Factors Affecting the Development of the Processus Vaginalis in the Rat

Rare case of transverse testicular ectopia - Case report and review of literature

This case report has been reported in line with the SCARE criteria; Consensus-based surgical case report guidelines of International Journal of Surgery 2016.

Introduction

Transverse Testicular Ectopia (TTE) is a rare condition which manifests with unilateral undescended testis and contralateral hernia. Till now around 100 cases have been described in the literature. The management depends on the anatomy of the vas, vessels and testis found on surgical exploration. An algorithm exists for its management and we propose a modified algorithm for management of TTE.

Case presentation

Five year male presented with complaints of unilateral undescended testis on the right and hernia on the left. Clinically the right testis was impalpable and left testis palpable in the left hemiscrotum and fluid hernia on the same side.

Discussion

Transverse testicular ectopia is a rare condition presenting with UDT and contralateral inguinal hernia. Although more than 100 cases have been described in the literature so far, those managed with a transeptal contralateral orchidopexy are two cases to the best of our knowledge. TTE was first described by Von Lenhossek in 1886. The mean age of presentation is around 4 years and most of the cases are diagnosed on surgical exploration. The management of TTE remains controversial even though an algorithm has been described for its management due to its varied presenting scenarios.

Conclusion

TTE is a rare condition which requires high index of suspicion for diagnosis preoperatively. Whenever suspected we recommend an USG and/or MRI prior to diagnostic laparoscopy and proceed with orchidopexy. Diagnostic laparoscopy is both helpful in diagnosis and management. Transeptal contralateral orchidopexy gives good tension free fixation of testes in the scrotum.

Regulation of testicular descent

Testicular descent occurs in two morphologically distinct phases, each under different hormonal control from the testis itself. The first phase occurs between 8 and 15 weeks when insulin-like hormone 3 (Insl3) from the Leydig cells stimulates the gubernaculum to swell, thereby anchoring the testis near the future inguinal canal as the foetus grows. Testosterone causes regression of the cranial suspensory ligament to augment the transabdominal phase. The second, or inguinoscrotal phase, occurs between 25 and 35 weeks, when the gubernaculum bulges out of the external ring and migrates to the scrotum, all under control of testosterone. However, androgen acts mostly indirectly via the genitofemoral nerve (GFN), which produces calcitonin gene-related peptide (CGRP) to control the direction of migration. In animal models the androgen receptors are in the inguinoscrotal fat pad, which probably produces a neurotrophin to masculinise the GFN sensory fibres that regulate gubernacular migration. There is little direct evidence that this same process occurs in humans, but CGRP can regulate closure of the processus vaginalis in inguinal hernia, confirming that the GFN probably mediates human testicular descent by a similar mechanism as seen in rodent models. Despite increased understanding about normal testicular descent, the common causes of cryptorchidism remain elusive.

Infertility in rats subjected to genitofemoral nerve section is not associated with testicular damage

This work was aimed at assessing the relationship between testicular ascent and infertility induced by genitofemoral nerve (GFN) section in rats. Eighteen male rats were assigned to three experimental groups as follows: (i) Group SGFN was subjected to surgical section of genitofemoral nerve; (ii) Group Sham; (iii) Control group. The GFN was cut at puberty (28D), and the contralateral testis removed at 90D, with fertility tests at 120D. At 150D, maturity index, epithelial area and histopathological index of seminiferous tubules of all rats were determined and statistically compared between superior and inferior testicle poles, and between groups. There were no differences in testicular parameters, sperm morphology or sperm concentrations (P > 0.05). Section of NGF interfered with fertility (58.3 ± 15.4 in SGFN versus 83.3 ± 10.5 in Sham) and litter size (6.2 ± 1.1 in SGFN versus 10.7 ± 1.4 in Sham). Cremaster of SGFN group showed early neuropathy. The GFN section induced partial testicular ascent and diminished fertility without damage on testicular morphology or spermatic parameters, because, cremaster could affect the contractibility and ejaculation mechanisms in which it participates. The study of the damage on cremaster induced by an injury on GFN could have an overview of the mechanisms inherent in the testicular ascent induced by this iatrogenic alteration and their potential risks on fertility.

