|LETTER TO THE EDITOR
|Ahead of print publication
Microdissection testicular extraction for a patient with transverse testicular ectopia and testicular fusion
Chen Chen, Yi-Chun Wang, Ya-Min Wang, Chao Qin, Ning-Hong Song
Department of Urology, State Key Laboratory of Reproductive Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210000, China
|Date of Submission||25-Feb-2017|
|Date of Acceptance||20-Jul-2017|
|Date of Web Publication||01-Sep-2017|
Department of Urology, State Key Laboratory of Reproductive Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210000
Source of Support: None, Conflict of Interest: None
Article in PDF
|How to cite this URL:|
Chen C, Wang YC, Wang YM, Qin C, Song NH. Microdissection testicular extraction for a patient with transverse testicular ectopia and testicular fusion. Asian J Androl [Epub ahead of print] [cited 2018 Mar 18]. Available from: http://www.ajandrology.com/preprintarticle.asp?id=213916
Transverse testicular ectopia (TTE) is a rare condition whereby both testes migrate toward the same hemiscrotum. Most of the cases (65%) are diagnosed intraoperatively during an inguinal hernia repair; only few are diagnosed preoperatively.  On the basis of various anomalies, TTE is classified into three types: Type 1, accompanied only by inguinal hernia (40%-50%); Type 2, accompanied by persistent Müllerian duct structures (30%); Type 3, accompanied by genitourinary anomalies, such as hypospadias (20%).  In the case of TTE, the spermatic vessels of the ectopic testis pass through the midline and the inguinal canal adjacent to the spermatic cord of the normal opposite testis.  To date, fewer than 150 cases of TTE have been reported in the literature,  mostly in children. Adult patients with TTE consult doctors mainly because of oligoasthenozoospermia or infertility. To date, there have been no reports in the literature about TTE in infertile males with fused testicles and unilateral congenital absence of vas deferens (CAVD). Microdissection testicular sperm extraction (micro-TESE) is an effective treatment option for patients with azoospermia. Herein, we present a case of application of Micro-TESE in an infertile patient with TTE.
A 29-year-old infertile male who had not taken any contraceptive measures during 5 years of marriage visited our clinic. Sperm analysis showed azoospermia. Blood tests showed a serum testosterone level of 287 ng dl−1 , luteinizing hormone 4.3 mIU ml−1 , and follicle-stimulating hormone 4.98 mIU ml−1 , all within normal limits. Physical examination revealed a testis-like mass in the right hemiscrotum and an empty left hemiscrotum. Scrotal ultrasonography showed hydrocele in the left testis and no testis on the left side, with right testicular volume slightly larger than that of a normal testis. Two fused testicles were revealed when we opened the left groin, one testis with epididymis and vas deferens and another with unilateral CAVD, both having a rich blood supply ([Figure 1]a). Micro-TESE was applied to the testis with CAVD ([Figure 1]b). A midline incision in the scrotal raphe was performed to expose the underlying testicular parenchyma. Microbiopsies of the testicle were made under higher magnification (15×-25×) ([Figure 1]c). The surgeon examined the microscopic images with the embryologist to enable definition of spermatozoa. Active sperms were found after culture and were kept under cryopreservation.
|Figure 1: ( a ) Two fused testicles without unilateral vas deferens. ( b ) A midline incision in the scrotal raphe. ( c ) Microsurgical extraction of testicular tissue with dilated seminiferous tubules using a microsurgical forceps.|
Click here to view
Ultrasonography and magnetic resonance imaging are used in the diagnosis of TTE. , However, the diagnosis before surgery is not always correct (as in our case) and is only revised intraoperatively. Hence, the detection of ectopic testis by radiologic evaluation remains controversial.  Moreover, azoospermia by semen analysis was the major reason for the patient's visit to our clinic. Once the diagnosis is confirmed during surgery, TESE can be introduced as an optional treatment for patients with azoospermia.
The utilization of TESE for nonobstructive azoospermia was reported in 1995 by Silber et al.,  and several procedures to obtain sperm have been reported. However, traditional TESE such as open single biopsy, fine-needle aspiration, and core biopsy does not obtain foci of spermatogenesis until tissue is excised from the patient. Although multiple TESE could obtain more testicular tissue for identification of testicular spermatozoa, larger resections could cause damage arising from pressure atrophy from intratesticular swelling and hematoma.  In other words, micro-TESE could minimize the damage to testicular tissue while maximizing sperm recovery. Moreover, spermatozoa retrieval improved from 45% to 63% after using the microdissection technique.  We performed micro-TESE on the testis with CAVD to protect the normal function of the other testis. This procedure can maximize sperm retrieval in minimal volumes of testicular tissue with minimal postoperative testicular damage.
In conclusion, micro-TESE can safely and effectively treat TTE patients with two fused testicles in the hemiscrotum without unilateral vas deferens (CAVD).
| Author Conributions|| |
CQ designed the study and revised the manuscript; NHS, YCW and YMW collected the clinical information; and CC drafted the manuscript. All authors read and approved the final manuscript.
| Competing Interests|| |
The authors declared no competing interests.
| References|| |
Pradhan A, Panta OB, Karki DB, Gurung G. Crossed testicular ectopia. JNMA J Nepal Med Assoc
2014; 52: 943-5.
Yildiz A, Yigiter M, Oral A, Bakan V. Transverse testicular ectopia. Pediatr Int
2014; 56: 102-5.
Zhu YP, Zhang SL, Ye DW, Shi GH, Xiao WJ. Yolk sac tumor in a patient with transverse testicular ectopia. World J Surg Oncol
2011; 9: 91.
Hasegawa Y, Kanemitsu I, Ueoka K. Transverse testicular ectopia with splenogonadal fusion: a case report. Int J Urol
2011; 18: 466-8.
Chen KC, Chu CC, Chou TY. Transverse testicular ectopia: preoperative diagnosis by ultrasonography. Pediatr Surg Int
2000; 16: 77-9.
Lam WW, Le SD, Chan KL, Chan FL, Tam PK. Transverse testicular ectopia detected by MR imaging and MR venography. Pediatr Radiol
2002; 32: 126-9.
Naji H, Peristeris A, Stenman J, Svensson JF, Wester T. Transverse testicular ectopia: three additional cases and a review of the literature. Pediatr Surg Int
2012; 28: 703-6.
Silber SJ, Nagy Z, Liu J, Tournaye H, Lissens W, et al
. The use of epididymal and testicular spermatozoa for intracytoplasmic sperm injection: the genetic implications for male infertility. Hum Reprod
1995; 10: 2031-43.
Schlegel PN. Testicular sperm extraction: microdissection improves sperm yield with minimal tissue excision. Hum Reprod
1999; 14: 131-5.
Alrabeeah K, Wachter A, Phillips S, Cohen B, Al-Hathal N, et al
. Sperm retrieval outcomes with microdissection testicular sperm extraction (micro-TESE) in men with cryptozoospermia. Andrology
2015; 3: 462-6.