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Transverse testis ectopia: diagnostic and management algorithm

With institutional review board approval, we reviewed six TTE cases, with a median age of 8months at presentation, managed surgically in our institution from January 2006 to June 2013. Clinical presentation, intraoperative findings, operative technique and follow-up duration of 5months to 7 years were assessed. Four patients (66%) presented with two palpable testes in one inguinoscrotal region. Of the patients whom we had no suspicion of TTE, we carried out inguinal incision on the testis with inguinal hernia and contralateral cryptorchidism, and on discovering TTE, we extended the incision medially for scrotal exploration. The other patient with bilateral cryptorchidism and hypospadias underwent diagnostic laparoscopy, showing an ectopic left testis crossing over the midline to the right inguinal region. We encountered rudimentary Müllerian duct structures in two cases, but did not carry out a biopsy to avoid potential vascular damage. Five patients underwent transabdominal orchiopexy, while one had transseptal orchiopexy. On follow up, all testes were normal-sized and palpable in the hemiscrotum, except for one atrophied testis. TTE etiology is unknown, but the most accepted theory comes from Lockwood, who noted the testis is pulled toward the distal insertions of the gubernacula: scrotal, abdominal wall, femoral, perineal, contralateral hemiscrotal and pubopenile. TTE is classified as: type I (40–50%) with inguinal hernia alone; type II (30%) with PMDS; and type III (20%) with hypospadias, inguinal hernia, scrotal abnormalities and pseudohermaphroditism. The mechanism involving between TTE and PMDS is not fully elucidated. Deficiencies in the synthesis or release of AMH or defects in its receptor functions are suspected causes but some patients with PMDS, however, express normal amount of AMH. In our experience, diagnostic laparoscopy was beneficial to confirm the diagnosis of TTE, check for presence of PMDS, map out the anatomy, assess the cord structures and vascular supply, and plan the definitive surgical management. The most common laparoscopic findings include crossing over the midline and to the contralateral internal ring of the vessels and vas of the ectopic testis, and the presence of rudimentary Müllerian structures, such as a uterus, round ligament and fallopian tubes. The surgical goals are fertility preservation and placement of the testis in the hemiscrotum for surveillance for potential malignant development. Based on our experience and literature review, we propose a diagnostic and management algorithm of TTE (Fig. 1). Once diagnosis is confirmed by incidental intraoperative findings on inguinal exploration, and/or diagnostic laparoscopy, one must assess the vas deferens, its vascular supply and proximal attachments, such as remnant Müllerian structures. Depending on the surgeon’s expertise and preference, one might apply open or laparoscopic technique. Transseptal orchiopexy is recommended if there is adequate length of the vas deferens to allow the ectopic testis to be placed tension-free to the correct scrotum (Fig. S1). A transseptal window is made, through which the ectopic testis is passed and is fixed to the correct hemiscrotum. The spermatic cord, however, still crosses the midline and goes through the contralateral inguinal canal. Another option is to proceed with transseptal “contralateral” orchiopexy, wherein the orthotopic testis with more than sufficient vas deferens length can cross transseptally, and the ectopic testis with inadequate length undergoes transseptal fixation. Transabdominal orchiopexy should be carried out if there is inadequate length of the vascular supply to the vas deferens despite dissection of the proximal attachments up the level of the internal inguinal ring. In this procedure, the spermatic cords and testes are not very proximal to each other, offering decreased risk of bilateral damage in cases of scrotal trauma, orchitis or epididymitis. Before orchidopexy, distend the bladder and check if there will be mechanical