TTE is a rare congenital anomaly where both testes descend through a single inguinal canal and are present in same hemiscrotum [1, 2]. The cause for this is not well-known, though there are some theories which include anomalous origin of both testis from same genital ridge [3], early adherence and fusion of the developing Wolfian ducts [4] or origin of both vas deferens from one side. The first case of TTE was described by Lenhossek in 1886 [5]. Till now, approximately 100 cases of TTE have been reported in published studies [6].
An inguinal hernia is invariably present on the side to which the ectopic testis has migrated, and further it is classified by Gauder et al. [5] as type 1: associated with inguinal hernia; type 2: along with persistent rudimentary Mullerian duct structure, and type 3: along with associating disorders other than persistent Mullerian duct abnormality which includes contralateral seminal vesicle aplasia, hypospadiasis, pseudohermaphroditism, and scrotal abnormality.
This anomaly is clearly described in children, with a mean age of 4 years at the time of diagnosis, but rarely encountered in adults [7]. Walsh et al. in their study concluded that testicular cancer was nearly 6 times more likely to develop in cryptorchid cases whose operations were delayed until after age 10 to 11 years [8].
So, an early and elaborate diagnosis of TTE should be made preoperatively by USG, magnetic resonance imaging, and a CECT abdomen-pelvis to look for associated anomalies [1, 9]. MRI and MRV is the fundamental imaging modality in the diagnosis of TTE with 82.4% and 100% sensitivity, respectively [10], as it can provide us with the pre-operative location of the impalpable testes, intricate analysis of vas deferens and seminal vesicle, and thus helping us in the decision-making of the required surgical technique. It is also useful in distinguishing TTE from testicular duplication [11]. Laparoscopy provides both diagnosis and management of TTE and its associated anomalies [12]. The rarity of our case is in the synchronous presence of two vas deferens, which are fused at its proximal end and terminates in a single left seminal vesicle; the right seminal vesicle is aplastic and varicocele.
Dahal et al. [9] described a similar case of left TTE in a 42-year-old adult who presented with the left side reducible inguinal hernia and was operated on with hernioplasty and bilateral orchidopexy, in our case which had a different presentation with an irreducible hernia on the contralateral side. Yu et al. [13] presented a left side TTE in a 51-year-old man with associated right congenital cryptorchidism who was treated with laparoscopic resection. Similarly, Tepeler et al. [14] described a case of TTE but in 15 years old boy in whom left testis was seen in right inguinal region with right inguinoscrotal hernia; Moslemi et al. [6] had a similar case report of right side TTE with ipsilateral inguinal hernia. Gkekas et al. [2] presented with a case report of left TTE with single fused vas deferens, hypoplastic seminal vesicle with varicocele but without hernia which is different to our case.
Once a diagnosis of TTE is made, the primary goal of treatment is to preserve fertility and prevent the occurrence of malignancy. This is achieved by performing repair of congenital anomaly, hernia, and a trans-septal transposition orchiopexy or extra-peritoneal transposition orchiopexy with follow-up [15, 16].
