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If an apparently hypoplastic or cystic intra-inguinal testicular nubbin is not subjected to full histological analysis, an intra-abdominal testis can be missed.
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.
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.
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.