Laparoscopic management of transverse testicular ectopia with spermatic cord fusion: a case report

Introduction

Transverse testicular ectopia (TTE), a rare congenital anomaly with an estimated incidence of 1 in 1 million births (1), is characterized by both testes descending through the same inguinal canal and residing on the same hemiscrotum. This condition often coexists with anomalies such as persistent Müllerian duct syndrome (PMDS) or inguinal hernias (2), but cases involving fused spermatic cords are exceptionally rare, with fewer than 20 documented cases (3). Embryologically, TTE likely results from aberrant migration of the gubernaculum or abnormal fusion of the Wolffian ducts during testicular descent, leading to complex anatomical relationships that challenge surgical correction.

Historically, trans-septal orchiopexy—relocating the ectopic testis across the scrotal septum—has been the standard treatment (3). However, this approach carries risks of vascular compromise, insufficient cord length, and scrotal deformity. The advent of laparoscopy has revolutionized the management of cryptorchidism and TTE by enabling precise visualization of retroperitoneal structures, identification of cord fusion patterns, and minimally invasive dissection.

This case highlights the successful management of TTE with fused spermatic cords using laparoscopic-assisted orchiopexy. Separation of the spermatic cords and fixation via their respective inguinal canals effectively restored normal anatomy and testicular function while minimizing complications. Laparoscopy provided excellent visualization, enabling precise diagnosis and tailored surgical intervention. We present this article in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-24-288/rc).

Case presentation

An 8-month-old male infant was admitted due to “bilateral empty scrotum for 8 months”. The parents noticed an absence of testes in the scrotum since birth, which showed no improvement over time. They brought the child to Huai’an Maternal and Child Health Care Hospital Affiliated to Yangzhou University. Physical examination revealed poorly developed scrotum with bilateral absence of palpable testes. No palpable testicular structures were detected in either inguinal region. Scrotal ultrasonography conducted at our hospital identified two testicular-like structures near the right internal inguinal ring, suggesting bilateral cryptorchidism with left-sided TTE. Further preoperative evaluation, including hormone levels, showed normal testosterone levels. The patient was subsequently scheduled for laparoscopic surgery.

Clinical findings

Both processus vaginalis were found to be patent. The two testes were located near the right internal inguinal ring, with the left spermatic cord crossing the pelvic cavity to fuse with the right spermatic cord (Figure 1). Both testes appeared normal in size and morphology, with a volume of approximately 0.5 mL each, and their epididymides were distinct (Figure 2). Further exploration revealed dual vas deferens that were not fused, the distance between the gonadal vessels and the vas deferens within the fused spermatic cords was approximately 1 cm. Surgical management involved separation of the fused spermatic cords, followed by orchiopexy of the testes into their respective scrotal compartments via their respective inguinal canals (Figure 3).

Figure 1 Bilateral testes with fused spermatic cords.

Figure 2 Fused spermatic cords.

Figure 3 The appearance of the scrotum one week postoperatively.

Timeline

• Birth: parents noticed the absence of testes in the scrotum.
• 8 months of age: parents observed no improvement and brought the child to the outpatient clinic.
• Physical examination: bilateral absence of palpable testes in the scrotum and inguinal regions was confirmed.
• Scrotal ultrasonography: detected two testicular-like structures near the right internal inguinal ring, consistent with bilateral cryptorchidism and left-sided TTE.
• Preoperative evaluation: hormonal levels, including testosterone, were within normal limits.
• Surgical intervention: laparoscopic surgery was scheduled and performed.

Diagnostic assessment

• Clinical history: bilateral empty scrotum since birth. No palpable testes in the scrotum or inguinal regions.
• Physical examination: poorly developed scrotum with no palpable testicular structures bilaterally.
• Scrotal ultrasonography: two testicular-like structures near the right internal inguinal ring. Suggestion of left-sided TTE.
• Preoperative hormonal assessment: normal testosterone levels.
• Laparoscopic findings: patent processus vaginalis on both sides. Both testes located near the right internal inguinal ring. Left spermatic cord crossing the pelvic cavity and fusing with the right spermatic cord. Normal testicular size (0.5 mL each) and distinct epididymides. Dual but unfused vas deferens.

Therapeutic intervention

• Surgical management:
  • Step 1: laparoscopic exploration revealed fused spermatic cords and confirmed the diagnosis.
  • Step 2: dissection along the midline of the fused spermatic cords to separate them without damaging the vas deferens or spermatic vessels.
  • Step 3: mobilization of vas deferens and spermatic cords to allow tension-free orchiopexy.
  • Step 4: single-stage orchiopexy was performed by fixing each testis into the subdartos pouch within its respective scrotal compartment via the inguinal canal.
  • Step 5: bilateral repair of patent processus vaginalis via high ligation at the internal inguinal ring.
• Postoperative care: recovered well, with both testes fixed in place successfully and no complications.

Follow-up and outcomes

At an 8-year postoperative follow-up (Figure 4), ultrasound confirmed that both testes were well-positioned with normal size and blood supply. Testosterone levels were monitored annually and remained within the normal range.

