Patients with disorders of sex development (DSD) at risk of gonadal tumour development: management based on laparoscopic biopsy and molecular diagnosis


  • Lutz Wünsch,

    Corresponding author
    1. Department of Paediatric Surgery, University of Lübeck, Lübeck
      Lutz Wünsch, Department of Paediatric Surgery, University of Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany. e-mail:
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  • Paul M. Holterhus,

    1. Department of Paediatrics, Division of Pediatric Endocrinology and Diabetes, Christian-Albrechts-University of Kiel, Kiel
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  • Lukas Wessel,

    1. Department of Paediatric Surgery, University of Mannheim, Mannheim
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  • Olaf Hiort

    1. Division of Paediatric Endocrinology, Department of Paediatric Endocrinology, University of Lübeck, Lübeck, Germany
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Lutz Wünsch, Department of Paediatric Surgery, University of Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany. e-mail:


Study Type – Therapy (case series)

Level of Evidence 4

What's known on the subject? and What does the study add?

In some individuals with disorders of sex development (DSD), gonadal tumour risk is increased. The individual risk is estimated based on the molecular diagnosis and the age and approaches 30% in the high-risk group. In the past, early gonadectomy has been advised for all individuals with 46XY DSD. Gonadectomy clearly represents an overtreatment for many individuals with 46XY DSD. Thus, further clinical indicators of individual tumour risk are urgently needed.

The present study provides a comprehensive description of gonadal morphology, as seen during laparoscopy. For the first time, laparoscopic features, molecular diagnosis and histopathological findings are presented in a comprehensive context. The present study adds a detailed morphological description of the variability found in different subgroups of 46XY DSD. As three of four detected tumours were microscopic, early diagnosis by inspection appears unfeasible. Biopsy, gonadopexy and precise localisation of the gonad will potentially allow for gonadal preservation in well-defined clinical situations.


  • • To investigate the role of laparoscopy for the early detection of gonadal tumours, with emphasis on gonadal preservation, in patients with 46XY disorders of sex development (DSD). In patients with DSD, gonadectomy is frequently recommended and depending on the age and the molecular diagnosis, an increased gonadal tumour risk exists and undesired hormone effects may arise. However, gonadectomy is irreversible and impacts considerably on body image. It represents an overtreatment for some patients and should be considered after a comprehensive diagnostic evaluation. Laparoscopy is an important technique, because it is able to retrieve small gonads and allows guided biopsies.


  • • We performed laparoscopic assessment of the gonads in 40 patients with various 46XY DSD.
  • • In all, 77 gonads were evaluated, images were analysed and compared with histological findings.
  • • Laparoscopic procedures included gonadectomy, biopsy, laparoscopic orchidolysis or the Fowler–Stephens procedure as well as the removal or splitting of uterine remnants.


  • • In all, 19 patients underwent gonadectomy and tumours were discovered in four.
  • • Three patients had only microscopic evidence of tumour, in one the tumour was diagnosed intraoperatively.
  • • In 21 patients, biopsies were taken and the gonads preserved.
  • • Laparoscopic biopsy and gonadopexy was performed in six patients with complete androgen insensitivity syndrome (CAIS).


  • • Laparoscopy and biopsy detected three microscopic tumours, one tumour was macroscopically evident.
  • • In CAIS, gonadopexy improved the visibility of the gonads on postoperative ultrasonography. This procedure facilitated the examination of the gonad at follow-up.
  • • In complete gonadal dysgenesis, a highly variable morphology of the gonads was found. Laparoscopy improved exposure of gonads and Müllerian structures, and facilitated biopsies and organ-preserving procedures.

disorders of sex development


complete gonadal dysgenesis




complete androgen insensitivity syndrome


placental alkaline phosphatase


tubular in situ neoplasia


The developmental stage and endocrine function of the gonads in 46XY disorders of sex development (DSD) varies greatly depending largely on the underlying diagnosis [1]. The most relevant clinical problems relate to the increased risk for germ cell tumours and desired or undesired hormone secretion due to gonadal activation during puberty and infertility. Additionally, avoidance of unnecessary or mutilating surgery is of utmost importance. However, the rareness of these disorders makes the development of strict guidelines for management difficult. At present, individualised care is necessary and should be based on an exact diagnosis and the best possible assessment of the phenotype. The molecular diagnosis and age of the patient seem to be the most relevant factors in the estimation of tumour risk (Table 1) [2].