Testicular fusion in a patient with crossed testicular ectopia: a rare entity

Crossed testicular ectopia (CTE) is a well-described, rare congenital abnormality of testicular descent, in which both testes migrate through one inguinal canal. The objective of this work is to present a case of fused two testicles in a hemiscrotum as a rare entity of CTE. We describe a rare case of CTE in a 19-year-old boy presenting to the Department with left testis placed in the right hemiscrotum with right inguinal hernia. Ultrasound and magnetic resonance imaging revealed fused testes with their own vasa deferentia in the left hemiscrotum. Azoospermia was detected in semen analysis. The patient was referred to microTESE and ICSI procedure for his infertility problem. CTE should be kept in mind in patients with an inguinal hernia and contralateral nonpalpable testis.

Transverse testicular ectopia: three additional cases and a review of the literature

PURPOSE

Transverse testicular ectopia (TTE) is a well described, rare congenital abnormality of testicular descent, in which both testes migrate through one inguinal canal. The objective of this work was to present three cases of TTE, one of them with a common vas deferens. To our knowledge, a fused vas deferens has only been reported four times in previously published reports.

METHODS

Three patients presented with inguinal hernia and contralateral cryptorchidism. In case 1, the diagnosis of TTE was made preoperatively by palpating two testes in one hemiscrotum. The diagnosis of case 2 was made intraoperatively and was found to be of a rare form in which the two vasa deferentia fused in the inguinal canal to form a common vas deferens. The diagnosis of case 3 was also done intraoperatively and a laparoscopy was performed to document the anatomy of TTE and to rule out the presence of Müllerian duct remnants. We also performed a literature search for other reports of TTE.

RESULTS

The three cases were operated with trans-septal orchidopexy. In addition, laparoscopy was performed in case 3 to clarify the anatomy. Biopsy revealed normal testicular tissue from both testes in the first two patients. Follow-up with ultrasound, 6 months after operation showed normal size and blood flow of both testes.

CONCLUSION

Transverse testicular ectopia should be suspected in a boy with an inguinal hernia and contralateral non palpable testis. Trans-septal orchidopexy is recommended when vasa deferentia are fused. Laparoscopy is useful to document the anatomy and to rule out the presence of Müllerian remnants.

[Transverse testicular ectopia]

Transverse testicular ectopia is an extremely rare anomaly, characterized by migration of one testis towards the opposite inguinal canal, usually associated with inguinal hernia. Spermatic cord of the ectopic testis originates from the appropriate side. In most reported cases, the accurate diagnosis has not been made before surgery. This is a case report of transverse testicular ectopia in eleven-year-old boy who had undergone an operation for the left inguinal hernia in age of ten months. At the time of herniorrhaphy, the right testis was absent. Ten years later, during re-operation of the left inguinal hernia, both testis were found in left inguinal canal and easily brought down sequentially through the left groin into the scrotum. The right testis was fixed in the left hemiscrotum, due to shorter funicular elements, and the left was trans-septally moved to the right hemiscrotum (a modified Ombrédanne operation). Ultrasonography and voiding cystoureterography showed no associated genitourinary anomalies and no Mülerian duct remnants. The rupture of gubernaculum and dysfunction of the genitofemoral nerve could explain the etiology of crossed testis ectopia. Although ectopic testis could be localized preoperatively by ultrasonography, CT, MRI, arteriography and venography, correct diagnosis was made intraoperatively in the majority of cases. Treatment modalities include laparoscopic and surgical procedures. Atrophic testis should be removed. If testes are fused, they have to be brought into one hemiscrotum. In cases where testes are completely separated with individual funicular elements and vas deferens, an ipsilateral or contralateral orchiopexy should be performed depending on the length of funicular elements.

Proximal insertion of gubernaculum testis in normal human fetuses and in boys with cryptorchidism

PURPOSE

We determine how the proximal gubernaculum testis is attached to the testis and epididymis in human fetuses, and compare these data with findings in boys who had undergone surgery for cryptorchidism.

MATERIALS AND METHODS

We analyzed 280 testes and epididymides with the gubernacula of 140 well preserved, fresh human fetuses ranging from 10 to 35 weeks after conception with no detectable congenital malformations and 36 undescended testes of 28 boys 2 to 15 years old (mean age 6.8) who had undergone surgery for cryptorchidism. In both groups the different conformations of the relationship among the proximal gubernaculum, testis and epididymis were classified according to a system used for patients with cryptorchidism. In group A the gubernaculum is attached to the testis and epididymis, in group B the gubernaculum is attached only to the testis with a tail disjunction epididymal anomaly, in group C the gubernaculum is attached only to the testis with total disjunction of the epididymis, in group D the gubernaculum is attached only to the epididymal tail and in group E there are no attachments among gubernaculum, testis and epididymis.

