Urachal diverticulum as a cause of midline testicular ectopia

We present a case report of medline testicular ectopia caused by urachal diverticulum in a seven-year old boy presented to our department with impalpable right undescended testis. The association of urachal diverticulum with midline testicular ectopia is an extremely rare finding. The ectopic testis was detected during diagnostic laparoscopy for unilateral right undescended testis. It was detected as a midline parietal structure adherent to the wall of urachal diverticulum. Open exploration was done and the tesis was dissected from the wall of urachal diverticulum. Orchiopexy was done with urachal diverticulectomy.

 

The association of testicular ectopia with embryologic abnormality is reported in the literature particularly with persistent Mullerian duct structures (PMDS) that alter the pathway of normal testicular descent and may lead to transverse testicular ectopia to the contralateral inguinal canal [2].

A seven year old boy presented to our department with impalpable right undescended testis. Examination did not reveal the right testis, but the right hemiscrotum was well-developed  and there was a normal testis on the left side of scrotum. He had unrepaired coronal hypospadias. Ultrasonography revealed no testis in the right inguinal canal and an ectopic left kidney. The patient underwent diagnostic laparoscopy under general anaesthesia using a 5mm infra-umbilical port that revealed a vas and vessel entering the left internal ring. Surprisingly, we found a midline parietal structure on the anterior abdominal wall. The vas was detected proximally then became less developed near the testis in the abdominal wall. Open exploration through a midline sub-umbilical incision was then undertaken, that revealed small size testis just deep to the anterior abdominal wall, midway between the umbilicus and the symphysis pubis (Figure 1).

 

The testis was closely adherent to a well-developed sac; with further dissection, the sac was identified as a urachal diverticulum. The balloon of a foley catheter was felt easily after opening of the diverticulum (Figure 2).

 

The testis was mobilized on a leash of vessels and the vas deferens, then positioned in a subdartos pouch. Classic urachal diverticulectomy was done with closure of the bladder in 2 layers over a suprapubic catheter for one week. Biopsy of the testis revealed normal testicular tissue.

The urachus is a tubular structure lying between the foetal bladder and the umbilicus and is susceptible to complete or partial involution after birth. Persistence of the urachus results in a wide spectrum of anomalies: patent urachus, vesicourachal diverticulum, urachal sinus and cysts [1].

The association of testicular ectopia with an embryologic abnormality is reported in the literature, particularly with persistent Mullerian duct structures (PMDS) that alter the pathway of normal testicular descent and may lead to crossed testicular ectopia to the inguinal canal [2,3,4]. Midline ectopia is a rare site of testicular ectopia and should be considered during diagnostic laparoscopy if the testis is not found near the internal ring or over the iliac vessels [5].

However, to our knowledge, the association of urachal diverticulum with midline testicular ectopia was not previously reported in the literature. This case could be explained embryologically in a manner similar to the effect of PMDS. The urachal diverticulum interferes with the normal pathway of testicular descent and diverts the testis to the dome of the diverticulum just deep to the anterior abdominal wall.

It is crucially important to investigate for other urological congenital anomalies especially if the patient has both hypospadias and undescended testis. The association of coronal hypospadias, ectopic kidney, urachal diverticulum and undescended testis correlates a the multiplicity of urological congenital anomalies [6].

Urachal diverticulum is an extremely rare cause of midline testicular ectopia that could be explained embryologically.

1. Bergami G, Inserra A, Ciprandi G, Barbuti D, Di Mario M, Boglino C. Persistent multiple urachal complex. Echographic-surgical correlations. Minerva Chir. 1992,15;47(9):879-883

2. Thambidorai C & Khaleed A. Transverse testicular ectopia: correlation of embryology with laparoscopic findings. Pediatr Surg Int. 2008;24(3):371-4

3. Wuerstle M, Lesser T, Hurwitz R, Applebaum H, Lee S. Persistent mullerian duct syndrome and transverse testicular ectopia: embryology, presentation, and management. J Pediatr Surg.; 2007, 42(12):2116-2119

4. Ozturk H, Eroglu M, Ozturk H, Uzunlar A , Okur H  Persistent Müllerian duct syndrome associated with transverse testicular ectopia: report of two cases. Fetal Pediatr Pathol. 2007, 26(1):41-46

5. Jordan G Laparoscopic management of the undescended testis. Urol clin North Am 2001. 28 (1): 23-29

6. Khatwa U , Menon P Management of undescended testis. Indian J Pediatr. 2000, 67(6):449-454