Table 1. Tumour risk in DSD (modified from [2])
HighComplete gonadal dysgenesis
Partial gonadal dysgenesis with nonscrotal gonad
Frazier syndrome
Partial androgen insensitivity with nonscrotal gonad
Denys–Drash syndrome
Intermediate17β-hydroxysteroid dehydrogenase deficiency
Partial androgen insensitivity with scrotal gonad
LowComplete androgen insensitivity
Ovotesticular DSD
Persistent Müllerian duct syndrome

Laparoscopy is a valuable technique for the diagnosis of DSD and interventions such as gonadal biopsy and gonadectomy [3–5]. In contrast, the role of laparoscopy for the preservation of gonads and potential fertility is less clear. For tumour risk, laparoscopy could potentially identify small subclinical tumours. Providing the exact position of the gonad, laparoscopy can guide biopsies and may direct imaging follow-up studies. It is also of value in orchidolysis and the Fowler–Stephens procedure. Because of the many unsolved questions about the best management of patients with the various forms of 46XY DSD, research efforts frequently accompany the clinical care. In 46XY DSD based on defined genetic alterations, the variation of clinical phenotypes is often puzzling and not explained. For young surgeons without experience in laparoscopic evaluation of patients with DSD, the internal gonadal structures do not always appear as predicted and, thus, further delineation and characterisation is needed in the literature. Because of its unparalleled resolution of small structures, e.g. surface architecture, sex duct anatomy and gonadal ligaments, laparoscopy may provide additional descriptive morphological details for further assessment of phenotype–genotype correlations and individualised tumour risk.

Specifically concerning gonadectomy, removal of all gonadal tissue, thereby, removing autonomous hormone production and all hope for fertility is traumatic and impacts on body image. Its recommendation should be based on the best possible individual risk assessment. The present study is based on a cohort of patients with various forms of 46XY DSD, 46XY/45X0 mosaicism. It provides an outline of our experience with intraoperative gonadal assessment and how it influenced the laparoscopic treatment.


From 2002 to 2009, 40 patients with various forms of 46XY DSD underwent laparoscopic procedures at our institution. We included all patients who underwent a complete laparoscopic examination. Two patients presented with hernias, all other patients were asymptomatic. The underlying diagnosis and the age range and the procedures are reported in Table 2. Molecular diagnosis was available at the time of surgery in 32 cases.

Table 2. Patients and procedures
Patient numberIndication for gonadal managmentSex of rearingAge, yearsProcedureHistologyGenetic abnormality
  1. Pg, prophylactic gonadectomy; AR, androgen receptor; SRY, sex-determining region Y. *The specimen was divided for several purposes but no gonadal tissue was detected in the part submitted to the Department of Pathology.

