Laparoscopic Removal of a Persistent Mullerian Duct in a Male: Case Report

Sir,

Since I first described the laparoscopic management of persistent mullerian duct syndrome (PMDS) in early 1997, there have been only very few publications in this field ([3]). I am, therefore, very much intrigued by the recent report on the laparoscopic excision of a mullerian remnant in a 15-year-old-boy. The report rekindles debates on this surgical dilemma.

The overwhelming majority of patients with PMDS present with testicular maldescent, frequently associated with an inguinal hernia. The cryptorchid testis can be found in one of the three typical locations ([2]). Thus, my original article focused mainly on laparoscopic orchidopexy, which is by no means easy in this entity. Removal of the mullerian structures is not justified based on the following clinical observations. First, the retained mullerian remnant almost always remains asymptomatic. Second, no malignant degeneration of the mullerian duct has been documented to date. Third, the wolffian structures are usually closely adherent to, or inseparable from, the mullerian structures, and therefore hysterectomy risks damage to the vasa deferentia, seminal vesicles, or the deferential blood supply to the testis (important when the internal spermatic vessels have to be divided to gain sufficient length).

The two subsequent papers on laparoscopic approach to PMDS revolved around excision of the mullerian derivatives, which is obviously unnecessary if not unwarranted ([1], [6]). In both cases, the persistent mullerian structures per se caused no symptoms. Indeed, one case presented with undescended testis while the other was referred for anejaculation.

Lima et al's case deserves special consideration since it is very unique in presenting with recurrent epididymitis, apparently due to reflux of urine up the vas that opens directly on to the mullerian duct. Urinary reflux up the urethra-mullerian duct communication has not been mentioned as a problem by previous authors. Notably, we have demonstrated by injection urethrography that reflux into the utricle remnant can be induced by a sudden increase in intra-urethral pressure ([4]). In Lima et al's patient, reflux was demonstrable only on the voiding cystourethrogram that was repeated after repair of the scrotal hypospadias. The possibility of a relatively outflow obstruction and resulting increased voiding pressure has to be ruled out. Were it not for the concern of persisting urethra-mullerian duct reflux, a good case could have been made for the prevention of recurrent epididymitis by simple procedures like vasectomy or excision of the dysgenetic testis without intrusion into the abdominal cavity, laparoscopically or otherwise.

Recently, successful laparoscopic orchidopexy in two more cases of PMDS reaffirmed our treatment regime ([5]).

References

• 1 Colacurci N, Cardone A, De Francisis P, Landolfi E, Venditto T, Sinisi A A. Laparoscopic hysterectomy in a case of male pseudohermaphroditism with persistent mullerian duct derivatives.  Human Reproduction. 1997;  12 272-274
• 2 Hutson J M, Chow C W, Ng W T. Persistent mullerian duct syndrome with transverse testicular ectopia.  Ped Surg Int. 1987;  2 191-194
• 3 Ng W T, Koh G H. Laparoscopic orchidopexy for persistent mullerian duct syndrome.  Ped Surg Int. 1997;  12 522-525
• 4 Ng W T, Kong C K, Wong Y W, Cheung C H, AuYeung M C. Catheter injection urethrogram in the evaluation of childhood epididymitis.  Ped Surg Int. 1994;  9 231-232
• 5 Ng W T. Laparoscopic approach to persistent mullerian duct syndrome.  Ann Coll Surg HK 2002. in press; 
• 6 Wiener J S, Jordan G H, Gonzales E T. Laparoscopic management of persistent mullerian duct remnants associated with an abdominal testis.  J Endourol. 1997;  11 357-359