Abstract:
Case report: A 14 month-old boy was referred from primary health care center to our outpatient clinic with history of empty right hemi-scrotum since birth. On examination, the right hemiscrotum was undeveloped and the right testis was impalpable. The left testis was normally descended and of average size. An abdominal examina-tion was otherwise unremarkable. Scrotal ultrasound showed that the left testicle was seen in left hemiscrotum with no hydrocele. It was normal in shape and of good size. The right testicle was not visualized neither intra-abdominal nor in the inguinoscrotal region. For further assessment with MRI. MRI of the pelvis and abdomen for undescended testis showed empty right hemiscrotum and right inguinal canal. There was a well circumscribed hyper intense structure seen in T2WI measuring 4 × 5 mm which may represent the right testis at the right inguinal region. The left testis was seen in left scrotum. Also, bilateral inguinal lymph nodes. Complete blood count, chemistry and hepatorenal function were normal. Laparoscopic orchiopexy was planned. But initial examination under general anesthesia (according to our protocol) showed palpable nubbin high in the inguinal region, so formal inguinal exploration was done initially which revealed no testicular tissue. The wound was extended laterally. The vanishing testicular vessels and vas were then traced along the lateral abdominal wall until an atrophic (4 mm) testis was seen attached to the inferio-lateral aspect of the right lobe of the liver. Orchidectomy was then performed and sent for histpathology. Microscopy showed an immature testicular tissue composed of small seminiferous tubules lined by polyhidral to cuboidal cells with no evidence of spermatogenesis. The tubules were disposed into mildly edematous fibrous stroma. Leydig cells were not recognized. In one focus within the epididymis keratinous cyst, composed of stratified squamous epithelial cells replacing normal duct lining and the cavity filled up with squames (keratin flakes). There was no definite glycogen deposit within the semineferous tubule cells (PAS stain). No evidence of malignancy
Discussion: Fusion of the undescended testes with splenic, renal and adrenal tissue have been described in several reports. In 1996, Ferro et al. described a heterotopic liver tissue adherent to the upper pole of the testis as an incidental finding at herniotomy. They attributed the presence of heterotopic liver tissue in testis to the trapping of hepatocyte aggregates in the area of peritoneum where the testis is developing. In 2012, Fan et al. observed a spermatic cord-like structure was connecting the liver and right testis in a 3-month-old boy at right inguinal hernia repair. The hepatic tissue was present along the entire length of this structure. In this report the testis was not directly attached to the liver but in case the testis was directly attached to the inferio-lateral aspect of the right lobe of the liver. In 2001, Lund et al. described an atrophic (4 mm) testis which was attached to the inferio-lateral aspect of the right lobe of the liver. Such anatomical association is similar to our case. They stated that their case was the first one in English literature . So our case is the 2nd such case in the English literature.
Conclusion: Fusion of the testis to liver either directly or via a cord-like structure is a very rare cause of cryptorchidism and the young pe-diatric surgeon should be aware of it as a one of etiological factors of undescended testicle.