 1PgF18Bilateral gonadectomyGonadoblastoma and stage I dysgerminomaSRY deletion
 2PgF25Bilateral gonadectomyNo gonadal tissue available*SRY deletion
 3PgF12Bilateral gonadectomyStreak gonad, fibrous stroma, no tumourDeletion 9p
 4PgF1Bilateral gonadectomyPrimitive tubuli and stroma, no tumourSF-1 mutation
 5PgF7Bilateral gonadectomyStreak gonads, stroma, no tumourUnknown
 6PgF3Bilateral gonadectomyGonadoblastomaSRY deletion
 8PgF11Left gonadectomy, right gonad previously removed because of dysgerminomaStreak gonad and immature testicular tissueFrazier-S, WT 1 mutation
Mixed and partial gonadal dysgenesis
 1  1Bilateral biopsy of the testis and orchidopexy, two-stage hypospadias repairTesticular tissue normal for ageDeletion 9p haploinsufficiency DMRT1/DMRT2
 2  1orchidopexy (right), biopsy (left) gonad two-stage repair of penoscrotal hyospadia, laparoscopic resection of the uterusOvarian stroma46XY, 45XO
 3  1Bilateral orchidopexy, hypospadias repairImmature testicular tissue46XY, 45X0
 4  1Excision of residual tissue after previous biopsies, laparoscopic resection of the uterus, single-stage hypospadias repair(Ovarial) stroma without residual germ cellsUnknown
 5  2Laparoscopic testicular mobilisation and hypospadias repairNot doneUnknown
 6  1Laparoscopy, bilateral biopsyBilateral immature testicular tissueUnknown
 7  1Laparoscopy, bilateral biopsyStromal tissue, testicular tubuli with TINUnknown
 8  1Bilateral orchidopexy, hypospadias repairNo biopsyUnknown
 9  2Stephens–Fowler I left testicle, orchidopexy right testicle, bilateral biopsyTesticular tissue with tubuli, no tumourWT-1 mutation
 10  3Bilateral gonadectomyStreaks, no tumour45XO/46XY
 11  12GonadectomyStreak gonads without germ cells, no tumour45XO, 46XY mosaic
 12  6GonadectomyGonadoblastoma, streak gonad45XO, 46XY
Disorders of testosterone synthesis
 1  11Bilateral gonadectomyHypoplastic testicular tissue, no tumourCYP11A1 mutation
 2  15Bilateral gonadal biopsyImmature testicular tissue with extensive calcificationCYP17A mutation
 3  13Bilateral gonadectomyTesticular tissue with immature tubuli, no tumourSF-1 mutation
 4  4Bilateral gonadectomyImmature tubuli appropriate for age, no tumourHSD17B3 mutation
 5  15Bilateral testicular biopsy, orchidopexyTesticular tissue, maturation delay, no tumourHSD17B3 mutation
 6  16Bilateral gonadectomyTesticular tissue, no tumourHSD17B3 mutation
 1  20Testicular biopsy, gonadopexytesticular tissue without spermatogenesis, no tumourAR mutation
 2  17Left gonad removed for suspicious nodule on US, right gonad fixed to abdominal wallTesticular tissue with no spermatogenesis, no tumourAR mutation
 3  3Hernia, bilateral gonadopexy, biopsyTesticular tissue with few germ cells, no tumourAR mutation
 4  18Bilateral gonadopexy and biopsyTesticular tissue with no germ cells, no tumourAR mutation
 5  17Biopsy of one gonad without gonadopexy, other gonad previously removedTesticular tissue with no germ cells, no tumourAR mutation
 6  18Bilateral gonadopexyTesticular tissue with few germ cells, no tumourAR mutation
 7  17bilateral biopsy, gonadopexyTesticular tissue with few germ cells, no tumourAR mutation
Ovotesticular DSD
 1  1Bilateral biopsiesPrimary follicles and stroma46XY
 2  1Bilateral biopsiesImmature ovarian and testicular tissue46XX
 3  1Bilateral biopsiesOvarian and testicular tissue46XY
Persistent Müllerian duct syndrome
 1  1Laparoscopic uterus split and resection, orchidopexyTesticular tissue appropriate for age 
 2   Laparoscopic uterus split and resection, orchidopexyTesticular tissue appropriate for age 
 1  8Bilateral gonadectomyImmature testicular tissue, no tumourpartial androgen insensitivity
 2  4Bilateral gonadectomyImmature testicular tissue with no germ cells, no tumourunclear

Informed consent was obtained from patients and families, and the study design was approved by the Local Ethics Board. Patients and their families were extensively informed about the range of surgical options. Two counselling sessions were offered when needed. Specifically, biopsy of the gonads was offered in all cases with unclear diagnosis. In these situations, the gonadectomy was deferred to a second operation after histological examination. Biopsy specimens were fixed in formalin and processed according to standard procedures. Laparoscopy was carried out under general anaesthesia with a 5-mm camera port placed at the umbilicus and other instruments inserted as necessary. Laparoscopy was undertaken as part of the diagnostic process, for gonadectomy in patients with complete gonadal dysgenesis (CGD) or due to the impossibility to visualise the gonads on ultrasonography (US) in cases with complete androgen insensitivity syndrome (CAIS). Pelvic anatomy was examined and video images were reviewed for the purpose of this study. The inguinal canal was explored when indicated. Macroscopic features of the gonads as size, Wolffian duct derivatives (epididymis, vas deferens), and localisation were documented. The urethra was examined for the presence of a colliculus seminalis and the vagina was examined for the assessment of length and the presence of a cervix.