RESULTS

Of the 280 fetal testes studied 194 (69.2%) were in the abdomen, 38 (13. 57%) in the inguinal canal and 48 (17.14%) in the scrotum. There were 277 cases (98.9%) in group A and 3 (1.1%) in group B. Of the 36 undescended testes analyzed 2 (5.6%) were abdominal and 34 (94.4%) were inguinal. There were 26 cases (72.2%) in group A, 8 (22.2%) in group B and 2 in group D.

CONCLUSIONS

In fetuses without congenital malformations or epididymal alterations, such as tail disjunction or elongated epididymis, the proximal portion of the gubernaculum was attached to the testis and epididymis in all cases. In undescended testes there was an increased incidence of paratesticular structure malformations accompanied by gubernacular attachment anomalies compared to the testes in normal fetuses.

Lack of carbachol response indicates the absence of cholinergic receptors in sacs associated with undescended testis

BACKGROUND/PURPOSE

The mechanism of testicular descent remains controversial. The processus vaginalis (PV) contains smooth muscle and should have contractile activity that may contribute to descent. This study was designed to evaluate the smooth muscle of PVs associated with incomplete obliteration for spontaneous activities and responses to various stimuli, to determine if differences exist according to sex, diagnostic source, or location of the testis.

MATERIALS

Peritoneal samples (n = 4); sacs from girls (n = 8) and boys with inguinal hernia (n = 12); and sacs from boys with hydrocele (n = 3), hydrocele of the cord (n = 2), or undescended testis (n = 7) were used for the current study. Tissues were attached to the isometric force displacement transducer in an organ bath containing mammalian Ringer's solution at 37 degrees C. Spontaneous mechanical activity and contractile responses of tissues to the electrical field stimulation, phenylephrine, carbachol, and serotonin were recorded. The values obtained from boys and girls with inguinal hernia and from boys with either undescended or descended testis were compared through Fisher's Exact test.

RESULTS

There were no statistically significant differences in patient age between groups. Among the parameters studied, only the carbachol response of the sacs associated with undescended testis showed a significant difference compared with the others (P = .001). None of the sacs associated with undescended testis responded to carbachol, whereas all of the sacs from boys and girls with inguinal hernia responded to carbachol.

CONCLUSIONS

Lack of carbachol response suggests the absence of cholinergic receptors within the sacs associated with undescended testis. The lack of cholinergic receptors may play a role in the failure of the process of testicular descent by hindering either PV elongation into the scrotum or a possible propulsive activity of the PV on the testis.

Does proximal genitofemoral nerve division induce testicular maldescent or ascent in the rat?

OBJECTIVE

To investigate whether the division of the proximal genitofemoral nerve (GFN) in neonatal rats induces testicular undescent or ascent in adulthood.

MATERIALS AND METHODS

Neonatal Wistar King A rats underwent a unilateral proximal GFN transection on either the right or left side. At the age of 30 days, testicular descent was examined in all rats and the position of the testis recorded. The animals were allowed to develop further and the position of the testis re-examined at the age of 90-180 days, when the testes were removed and weighed. Sham-operated rats were used as controls.

RESULTS

At the age of 30 days, four of the 46 (9%) operated rats showed a unilateral undescended testis on the operated side. At the age of 90-180 days, 43 rats were re-examined (three rats died before re-examination); 34 (79%) of these rats showed undescended testes on the operated side. The occurrence of cryptorchidism was significantly higher in the 90-180-day-old mature rats than in 30-day-old prepubertal rats (P<0.01). The mean (sd) weight of the undescended testes, at 2.36 (0.21) mg/g body weight, was significantly less than that of the contralateral scrotal testes, at 3.83 (0.23) mg/g; P<0.01) and of the control testes at the age of 90-180 days. In the sham-operated rats, all testes were located at the bottom of the scrotum at 30 days of age and no rats showed any testicular ascent thereafter.

CONCLUSIONS

The proximal division of the GFN in neonatal rats not only causes inguinoscrotal testicular maldescent but may also induce testicular ascent in adulthood. Testicular ascent may thus be caused by some intrauterine disorders of the GFN in patients with ascending testis.