens Study
FIGURE 1. Groin exploration revealing two testes with fused vas deferens.
Year
Age
Findings
5
Miura et al.
1985
10 mo
Arrizabalaga et al.6 Barrack7
1989
3 yr
Common vas deferens; right to left inguinal canal Common vas deferens
1994
22 mo
Case 1
2005
20 mo
Case 2
2005
6 mo
Common vas deferens; left to right inguinal canal Common vas deferens; left to right inguinal canal Common vas deferens; no transverse testicular ectopia
ferred to as the Ombrédanne procedure. The ectopic testis is brought down through the contralateral inguinal canal and placed into the correct hemiscrotum using a transseptal technique. Our second case is notable in that we performed a laparoscopic-assisted Ombrédanne orchiopexy. These cases illustrate that with development of the Wolffian duct, it is possible to have fused vas deferens. It is especially important to be aware of this entity during orchiopexy, because the existence of a common vas deferens may hinder the testis from being placed into the scrotum. FIGURE 2. Diagnostic laparoscopy with intra-abdominal testes and fused vas deferens.
ectopia is exceedingly rare and has been previously described only three times5–7 (Table I). We believe that our second case is unique in that this is the first time that a common vas deferens has been reported outside of transverse testicular ectopia. Although mullerian remnants have been reported in transverse testicular ectopia, they are relatively uncommon in childhood.8 In both of our cases, no definitive mullerian structures were found. However, a thickened retrovesical vas deferens may initially be confused with a uterus, requiring careful dissection and biopsy, as necessary. The surgical treatment for transverse testicular ectopia is re-
1085.e18
REFERENCES 1. Von Lenhossek M: Ectopia testis transversa. Anat Anz 1: 376 –381, 1886. 2. Gauderer MWL, Grisoni ER, Stellato TA, et al: Transverse testicular ectopia. J Pediatr Surg 17: 43– 47, 1982. 3. Golladay ES, and Redman JF: Transverse testicular ectopia. Urology 19: 181–186, 1982. 4. Marsh F: Two testicles on one side. BMJ 2: 1354 –1354, 1911. 5. Muira T, and Takahashi G: Crossed ectopic testis with common vas deferens. J Urol 134: 1206 –1208, 1985. 6. Arrizabalaga M, Benitez J, Gallardo C, et al: Transverse testicular ectopy with common deferent duct. Actas Urol Esp 13: 457– 459, 1989. 7. Barrack S: Crossed testicular ectopia with fused bilateral duplication of the deferential: an unusual finding in cryptorchidism. East Afr Med J 71: 398 – 400, 1994. 8. Karnak I, Tanyel FC, Akçören Z, et al: Transverse testicular ectopia with persistent müllerian duct syndrome. J Pediatr Surg 32: 1362–1364, 1997.
UROLOGY 67 (5), 2006
PRESENTATION OF FUSED VAS DEFERENS JOB K. CHACKO, PETER D. FURNESS III,
AND
GERALD C. MINGIN
ABSTRACT Transverse testicular ectopia is a rare condition that usually presents as a unilateral nonpalpable testis and a contralateral descended testis with an associated hernia. Currently, with the use of diagnostic laparoscopy, transverse testicular ectopia is found before groin exploration. We reviewed 2 cases that were referred to our institution. Both patients had a common vas deferens with proximal fusion. To our knowledge, a fused vas deferens has only been reported three other times in published reports. Our second case is unique in that this is the first time a common vas deferens has been reported outside of transverse testicular ectopia. UROLOGY 67: 1085.e17–1085.e18, 2006. © 2006 Elsevier Inc.