Laparoscopic gonadopexy was done in six patients with CAIS to place the gonads in a defined position near the abdominal wall. First, a biopsy was taken from each gonad. The gonads were then fixed with two absorbable sutures at the position of the laparoscopy ports. So the position of the gonad was marked by a small cutaneous scar.

Gonadectomy was carried out using bipolar coagulation or clips. Cryoconservation of gonadal tissue was offered in these circumstances. All hernias that were encountered during these procedures were repaired.

One or two biopsies of each gonad were taken. Histological examination included staining with haematoxylin-eosin and for placental alkaline phosphatase (PLAP) and Ki 67 and CD 117 (c-kit).

Further laparoscopic procedures included orchidolysis of an abdominal testis or the two-stage Stephens–Fowler orchidopexy (six patients) and laparoscopic split or removal of large Müllerian remnants (four patients). Direct visualisation of the vas deferens at its entrance was always obtained.


In 21 patients preservation of the gonads was possible, 19 patients underwent gonadectomy. Of those, in 17, gonadectomies were carried out because of an estimated high tumour risk. Two patients had their gonads removed because a tumour was suspected during the procedure. In 21 patients, biopsies were taken and the gonads preserved.

Three patients presented with a single gonad, after prior removal of one gonad before submission to our institution. Of these, two had dysgerminoma and one with a suspicion of tumour that was not confirmed (Table 2).

Laparoscopy visualised the gonads in all eight patients with CGD. They had small, intra-abdominal gonads that had not been detected at preoperative MRI or US. Their macroscopic appearance varied considerably (Figs 1,2).

Figure 1.

Gonads containing tumour. a, Complete gonadal dysgenesis (CGD): persistent ovoid shape with irregular surface, gonadoblastoma and dysgerminoma (CGD, patient 1). b, Gonad in CGD in the first year of life, containing microscopic gonadoblastoma (patient 6). c, Male patient with partial gonadal dysgenesis, the biopsy revealed a tubular intraepithelial neoplasia (patient 7). d, CGD, gonad containing dysgerminoma (patient 8).

Figure 2.

Gonads with no tumour detected at biopsy. a, Partial gonadal dysgenesis, right testis: no tumour at biopsy (patient7). b, Partial gonadal dysgenesis: small gonad and uterine tube, indicating insufficient anti-Müllerian hormone effect, persistent cranial gonadal ligament (arrow, patient 4). c, CGD at 12 years: streak gonad with no tumour (patient 3), the insert shows the histological view of an ovarian follicle (×100 haematoxylin-eosin). d, Hypoplastic testicular tissue in an individual with a disorder of testosterone synthesis (CYP11A1 Mutation, patient 1).

All CGD patients underwent surgery with the intention of gonadectomy. Four of eight patients with CGD had a histologically confirmed gonadoblastoma. One of these also had a dysgerminoma; two patients of this group had had dysgerminomas removed at other institutions.

Only in one case did the laparoscopy revealed suspicious findings. Irregularity of the surface and small nodules were found in an adult woman (CGD patient 1). Histologically, the tumour had completely replaced the gonad (Fig. 3). In the other two patients only microscopic tumours were found.

Figure 3.

Histology. a, Gonadoblastoma x 200, CD 117 (c-kit), a germ cell tumour marker is intensively positive in a patient with CGD, (patient 1). b, Dysgerminoma ×200, haematoxylin-eosin (H&E), in a patient with CGD (patient 1). c, TIN ×200, H&E, in a patient with partial gonadal dysgenesis (patient7). d, TIN x 400, CD 117 (c-kit), same patient as panel c.

