Excision versus division of Müllerian duct remnants in male disorders of sexual development and differentiation: a prospective study to generate anatomical assessment criteria.

BACKGROUND

Müllerian duct remnants (MDRs) in male disorders of sexual development (DSD) exhibit variable degrees of development and Wolffian duct relations, influencing surgical decision-making.

OBJECTIVES

This study introduces the G-VD-MDR classification to guide excision versus division decisions. It also examines the correlation between the external masculinisation score (EMS) and surgical approach for improved preoperative planning.

METHODS

A cohort of 18 male-reared DSD patients with MDRs was prospectively managed laparoscopically, out of 20 initially considered cases. Surgical approaches included either longitudinal splitting/division or near-total excision. G-VD-MDR classification was introduced, which categorises MDRs based on three anatomical parameters: (A) gonadal status (G0-G3), (B) relation to the vasa deferentia (V0-V2), and (C) degree of Müllerian development (M1-M5). In addition, the predictive value of the EMS in determining surgical feasibility was evaluated.

RESULTS

Patients with higher EMS (≥ 8.5) were more likely to require MDR division due to complex MDR-vas deferens relations, while those with EMS ≤ 5.5 underwent excision. Bilateral MDR-vas deferens relations favoured division (83.3%), whereas unilateral or absent MDR-vas deferens relations were more common in the excision group (41.6% and 50%, respectively). A significant correlation was found between EMS and surgical approach (p = 0.004).

CONCLUSION

The G-VD-MDR classification, combined with EMS assessment, offers a structured and predictive framework for optimising MDR surgical management. The need to achieve single-stage, tension-free orchidopexy and the anatomical relationship between MDRs and the vas deferens govern the choice between excision and division.