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

Abstract

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-V_D-M_DR 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-V_D-M_DR 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-V_D-M_DR 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.