Of the 12 patients with partial and mixed gonadal dysgenesis, nine patients were reared as males and three patients were reared as females. Five patients presented with variable degree of 45XO, 46XY mosaicism. In two patients with virilised external genitalia, the gonads showed testicular features at laparoscopy. Three patients with female external genitalia showed typical streak gonads at laparoscopy. In these cases, histology showed ovarian stroma without germ cells. One 6-month-old patient assigned to male sex with partial gonadal dysgenesis had a tubular in situ neoplasia (TIN) at biopsy (Figs 1,3). His gonads were symmetric, and the biopsy from the other gonad showed no TIN. These gonads were very small and because of the young age, only biopsies were taken. The diagnosis of TIN was made by a reference pathologist. We recommended a Stephens–Fowler procedure but the patient was lost from follow-up.

One patient had Denys–Drash Syndrome, due to a WT-1 mutation, and a nephroblastoma developed 6 months after orchidopexy. This case underlines the need for straight surveillance in these situations.

All patients with CAIS requested gonadal preservation. Two of them presented with inguinal hernia; in five others the gonads were located in the abdomen. In one girl with CAIS, preoperative US showed a suspicious finding. A hyperechogenic nodule was visible, but at surgery no tumour was found and histology was unremarkable. The gonads of all other patients were preserved. Biopsies showed no signs of invasive tumour or TIN. Gonadopexy to the anterior abdominal wall was performed to facilitate postoperative US. Preoperatively, the gonads could not be reliably detected by US. Postoperatively, the visibility of the gonads was improved in all patients (Fig. 4).

Figure 4.

Intra-abdominal gonads in CAIS. a, Intra-abdominal testis in CAIS. Note the cystic dilatation of residual epidydimal structures (patient 4). The testis is very mobile and has not been detected on preoperative US. b, Laparoscopic view during gonadopexy in the same patient. A biopsy has been taken and the gonad is pulled toward the entrance point of the trocar. c, After gonadopexy to the anterior abdominal wall, the gonad is visible on US.

Both US and laparoscopy have significant false-positive and false-negative rates. They should therefore be combined with gonadal biopsy.

Four of the eight boys with partial gonadal dysgenesis had intra-abdominal testes and laparoscopy was used for a one- or two-stage orchidopexy. In particular, mobilisation of the testicular vessels and transfer to the scrotum were facilitated by laparoscopy (Fig. 5). Laparoscopy also identified the point of entrance of the vas to the Müllerian residuals, facilitating the split or removal of these structures. Laparoscopy allowed in all cases a complete description of the sex duct anatomy with minimal invasiveness. It also provided information on gonadal ligaments and mobility relative to the inguinal canal. Gonadal appendages were also clearly visible. In contrast to MRI or US, a complete description of gonads and sex ducts was possible in all 40 patients.

Figure 5.

Dysgenetic testes. a, Partial gonadal dysgenesis: dysgenetic testis (patient 9), evaluation before Stephens–Fowler I procedure. b, small dysgenetic testis mobilised before scrotal fixation (patient 3).


The age and conditions of the investigated patients varied widely. However, the descriptive research approach on this comparably high number of patients with DSD offers valuable perspectives on the role of laparoscopy in the clinical management of DSD.

Complete gonadal dysgenesis (CGD) and subtypes of 46XY DSD with abdominal gonads carry the highest risk and tumours develop in 35% of these patients [2]. Female 46XY patients within this subgroup of DSD have small, often streak-like gonads with absent or minimal function. They must balance their tumour risk mainly against that of unnecessary surgery. Given the low risk in some subgroups, the practice of early gonadectomy regardless of diagnosis is intensely debated. At a microscopic level, the borderline between a neoplasia and a delay of maturation is hard to define [6,7]. Imaging of the gonads by US or MRI is difficult because of the small size and the variable localisation [8]. Some of these gonads are very mobile, making the serial imaging by US challenging. For these reasons, early gonadectomy is usually advised for all patients. The significance of intraoperative evaluation of the gonad is actually unclear and addressed by the present study.

Laparoscopy detected one macroscopic tumour in 77 gonads. It revealed no macroscopic anomalies in those three gonads that showed microscopic evidence of tumour. Laparoscopic gonadal biopsy is a useful technique for the early diagnosis of germ cell tumours or follow-up. However, laparoscopic gonadopexy may theoretically add a risk of lymphatic tumour spread to the inguinal lymph nodes draining the abdominal wall.

