JRSM >
Volume 97, Number 12 >
Pp. 586-587
St Helier Hospital, Carshalton SM5 1AA
Correspondence to: P Azarbod, 7 King's Avenue, London TW3 4BL, UK E-mail: parhamazarbod{at}yahoo.co.uk
If an apparently hypoplastic or cystic intra-inguinal testicular nubbin is not subjected to full histological analysis, an intra-abdominal testis can be missed.
CASE HISTORIES
Case 1
At age 20 a man with an absent left testis was referred with a swelling in
the left inguinal canal which was removed as a suspected undescended testis.
The histopathology was reported as a 3.5 cm62.5 cm thick-walled cyst with
firmer nodular area and lined by flattened cuboidal epithelium with smooth
muscle in the wall. Epididymal tissue was present in the wall but no
testicular tissue was seen. It was thought that any testicular remnants had
become atretic and no further action was taken. Having been symptom-free for
13 years the man began to experience intermittent swelling and pain in the
left groin. Abdominal CT revealed a large complex mass in the left
retroperitoneal region involving the psoas muscle and the left ureter. The
mass was removed and proved to be a seminoma. This was presumed to have arisen
from an abdominal left testis.
Case 2
A man aged 48 known to have a right undescended testis reported a few
months of slight discomfort and a mass in the right inguinal canal. A right
inguinal orchidectomy led to resolution of his symptoms. On microscopy the
1.561 cm mass showed fibrovascular soft tissue, vas deferens and epididymis
with cystic dilatation of tubules and retained secretions. No unequivocal
residual or remnant of testis was seen. Subsequent abdominopelvic MRI revealed
a well-defined mass at the level of the right internal ring
(Figure 1). This was removed
intact laparoscopically and proved to be a testis with histopathological
features of atrophy.
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COMMENT
Testicular descent is a complex process and this accounts for the variety of positions observed in cases of maldescent.1 Undescended testis occurs in 4–5% of males at birth and of these 15–20% are intra-abdominal.
The phenomenon of an absent testis in association with inguinal hypoplastic vessels and/or vas deferens is well documented2 and is presumed to be due to a vascular event in utero or infancy. In such cases, however, it is important to be aware that the testis may be in a different position.3 On the macroscopic level it is vital to be aware that residual epididymal and vas deferens tissue may undergo cystic changes with time and hence an inguinal mass observed at surgery may mimic but not represent a testis. Furthermore, such tissue may be associated with a symptomless intraabdominal testis which may or may not be hypoplastic. Such tissue must be recognized and removed since, as in case 1, it can undergo malignant change. When a mass that is clinically an undescended testis shows no histologically proven testicular tissue we advocate further imaging and consideration of laparoscopy.
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