T
ransverse testicular ectopia is an uncommon occurrence in pediatric urology. Transverse testicular ectopia associated with a common vas deferens is exceedingly rare. We report our experience with 2 cases of a common vas deferens. CASE REPORT
CASE 1 A 20-month-old boy was referred to the Children’s Hospital (Denver, Colo) after bilateral groin exploration for nonpalpable testes. Intraoperatively, two testes were found in the right inguinal canal. The testes were left in situ, and the incisions were closed. Physical examination revealed normal external genitalia. Diagnostic laparoscopy revealed closed internal rings bilaterally with a vas deferens crossing from the left side to join the vas deferens on the right. At open exploration, each testis was dissected free. Both appeared of equal size, with each having a normal epididymis and separate vas deferens that were fused proximally (Fig. 1). Medial and cephalad retroperitoneal dissection provided adequate length for the cord structures to allow them to be passed over the right pubic tubercle into the right hemiscrotum. The testes (biopsy proven) were brought down, and the right testis was placed in a subdartos pouch. The left testis was brought through the scrotal septum and placed From the Children’s Hospital of Denver, Denver, Colorado Address for correspondence: Job K. Chacko, M.D., Department of Urology, University of Colorado Health Sciences Center, 4200 East 9th Avenue, Room 5415, Denver, CO 80262. E-mail: job.chacko@ uchsc.edu Submitted: June 20, 2005, accepted (with revisions): November 30, 2005 © 2006 ELSEVIER INC. ALL RIGHTS RESERVED
into a subdartos pouch on the left side. Postoperative follow-up revealed both testes in a good position in the scrotum. CASE 2 A 6-month-old phenotypic male was referred for bilateral undescended testes. Chromosomal analysis revealed a 46XY karyotype. On physical examination, the child had a normal-appearing phallus without hypospadias or chordee. The anti-mullerian hormone level was slightly elevated at 73 ng/mL (normal 15.5 to 48.7). Diagnostic laparoscopy revealed two intra-abdominal gonads approximately 2 to 3 cm from their respective internal inguinal rings (Fig. 2). Each testis was connected by a common vas deferens that emanated from the left retrovesical space (off midline) that initially appeared mullerian in nature. A well-defined cap suggestive of ovarian tissue was observed. The diagnosis of hermaphrodite was considered; however, bilateral polar biopsies revealed normal testicular tissue. A first-stage laparoscopic bilateral Fowler-Stevens orchiopexy was performed. Six months later, a second-stage laparoscopic Fowler-Stevens orchiopexy was undertaken, with the left testis brought over to the right side. Both testes were placed into the right scrotum. COMMENT Transverse testicular ectopia is an uncommon entity that has been well described in published studies.1– 4 In almost all cases, two testes are present on one side, with each testis having its own blood supply, epididymis, and vas deferens. The finding of a common vas deferens in transverse testicular 0090-4295/06/$32.00 doi:10.1016/j.urology.2005.11.056 1085.e17
TABLE I. Previous reports of common vas deferens Study
FIGURE 1. Groin exploration revealing two testes with fused vas deferens.
Year
Age
Findings
5
Miura et al.
1985
10 mo
Arrizabalaga et al.6 Barrack7
1989
3 yr
Common vas deferens; right to left inguinal canal Common vas deferens
1994
22 mo
Case 1
2005
20 mo
Case 2
2005
6 mo
Common vas deferens; left to right inguinal canal Common vas deferens; left to right inguinal canal Common vas deferens; no transverse testicular ectopia
ferred to as the Ombrédanne procedure. The ectopic testis is brought down through the contralateral inguinal canal and placed into the correct hemiscrotum using a transseptal technique. Our second case is notable in that we performed a laparoscopic-assisted Ombrédanne orchiopexy. These cases illustrate that with development of the Wolffian duct, it is possible to have fused vas deferens. It is especially important to be aware of this entity during orchiopexy, because the existence of a common vas deferens may hinder the testis from being placed into the scrotum. FIGURE 2. Diagnostic laparoscopy with intra-abdominal testes and fused vas deferens.
ectopia is exceedingly rare and has been previously described only three times5–7 (Table I). We believe that our second case is unique in that this is the first time that a common vas deferens has been reported outside of transverse testicular ectopia. Although mullerian remnants have been reported in transverse testicular ectopia, they are relatively uncommon in childhood.8 In both of our cases, no definitive mullerian structures were found. However, a thickened retrovesical vas deferens may initially be confused with a uterus, requiring careful dissection and biopsy, as necessary. The surgical treatment for transverse testicular ectopia is re-
1085.e18
REFERENCES 1. Von Lenhossek M: Ectopia testis transversa. Anat Anz 1: 376 –381, 1886. 2. Gauderer MWL, Grisoni ER, Stellato TA, et al: Transverse testicular ectopia. J Pediatr Surg 17: 43– 47, 1982. 3. Golladay ES, and Redman JF: Transverse testicular ectopia. Urology 19: 181–186, 1982. 4. Marsh F: Two testicles on one side. BMJ 2: 1354 –1354, 1911. 5. Muira T, and Takahashi G: Crossed ectopic testis with common vas deferens. J Urol 134: 1206 –1208, 1985. 6. Arrizabalaga M, Benitez J, Gallardo C, et al: Transverse testicular ectopy with common deferent duct. Actas Urol Esp 13: 457– 459, 1989. 7. Barrack S: Crossed testicular ectopia with fused bilateral duplication of the deferential: an unusual finding in cryptorchidism. East Afr Med J 71: 398 – 400, 1994. 8. Karnak I, Tanyel FC, Akçören Z, et al: Transverse testicular ectopia with persistent müllerian duct syndrome. J Pediatr Surg 32: 1362–1364, 1997.
UROLOGY 67 (5), 2006