In CAIS, laparoscopic gonadal biopsy with gonadopexy permits serial US follow-up. Once the position of the gonad is precisely known, US can be focused on this area. Preservation of endocrine function of the gonads at least until puberty is beneficial for patients with CAIS due to postponement of surgery until an age at which the propositus can participate in decision making. Later in life, an increasing risk of TIN and dysgerminoma has been reported [9] and therefore, gonadectomy has been recommended after puberty. However, it is actually unknown how to provide reasonable safety to those adult women with CAIS who want to retain their gonads. Serial imaging with US or MRI has not been effective [8], and CT is associated with a prohibitive high radiation exposure. Laparoscopy offers the opportunity for inspection, localisation and biopsy of the gonad. It also allows fixation of the gonads in a position, where it can easily be monitored by US. In none of the present patients with CAIS, were there any signs of tumour at inspection, confirmed by the histological examination of the biopsy. We carefully conclude from the present series and published data that preservation of the gonads in CAIS is ‘safe’ until puberty [9]. However, it is unclear how the risk progresses later in life. TIN starts as a small focal lesion. It has been related to microlithiasis of the testes but size of the gonad may be a more relevant indicator of tumour development [10]. Gonadopexy is similar to transposition of the ovaries, a procedure developed to lift the ovaries out of a pelvic radiation field [11]. Laparoscopic gonadopexy enhanced the visibility of the gonad and allowed for better monitoring. Prospective long-term studies involving more patients and a close follow-up of adults with CAIS are required to elucidate the risk : benefit ratio after puberty. Patients who present with a herniated gonad can be treated by fixation of the gonad in the inguinal canal. The gonad will be less prominent, the hernia can be repaired and the position of the gonad can be easily identified.

In CGD, various macroscopic features were detected that have not been generally appreciated in the literature. It is presently unknown whether these differences relate to patient age-related changes or tumour risk. Failing regression to a true ‘streak’ with persistence of an ovoid shape may indicate a persistence of tumour risk. Because tumours arise at a very early age in CGD, the practice of early gonadectomy is not challenged by the present results. The small size of these gonads makes non-invasive monitoring difficult even in expert hands. Shape and size of the gonads in CGD should be precisely described in future prospective studies.

Fertility in 46XY DSD has been exceptional in the past, and the complexity of surgical procedures in these patients may have contributed to this problem. With modern surgical approaches, hypospadias are repaired more successfully and more and more patients with partial or mixed gonadal dysgenesis are raised as males. Laparoscopy and its improved visualisation contribute to the safety of scrotal placement of abdominal and high inguinal testicles. The removal of a uterine residuum in proximity to the vasa deferentia is a technically demanding procedure. Laparoscopy visualises the point of entrance of the vas to persistent Müllerian structures, making its preservation easier. The more favourable scrotal environment will eventually favour the development and maturation of residual germ cells. Laparoscopy improves visibility of small structures in the pelvis.

The present results are largely descriptive, but they allow the cautious conclusion that in CGD and also in partial gonadal dysgenesis with nonscrotal gonads, early gonadectomy may still be warranted to prevent tumour development. However, in CAIS, early gonadectomy is not mandatory and patients may profit immensely from preservation of the gonads beyond puberty, because surgery is avoided and hormone replacement therapy remains unnecessary. To create statistically relevant data, much larger series relating individual diagnosis to age and management are needed in a prospective long-term study design. This might be facilitated through European collaborative research in the future.

The inclusion of surgical procedures into the clinical management of 46XY DSD may have additional advantages. Most DSD are genetic disorders with characteristic aberrations in various genes. The phenotypic variation seen in association with similar genetic abnormalities has stimulated research on modulators of development, e.g. co-factors of androgen action or epigenetic modulation. Laparoscopic findings, e.g. the variability seen in sex duct development or in gonadal shape, size and location, may provide valuable elements to define the range of both ‘normal’ and ‘abnormal’ gonadal development. It may also provide insight into genotype–phenotype correlations and contribute to the understanding of morphogenesis of gene effects [12]. This might then lead to a much more comprehensive and structured description of DSD-related morphology.


None declared.