Crossed-Fused Testicular Ectopia: A Case for the Use of Laparoscopy to Evaluate Nonpalpable Testicles

Abstract

A 1-year-old male was referred for evaluation of a nonpalpable right testicle. In children with nonpalpable testicles, it our practice to proceed with diagnostic laparoscopy in an attempt to identify an intra-abdominal testicle or blind-ending spermatic vessels regardless of ultrasound findings. In the operating room, we performed diagnostic laparoscopy through the umbilical stump. We identified a vas deferens passing from the right side to the left side, and what appeared to be a testicle in the area of the left internal inguinal ring (Figures 1 and 2). In the left groin, we found both testicles fused together with a common blood supply, but a separate vas deferens. We placed the right testicle transseptally into the right hemiscrotum.Figure 2Right testicle entering the left inguinal ring.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Crossed testicular ectopia, or transverse testicular ectopia, is an extremely rare finding on exploration for an undescended testicle, with just slightly more than 100 cases reported in the literature to date.1Lam W.W. Le S.D. Chan K.L. Chan F.L. Tam P.K. Transverse testicular ectopia detected by MR imaging and MR venography.Pediatr Radiol. 2002; 32: 126-129Crossref PubMed Scopus (45) Google Scholar, 2Malik M.A. Iqbal Z. Chaudri K.M. Malik N.A. Ahmed A.J. Crossed testicular ectopia.Urology. 2008; 71 (984 e5-6)Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar A classification system has been proposed that accounts for accompanying anomalies, including hernias and mullerian duct structures.3Gauderer M.W. Grisoni E.R. Stellato T.A. Ponsky J.L. Izant Jr., R.J. Transverse testicular ectopia.J Pediatr Surg. 1982; 17: 43-47Abstract Full Text PDF PubMed Scopus (88) Google Scholar The ectopic testicle is usually structurally normal; however, it does carry a risk of malignancy, similar to that associated with other forms of intra-abdominal testicles.4Berkmen F. Persistent mullerian duct syndrome with or without transverse testicular ectopia and testis tumours.Br J Urol. 1997; 79: 122-126Crossref PubMed Google Scholar, 5Naouar S. Maazoun K. Sahnoun L. Jouini R. Ksia A. Elezzi O. et al.Transverse testicular ectopia: a three-case report and review of the literature.Urology. 2008; 71: 1070-1073Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar Although there are reports of successful diagnosis of this anomaly using ultrasonography6Pinto C.W. Toro R.C. Mansilla K.H. Castro T.A. Fuente-Alba C.S. Crossed testicular ectopia.J Ultrasound Med. 2010; 29: 847-849PubMed Google Scholar or magnetic resonance imaging1Lam W.W. Le S.D. Chan K.L. Chan F.L. Tam P.K. Transverse testicular ectopia detected by MR imaging and MR venography.Pediatr Radiol. 2002; 32: 126-129Crossref PubMed Scopus (45) Google Scholar during evaluation of nonpalpable testicles, neither of these studies is sufficiently sensitive to safely rule out an ectopic testicle.7Gokce M.I. Burgu B. Aydogdu O. Fitoz S. Soygur T. Transverse testicular ectopia associated with persistent Mullerian duct syndrome: another entity in which magnetic resonance imaging is unreliable.Urology. 2010; 76: 1475-1477Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar, 8Tasian G.E. Copp H.L. Diagnostic performance of ultrasound in nonpalpable cryptorchidism: a systematic review and meta-analysis.Pediatrics. 2011; 127: 119-128Crossref PubMed Scopus (93) Google Scholar Laparoscopy has consistently demonstrated superior diagnostic accuracy in nonpalpable testicles9Papparella A. Romano M. Noviello C. Cobellis G. Nino F. Del Monaco C. et al.The value of laparoscopy in the management of non-palpable testis.J Pediatr Urol. 2010; 6: 550-554Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar, 10Cortesi N. Ferrari P. Zambarda E. Manenti A. Baldini A. Morano F.P. Diagnosis of bilateral abdominal cryptorchidism by laparoscopy.Endoscopy. 1976; 8: 33-34Crossref PubMed Scopus (278) Google Scholar, 11Jordan G.H. Winslow B.H. Laparoscopic single-stage and staged orchiopexy.J Urol. 1994; 152: 1249-1252PubMed Google Scholar, 12Siemer S. Humke U. Uder M. Hildebrandt U. Karadiakos N. Ziegler M. Diagnosis of nonpalpable testes in childhood: comparison of magnetic resonance imaging and laparoscopy in a prospective study.Eur J Pediatr Surg. 2000; 10: 114-118Crossref PubMed Scopus (33) Google Scholar and is instrumental in their evaluation and treatment as underscored by this unusual finding on exploration.