Figure 4 The appearance of the scrotum during circumcision performed 8 years later.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient’s legal guardians for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

TTE is a rare congenital anomaly, with approximately 121 cases reported in the literature (Tables 1,2), in which both testes descend through the same inguinal canal and are located on the same side (1,2). TTE cases with fused spermatic cords are even rarer. The etiology likely involves abnormal migration or developmental anomalies of the spermatic cords and testes during embryogenesis (4). Fusion of the spermatic cords can involve shared components such as blood vessels, vas deferens, or tunica vaginalis, significantly complicating surgical management (4,5).

Challenges in surgical management

The traditional approach for TTE is trans-septal orchiopexy (6,7), but this method has limitations, including:

• Vascular compromise: mobilization and relocation of the testes may stretch or compress the spermatic vessels, increasing the risk of testicular atrophy.
• Limited spermatic cord length: insufficient length may result in failure of proper fixation or difficulty in maintaining the position of the testes.
• Impact on scrotal anatomy: incising the scrotal septum may disrupt the anatomical integrity and appearance of the scrotum, affecting its function.
• Risk of injury to vas deferens or vessels: surgical dissection may lead to damage, potentially impairing fertility.
• Difficulty in malignancy surveillance: locating both testes in the same hemiscrotum complicates monitoring for malignant transformation.

In this case, separation of the fused spermatic cords and fixation of each testis through the respective inguinal canal avoided the complications associated with trans-septal orchiopexy. This approach restored normal anatomy, preserved testicular function, and maintained scrotal integrity, thereby reducing the risk of long-term complications. The 8-year follow-up confirmed the safety and efficacy of this method. The patient expressed satisfaction with the thorough diagnosis, successful surgical outcome, and complication-free recovery, highlighting the professionalism and effectiveness of the medical team. Although this case did not present with classic features of disorders of sexual differentiation (DSD), clinicians must prioritize excluding CAH in infants with bilateral non-palpable testes (8).

Conclusions

The introduction of laparoscopy has revolutionized the diagnosis and treatment of TTE with fused spermatic cords (9). The magnified laparoscopic view allows precise evaluation of the spermatic cord length, the degree of fusion, and the course of the vas deferens, enabling the surgeon to tailor the surgical approach (10). Laparoscopy offers minimal invasiveness, faster recovery, improved cosmetic outcomes (11), and the ability to address associated intra-abdominal anomalies. This case highlights its significant role in the management of complex anomalies like TTE.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-24-288/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-24-288/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-24-288/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient’s legal guardians for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Zhou G, Yin J, Jiang M, et al. Clinical Characteristics, Ultrasonographic Findings, and Treatment of Pediatric Transverse Testicular Ectopia: A 10-Year Retrospective Review. Urology 2021;154:249-54. [Crossref] [PubMed]
2. Zhou W, Li S, Wang H, et al. Diagnostic value of ultrasound in children with transverse testicular ectopia. Front Pediatr 2022;10:914139. [Crossref] [PubMed]
3. Yang C, Chen H, Huang Y, et al. Transverse testicular ectopia associated with persistent Mullerian duct syndrome in infertile male: two case reports and literature review. Transl Androl Urol 2021;10:512-9. [Crossref] [PubMed]
4. Unal E, Karakaya AA, Beştaş A, et al. Identification of four novel variant in the AMHR2 gene in six unrelated Turkish families. J Endocrinol Invest 2021;44:1301-7. [Crossref] [PubMed]
5. Kotb M, Hassan A, Abouheba M. Transverse testicular ectopia with Müllerian duct remnant in an incarcerated congenital inguinal hernia - a case report. BMC Urol 2020;20:112. [Crossref] [PubMed]
6. Sun Z, Yang M, Zhuang Y, et al. Research progress on the pathogenesis of pediatric transverse testicular ectopia with persistent Mullerian duct syndrome. Asian J Surg 2023;46:5897-8. [Crossref] [PubMed]
7. Spicchiale CF, Collura G, Mendes LL, et al. Where is the testis? The role of ultrasound and diagnostic laparoscopy for Crossed Testicular Ectopia (CTE): Case report and review of literature. Ann Ital Chir 2023;94:400-3.
8. Claahsen-van der Grinten HL, Speiser PW, Ahmed SF, et al. Congenital Adrenal Hyperplasia-Current Insights in Pathophysiology, Diagnostics, and Management. Endocr Rev 2022;43:91-159. [Crossref] [PubMed]
9. Sherburne H, Hamel R, Schlessinger DI, et al. Infantile scrotal hemangioma with transverse testicular ectopia. Pediatr Dermatol 2021;38:1577-8. [Crossref] [PubMed]
10. Picard JY, Josso N. Persistent Müllerian duct syndrome: an update. Reprod Fertil Dev 2019;31:1240-5. [Crossref] [PubMed]
11. Yang B, Xie CH, Wang YQ. Misdiagnosis and mistreatment of transverse testicular ectopia-two case report and review of literature. Medicine (Baltimore) 2023;102:e35850. [Crossref] [PubMed]