Abstract
Isolated duplication of the vas deferens is a rare male reproductive system congenital anomaly with an estimated worldwide prevalence of 0.05%. It is often recognized as an incidental finding during surgeries including vasectomy, inguinal hernia repair, orchidopexy, or varicocelectomy. The number of case reports on this condition are very limited suggesting it is either rarer than the reported estimates or highly underrecognized and underreported. Failure to recognize an iatrogenic injury to the vas deferens can lead to postoperative complications including chronic pain, spermatic granuloma, and failure of sterilization after vasectomy. Considering the high number of hernia repair procedures performed worldwide, surgeons should be aware of this anomaly to reduce the risk of complications. Herein, we present a 69-year-old man with an isolated duplicated vas deferens which was discovered during robot-assisted laparoscopic unilateral inguinoscrotal hernia repair.
Introduction
The ductus or vas deferens transports sperm from the epididymis to the ejaculatory duct. Its anatomic variations include absence, hypoplasia, ectopia, diverticulum, and duplication, with duplication considered as one of the rarest congenital anomalies [1]. Embryologically, the vas deferens develops from the central portion of the mesonephric (Wolffian) duct, known as the proximal vas precursor. Duplication of the fetal mesonephric system or proximal vas precursor during development has been proposed as the mechanism underlying duplication of the vas deferens [2–5]. Duplicated vas deferens differs from double vas deferens in which an ectopic ureter, typically associated with ipsilateral renal dysgenesis, drains into the ejaculatory system and may resemble a second vas deferens [1]. Duplicated vas deferens might be associated with cystic fibrosis and renal anomalies including unilateral renal agenesis [2, 4]. The estimated prevalence of isolated vas deferens duplication in general population is <0.05% [2]. Identification of the vas deferens during surgeries involving the inguinal canal is critical to preventing iatrogenic injury [5]. Despite the high volume of inguinal hernia repairs, few case reports of vas deferens duplication have been reported, suggesting that it is underrecognized or underreported [5]. Herein, we present a case of an isolated duplicated vas deferens discovered during robot-assisted laparoscopic unilateral inguinoscrotal hernia repair.
Case report
A 69-year-old man with Parkinson’s disease and hypertension presented with a large symptomatic right inguinoscrotal hernia. He denied urinary symptoms, abdominal pain, and changes in bowel habits but reported that the hernia had progressively enlarged, recently extending into the right scrotum and causing increasing discomfort. On physical exam, a large reducible inguinoscrotal hernia was noted. Preoperative computed tomography (CT) demonstrated that the hernia contained most of the urinary bladder and the distal ureters, with mild bilateral hydroureter extending to the level of the bladder (Fig. 1). No vas deferens abnormality was reported. Both kidneys were symmetric and normal in size, and the prostate was also normal in size.
Preoperative CT scan demonstrating the right inguinal hernia containing the majority of bladder as well as part of the right ureter.
The patient underwent a robotic-assisted laparoscopic right inguinoscrotal hernia repair utilizing a transabdominal preperitoneal approach (TAPP). Intraoperatively, the patient was noted to have an ~4 cm right indirect inguinal hernia defect with a sliding component consisting of the bladder and colon. After achieving a critical view of the myopectineal orifice, the patient was noted to have three sets of structures entering the right internal inguinal ring. The most lateral was the gonadal vessels which were traced proximally. The medial two structures appeared to be a duplication of the right vas deferens. The bladder at that point had been completely reduced, and the ureter
was identified inserting into the bladder. No cord lipoma was identified. The hernia defect was covered with a 10 × 15 cm self-fixating Proline mesh without complication with preservation of all structures passing through the internal inguinal ring (Fig. 2). The remainder of the case was uncomplicated and he was discharged the same day. His postoperative course remained uneventful without any unexpected clinical issues at his 2-week postoperative evaluation; however, the limited duration of follow-up precluded assessment of longer-term outcomes. Although duplication of the vas deferens may be associated with other genitourinary anomalies, no additional postoperative imaging was obtained because preoperative imaging had demonstrated normal renal anatomy. The mild bilateral hydroureter was attributed to the inguinal hernia and was expected to resolve following its repair; therefore, no follow-up imaging was considered necessary.
(A) Initial view of the right indirect inguinal hernia defect with bladder and colon involvement; (B) global view showing pubis, duplicated vas deferens, indirect inguinal defect, ureter, and gonadal vessels; (C) closer view of duplicated vas deferens with pubis and indirect inguinal defect; (D) final view after self-fixating mesh placement.
The patient was informed of the intraoperative finding, which was also added to his problem list in the electronic medical record to alert clinicians during any future urologic procedures. Consent for publication of the case and images was obtained from the patient as well.
Discussion
Duplication of the vas deferens is a rare asymptomatic anatomic variation with an estimated worldwide prevalence of 0.05%. It is often an incidental finding during operations involving the spermatic cord, including varicocelectomy, inguinal hernia repair, vasectomy, and orchidopexy [1]. Failure to identify duplicated vas deferens intraoperatively predisposes patients to unique complications, which makes this anatomic anomaly critical for surgeons to recognize [3]. These complications include scarring of the cord, sperm granulomas, and chronic pain. Sperm are highly antigenic, and extravasation after cord injury can result in development of nodules around the injury site, which can subsequently cause postoperative groin pain [6]. Other complications include failure of sterilization after vasectomy requiring re-exploration.
Preoperative imaging can provide guidance for preservation of structures. In cases of suspected duplicated vas deferens intraoperatively during open inguinal hernia repair, this structure should be tracked down from the internal ring to the epididymis [7]. Intraoperative Doppler ultrasound may assist with differentiating duplicated vas deferens as well. In the postoperative course, it is recommended that patients undergo abdominal and genitourinary ultrasound to eliminate the possibility of associated anomalies including renal agenesis and testicular ectopia [1]. Other congenital anomalies of the vas deferens include agenesis, hypoplasia, ectopia, and fusion. Fusion into a single common vas is particularly rare and may coexist with transverse testicular ectopia, as reported in a patient evaluated for persistent left testicular pain [8].
The number of case reports regarding this anomaly is much lower than the reported prevalence. The paucity of data suggests either it is rarer than the estimated prevalence or it is underrecognized. Routine recognition and reporting of duplicated vas deferens is important to increase awareness of this condition among surgeons and decrease the rate of associated complications [1].
There are multiple case reports of discordance between imaging and operative findings. While preoperative imaging may help with obtaining a preoperative diagnosis, surgeons must still uphold a strong sense of clinical awareness and meticulously identify anatomical structures intraoperatively. To illustrate, our patient’s preoperative imaging failed to reveal duplicated vas deferens. In another case study by Symeonidis et al., the authors documented a scenario where a germ cell tumor was present despite preoperative imaging suggesting a complex hydrocele [9].
In conclusion, identification of the vas deferens during surgeries involving the spermatic cord, such as inguinal herniorrhaphy, is mandatory. Recognizing and reporting anomalies including duplications helps to reduce surgical complications by increasing awareness among surgeons.
Conflicts of interest
Authors do not have any conflict of interest to report.
Funding
None declared.
