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| CASE REPORT |
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| Year : 2020 | Volume
: 31
| Issue : 6 | Page : 282-284 |
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Tubular ectasia of the rete testis: A cautionary tale
Hui-Ming Chun
Department of Urology, Mennonite Christian Hospital, Hualien, Taiwan
| Date of Submission | 09-Jun-2020 |
| Date of Decision | 06-Aug-2020 |
| Date of Acceptance | 13-Aug-2020 |
| Date of Web Publication | 26-Dec-2020 |
Correspondence Address:
Hui-Ming Chun
No. 44, Min-Chuan Road, Hualien
Taiwan
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/UROS.UROS_82_20
A 60-year-old male reported a painless left scrotal mass for months. The testicle was removed due to the fact that malignancy could not be excluded from physical examination, tumor markers, or scrotal imaging. Afterward, further pathological examinations diagnosed the patient's condition as tubular ectasia of the rete testis (TERT) rather than malignancy. TERT is a rare benign lesion that may be mistaken for malignant tumors at first glance. However, distinguishing diagnoses can be made with a combination of sonography and magnetic resonance imaging without much difficulty. That is why it is highly recommended to consider this condition before confirming the final diagnosis of similar cases.
Keywords: Neoplasm, rete testis, testis, tubular ectasia
How to cite this article:
Chun HM. Tubular ectasia of the rete testis: A cautionary tale. Urol Sci 2020;31:282-4 |
| Introduction | |  |
While the presence of intratesticular lesions is usually an indicator of malignant neoplasm, in some cases, nonmalignant pathological entities might be the real cause. Tubular ectasia of the rete testis (TERT) is a common cause of lesions, arising as the result of epididymal obstruction or postsurgical changes to the rete testis (e.g., after a dialysis or a vasectomy).[1] As benign lesions are relatively uncommon, awareness and correct diagnosis of such cases are crucial to prevent unnecessary surgical removal of the testes.[2],[3],[4] Here, an instance of TERT – that had not been diagnosed before orchiectomy – is reported.
| Case Report | | |
A 60-year-old male presented with a painless left scrotal mass for months, without enlargement, about 1–2 cm in size. Physical examination found induration, but no tenderness. All tumor markers were negative. On ultrasound examination [Figure 1], the appearance of the testis suggested intratesticular cysts with tubular ectasia. Computed tomography scan revealed a hypodensity in the left testis. Since the possibility of malignancy could not be excluded at the time, the patient was treated with radical orchiectomy. The patient recovered uneventfully after surgery. Afterward, further pathological examinations showed cystic dilation of the rete testis at the hilar area [Figure 2] and yielded a diagnosis of TERT. | Figure 1: Multiple tiny cystic spaces (indicated by arrow) in the testicular mediastinum of the left testis
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 | Figure 2: Microscopic section showed cystic dilation (indicated by arrow) of the rete testis at the hilar area (×100)
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| Discussion | | |
TERT is a benign condition that consists of spermatozoa-containing cysts that communicate with the tubular system into the epididymis. It can occur in a wide age range, though more commonly seen in older men with a median age of 62 years.[5] It is mostly associated with epididymal abnormalities such as spermatocele, epididymal cysts, or epididymitis resulting in tubular obstruction, the evidence of which is derived from a histological study of 1798 autopsies and 518 surgeries.[6] Obstruction at the level of the epididymis or the efferent ducts may be caused by trauma or inflammation as the result of mechanical compression,[1] though postsurgical changes, hormonal, and congenital malformations have also been suggested.[6]
TERT is characterized by dilated testicular mediastinal tubules on sonography. It appears as multiple small cystic spaces clustered in, or adjacent to, the mediastinum testis. More often bilateral than unilateral, the low-reflective cystic swellings are often only 1–3 mm but occasionally can be larger. While ectasia following compression by testicular tumor is possible, the absence of internal vascularity and the adjacent solid components are strongly suggestive of a nonmalignant lesion.[7]
Distinguishing examinations should be made for other entities that have an appearance similar to that of this benign condition. The first of these is an intratesticular varicocele, which may be ruled out by the lack of vascular flow within the mediastinum testis on ultrasonography. Meanwhile, cystic dysplasia is a congenital lesion more often accompanied by renal or urogenital excretory duct malformations.[8] Papillary adenocarcinoma of the rete testis is a malignancy that can also have a multicystic appearance; however, it is quite rare and can be differentiated according to the patient's age, clinical symptoms, and tumor markers.[9] The presence of nodular areas within the cyst may also be a clue to this rare diagnosis.[4],[10]
On magnetic resonance imaging (MRI), TERT shows a signal intensity comparable to water, that is, hypointense on T1-weighted images and hyperintense on T2-weighted images. These lesions can be distinguished from neoplastic lesions by their signal homogeneity in intensity and density. In some cases, MRI may successfully identify tubular ectasia where sonography findings seem indeterminate.[10]
In short, given the possibility of TERT, sonography should suffice as the major diagnostic tool, followed by confirmatory MRI to give conclusive findings. Diagnosis of lesions as tubular dilation would render further biopsy or unnecessary orchiectomy.
| Conclusion | | |
TERT is a pathologically benign condition that results from tubular obstruction. Lesions localized to the mediastinum testis, copresence of epididymal abnormalities, and higher patient age are all indicative of TERT rather than neoplasm. Differential diagnosis can be made by sonography and additional confirmative MRI if needed. Awareness of this condition and correct diagnosis are important to avoid unnecessary surgical intervention and invasive diagnostic procedures.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 8. | Jimenez-López M, Ramírez-Garrido F, López-González Garrido JD, Mantas-Avila JA, Nogueras-Ocaña M, Jimenez-Verdejo A, et al. Dilatation of the rete testis: Ultrasound study. Eur Radiol 1999;9:1327-9. |
| 9. | Pandya VK, Sutariya HC, Patel KM. Tubular ectasia of rete testis-a diagnostic dilemma. Clin Queries Nephrol 2016;5:33-4. |
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[Figure 1], [Figure 2]
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